Sunday, October 14, 2012

More Data for More Reflection on Health Care and the Market

In my last post, I asked this question: "If [employer-provided] health insurance grew as a benefit because there were more jobs than workers, what can we expect when there are more workers than jobs?" Well, I think we have an answer, and it isn't a happy one. 

Take a look at this article from Associated Press, picked by the Huffington Post: "Darden Restaurants Tests Hiring Of More Part-Time Employees To Avoid Obamacare Costs." Darden Restaurants, Inc., best known as owners of Olive Garden and Red Lobster, is making a deliberate choice to reduce its costs for employer-provided health care by reducing the number of employees who work enough hours to qualify. The authors of the article also note that other restaurant chains are making the same decision.

Now, there's nothing illegal about this. I think it's immoral, but in one sense that's neither here nor there (and, in the classic trilogy, I would worry about "fattening," but that's for another time). I simply hold this up as the other side of depending on the market and competition to provide access to health care. If we believe that universal access to health care is a good thing, and should be seen as a civil right, we simply can't depend on the market and competition to bring it about.


Thursday, October 11, 2012

More Reflection on Health Care and the Market

While I'm not watching the Vice Presidential Debate....

There are two things that bother me when anyone speaks optimistically about how a market approach and competition will solve problems of access to health care (whether in response to the Affordable Care Act, or as a means for changing Medicare). One is that those persons either don't know how the market for health care actually works, or they hope that we don't know.

The second is that we have seen how the market and competition will (or won't) work in providing access to health care. We have a long tradition of treating access to health care (not to say health itself) as a retail commodity. In private practice, each physician practice is a small business. It stands or falls on whether it makes enough revenue to pay the physician and all the physician's employees and all the business' expenses. That is, the physician practice needs to make a profit. 

The same is true of institutions. Oh, there are not-for-profit institutions; but they still have to keep ahead of the cost of living. Call it "margin" instead of "profit;" but the institution has to accomplish it. As the not-for-profit folks remind themselves, "no margin, no mission." For-profit institutions, like any other for-profit businesses, are accountable to their owners and investors to be profitable.

The same is true of insurance companies. Certainly, there are several important government insurance programs - Medicare, Medicaid, and TriCare - but the vast majority of insurers are for-profit corporations. The negotiations that happen, whether between individual and agent or between corporate  benefits departments and brokers, involve striking a balance between service and price. It's really not that different, really, from leasing a car.

Now, those negotiations rarely happen at "point of sale." That's because we do participate in groups to purchase access to health care. So, others do the negotiating on our behalf. So, maybe it's not retail. If not, though, it's wholesale, just as GM and Ford negotiate with their parts suppliers, and the person who purchases the car doesn't get to negotiate for one starter motor over another. Nobody questions that the wholesale process is a market process with a lot of competition involved.

Now, some might say that the government insurance programs have totally changed the market. I would suggest that they haven't for two reasons. The first is that most of us get our insurance, our access to health care, through an employer, whether our own or a family member's; and most of us don't work for government (including all the various governmental levels and bodies). The second is that the not-for-profit players haven't affected the ability of the for-profit players to make a profit. Sure, there are some insurers who don't have members because those members are covered by government; but all those government insurers are still doing business with physicians, institutions, pharmaceutical companies, etc, that are not government institutions, and most are making a reasonable and healthy profit.

There was, however, a time when we did have an entirely market orientation to health care. It lasted until the establishment of Medicare in 1967. Last weekend I spoke to nurses who graduated from nursing school well before that date. I was young then, but I still remember the public service announcements focusing on how many of our elderly were impoverished. One of the consequences of that poverty was that many couldn't afford health care. In recent years we've been concerned about seniors being faced with a choice between food and medicine. In those days it was also an issue - there just weren't as many medications available. Medicare wasn't created on a whim. It was created because this was a real problem, and people were suffering and dying for lack of care. The same is true of Medicaid. Medicare and Medicaid were developed because in a market approach to health care, competition wasn't working. If competition were going to work now, why wasn't it working then?

Now, some might ask about employer-based health care. Actually, employer-based health care was a result of competition in the market. In World War II there was a shortage of labor - more jobs than employees, what with so many in the military, and the demand so great for war materiel. However, wages were frozen, in an effort to control costs. So, employers had to find a new way to compete for employees. They started offering new benefits, including health insurance that the employer helped provide. So, employer-based health insurance did come as a result of a market.

But, that was a different market indeed. We're nowhere near the demand for labor that we knew in the War Years, or even in the Post-war Years. If health insurance grew as a benefit because there were more jobs than workers, what can we expect when there are more workers than jobs? See, that's the other problem with trusting competition to solve the issue. That works in the individual's favor when the market is up and tight, but the market isn't always up and tight. Indeed, it's not realistic to imagine that it will always be up and tight, or even much more than half the time. But, as we will remember if we remember what it was like before Medicare for seniors, or before the expansion that came with the Second World War, there were an awful lot of folks who couldn't afford health care. A market approach and competition just weren't getting the job done.

So, no, I'm not prepared to leave it to the market, or to trust competition to address the problem. It didn't it before. Indeed, it isn't doing it now, even with government programs to cover an awful lot of the most vulnerable, the least insurable. Based on history, on our national experience, I have no hope that it will work in the future.

Saturday, October 06, 2012

Appreciating Nurses


An address delivered to the 2012 Homecoming of the Saint Luke's College of Health Sciences.The luncheon was hosted by the class of 1962.

First, let me thank the Alumni of Saint Luke’s College, along with the Faculty and Administration of the College, for the opportunity to be with you today. I’m pleased and honored.

The story is told that in the world as it was before the turn of the Twentieth Century two men met in a train compartment. One was a businessman of some success, an important man and a Christian. The other was an older man, a Jew wearing clothes worn with age and dusty with long travel. The world being as it was back then, the Christian merchant behaved toward the elderly Jew badly. He was rude and even obnoxious. Fortunately, the encounter was blessedly short. The businessman stayed just long enough to make clear his bigotry, and then huffed off to find another compartment.

When he reached his the city that was his destination, he happened to remark at the station about how annoyed he had been to encounter the elderly Jew on the train. The person listening, however, had a different reaction. “The man you met,” he said, “is the Chief Rabbi of this town. He is a scholar recognized even by our Christian clergy, and the most important leader of his people here. He is a man of great influence throughout the city.”

This caused the businessman no end of concern. The last thing he had wanted to do was to offend someone with that kind of influence. He decided that he had to apologize, and as soon as possible. He sought and was granted a meeting.

This time the rabbi received him in his own home. It was comfortably and elegantly appointed. Fine carpets were on the floors. Lamps made the room bright. This time the rabbi was dressed, not in his traveling clothes, but in the finest black wool. It was altogether a different appearance. The businessman apologized humbly, making clear that he would not have been so rude had he know whom he addressed.

“Ah,” said the rabbi. “I appreciate your wish to apologize. Unfortunately, I can’t accept your apology. You see, when you were so rude, you were rude to someone you thought a poor and ordinary Jew. Therefore, you must find a poor and ordinary Jew and apologize to him.”

When I was invited to speak to you, it was suggested that I speak to you to thank you for your dedication to nursing and to healing, and to appreciate your caring spirits. I found myself thinking that these would be fine things to do. On the other hand, I had to stop and think about how best to do that, and about what perspectives I might want to bring to the process.

For example, sort of like the businessman in the story, I found myself stopping to think about just whom I should thank. Should I thank the mature and experienced nurses whose lives and careers were shaped so long ago by their three years learning nursing at Saint Luke’s Hospital? Certainly, there is a lot to express gratitude for in years of service to patients and their families, working with so many professional colleagues. I think, too, that there’s a lot to be thankful for in how the perspective of nursing shaped their lives out of the hospital. All the nurses I know – and I’ve lived with one myself for almost twenty-five years now – brought to all of their lives the balance of compassion and organization, of gentle hands and rigorous minds, that they brought to their careers at the bedside. Yes, there much to thank them for.

On the other hand, shouldn’t I also thank those young women, however many years ago, who finished three strenuous years and walked, wide-eyed and scared and excited into new careers as nurses?  There is much to appreciate about the hope and energy and commitment that they brought to work that was so important and that they were only beginning to understand. They entered into a field of nursing and a context of health care that was changing even as they were learning it. The graduates of 1962 hadn’t heard yet of Medicare, because it didn’t exist. The Bird Ventilator was just replacing the Iron Lung. The multidisciplinary intensive care unit was still a new concept. How could they have imagined all the changes they would experience in their careers? Certainly, we need to be grateful for their enthusiasm and their courage in those first days after their graduation.

Or, is there some point in between? Nurses at any point in their varied careers continue to encounter patients and families and colleagues who need all the care and compassion and wisdom that they have to offer. They show again and again the courage and patience, the flexibility and resilience, the knowledge they have and the commitment to gain more, that is all part of a career in nursing. At any point in a nurse’s career we can find many things to appreciate.

I had to think, too, about what perspective I might bring to offering gratitude. Who am I to thank you and to offer appreciation, not only on my own behalf but for Saint Luke’s Hospital?

Should I express my gratitude as a patient? Certainly, I’ve been a patient. I’ve had a number of surgeries and procedures at Saint Luke’s Hospital and in the Saint Luke’s Health System. That’s in no small part because I trusted the nurses and other colleagues with whom I have worked. Now, like others in health care I can be – well, let’s say I can be a bit idiosyncratic as a patient. I was in recovery after knee surgery, and just becoming aware. I knew the voice of my nurse when she said, “Marshall, are you awake?” I must have said something like “Yes,” because she said, “We just want to see if your brain is working.”

I said, “The square of the hypotenuse of a right triangle is equal to the sums of the squares of the other sides.”

The nurse said, “What?”

I said, “Four score and seven years ago our forefathers brought forth upon this continent a new nation.”

She said, “What are you doing?”

I said, “I’m seeing if my brain works.” Then I don’t remember anything for a while.

Well, we know that those of us who work in health care can be odd, not to say difficult patients. In spite of that – or perhaps more because of that – I am grateful for the nurses who have taken care of me. Now, I’ll admit that as a child I wasn’t as immediately grateful for the nurse’s care as I became. However, from the nurse who fought my childhood fever with an ice bath to the nurse who just this week gave me an absolutely painless flu shot, nurses have taken care of my health and met my needs, and I appreciate that.

Or, should I express my appreciation as a colleague? Ministers, and especially chaplains, sometimes get called “doctors of the soul.” However, I have long contended that we have more in common with nurses than with doctors. In general, we don’t diagnose; we assess. We aren’t looking as much for pathology as for holistic function. We are concerned with the whole person, and not specialized for isolated systems. No, clergy are much more nurses of the soul than physicians.

I’m especially conscious of that as a chaplain. Chaplains work more closely with nurses than with any other professionals in health care. The biggest reason for that is that the nurse is truly the care coordinator. In a sense doctors direct care, determining goals of treatment and writing appropriate orders. It’s still the nurse who coordinates care, both in the direct care she or he provides and in how she or he guides and coordinates the care of others, including chaplains. And there is another reason. Uniquely among our colleagues in health care, it is nurses who share our concern about a patient’s spiritual needs. As a chaplain I can’t be everywhere at once. God can, but I can’t. I depend on the wisdom and the holistic perspective of the nurses I work with to help me be with the patients and families, and the staff, who most need my care. I can hardly tell you how grateful I am for that.

Or, perhaps I should express my gratitude as an Episcopal priest and as Director of Spiritual Care in an Episcopal hospital. You know, when you came as students you were not most of you part of the Episcopal tradition, but you were soon aware it was an Episcopal hospital. I’m sure many of you remember chapel attendance with Chaplain Beachy. Nor perhaps are you members of the Episcopal tradition now. However, you share with the Episcopal tradition a commitment to health and wholeness, and to respecting the dignity of every human being.

You quickly became aware that you shared in that with the Episcopal Church as you trained in an institution started and led by Episcopalians. However, you probably weren’t aware of many ways in which the Episcopal Church shared with you that commitment to ministries of healing. We have long had, for example, a Standing Commission for Health for the Episcopal Church. I have the honor of serving on it.

More important, at least for an Episcopalian, it shapes our worship. Like some other churches, the Episcopal Church remembers in worship those who have been heroes and heroines of the faith. You know, I’m sure, that we remember Saint Luke. Indeed, Saint Luke’s Day and Saint Luke’s Week are just around the corner, when the hospital and the health system celebrate the ministries of chaplains. But, perhaps you didn’t know that Florence Nightingale is also in the Episcopal Calendar. Vincent De Paul is in the Episcopal Calendar. So are the Mayo and the Menninger families. And there are those known less well. There are the Martyrs of Memphis, who died providing care at the bedsides of yellow fever victims in Memphis, Tennessee. There are Damian and Marianne of Molokai, who served to the end patients suffering with leprosy. There is Innocent of Alaska, an Orthodox bishop who served among the Aleut and saved many lives when he convinced them to accept smallpox vaccination. They were not all Episcopal either, but they all shared, and shared with us, a commitment to the health and wholeness of those they served. So, perhaps as a chaplain and Episcopal priest, and as the Director of Spiritual Wellness at Saint Luke’s Hospital I can offer you thanks.

Really, all these perspectives are important. We can express appreciation for the nurses you were as new grads and for the nurses you became in your careers. We can be grateful as patients you served and as colleagues you served with. We can offer our thanks as individuals, and as members with you of that community across years of history and lines of tradition that is committed to service and health and wholeness. The fact is that you are deserving of our thanks and of our appreciation; and I am honored with this opportunity in some small way to express our gratitude. So, for all you have offered and all you have been as nurses, and for the many ways that you have cared for us and honored the hospital and the school where you began: thank you. Thank you very much. the 2012 Homecoming of the Saint Luke's College of Allied Health

First, let me thank the Alumni of Saint Luke’s College, along with the Faculty and Administration of the College, for the opportunity to be with you today. I’m pleased and honored.

The story is told that in the world as it was before the turn of the Twentieth Century two men met in a train compartment. One was a businessman of some success, an important man and a Christian. The other was an older man, a Jew wearing clothes worn with age and dusty with long travel. The world being as it was back then, the Christian merchant behaved toward the elderly Jew badly. He was rude and even obnoxious. Fortunately, the encounter was blessedly short. The businessman stayed just long enough to make clear his bigotry, and then huffed off to find another compartment.

When he reached his the city that was his destination, he happened to remark at the station about how annoyed he had been to encounter the elderly Jew on the train. The person listening, however, had a different reaction. “The man you met,” he said, “is the Chief Rabbi of this town. He is a scholar recognized even by our Christian clergy, and the most important leader of his people here. He is a man of great influence throughout the city.”

This caused the businessman no end of concern. The last thing he had wanted to do was to offend someone with that kind of influence. He decided that he had to apologize, and as soon as possible. He sought and was granted a meeting.

This time the rabbi received him in his own home. It was comfortably and elegantly appointed. Fine carpets were on the floors. Lamps made the room bright. This time the rabbi was dressed, not in his traveling clothes, but in the finest black wool. It was altogether a different appearance. The businessman apologized humbly, making clear that he would not have been so rude had he know whom he addressed.

“Ah,” said the rabbi. “I appreciate your wish to apologize. Unfortunately, I can’t accept your apology. You see, when you were so rude, you were rude to someone you thought a poor and ordinary Jew. Therefore, you must find a poor and ordinary Jew and apologize to him.”

When I was invited to speak to you, it was suggested that I speak to you to thank you for your dedication to nursing and to healing, and to appreciate your caring spirits. I found myself thinking that these would be fine things to do. On the other hand, I had to stop and think about how best to do that, and about what perspectives I might want to bring to the process.

For example, sort of like the businessman in the story, I found myself stopping to think about just whom I should thank. Should I thank the mature and experienced nurses whose lives and careers were shaped so long ago by their three years learning nursing at Saint Luke’s Hospital? Certainly, there is a lot to express gratitude for in years of service to patients and their families, working with so many professional colleagues. I think, too, that there’s a lot to be thankful for in how the perspective of nursing shaped their lives out of the hospital. All the nurses I know – and I’ve lived with one myself for almost twenty-five years now – brought to all of their lives the balance of compassion and organization, of gentle hands and rigorous minds, that they brought to their careers at the bedside. Yes, there much to thank them for.

On the other hand, shouldn’t I also thank those young women, however many years ago, who finished three strenuous years and walked, wide-eyed and scared and excited into new careers as nurses?  There is much to appreciate about the hope and energy and commitment that they brought to work that was so important and that they were only beginning to understand. They entered into a field of nursing and a context of health care that was changing even as they were learning it. The graduates of 1962 hadn’t heard yet of Medicare, because it didn’t exist. The Bird Ventilator was just replacing the Iron Lung. The multidisciplinary intensive care unit was still a new concept. How could they have imagined all the changes they would experience in their careers? Certainly, we need to be grateful for their enthusiasm and their courage in those first days after their graduation.

Or, is there some point in between? Nurses at any point in their varied careers continue to encounter patients and families and colleagues who need all the care and compassion and wisdom that they have to offer. They show again and again the courage and patience, the flexibility and resilience, the knowledge they have and the commitment to gain more, that is all part of a career in nursing. At any point in a nurse’s career we can find many things to appreciate.

I had to think, too, about what perspective I might bring to offering gratitude. Who am I to thank you and to offer appreciation, not only on my own behalf but for Saint Luke’s Hospital?

Should I express my gratitude as a patient? Certainly, I’ve been a patient. I’ve had a number of surgeries and procedures at Saint Luke’s Hospital and in the Saint Luke’s Health System. That’s in no small part because I trusted the nurses and other colleagues with whom I have worked. Now, like others in health care I can be – well, let’s say I can be a bit idiosyncratic as a patient. I was in recovery after knee surgery, and just becoming aware. I knew the voice of my nurse when she said, “Marshall, are you awake?” I must have said something like “Yes,” because she said, “We just want to see if your brain is working.”

I said, “The square of the hypotenuse of a right triangle is equal to the sums of the squares of the other sides.”

The nurse said, “What?”

I said, “Four score and seven years ago our forefathers brought forth upon this continent a new nation.”

She said, “What are you doing?”

I said, “I’m seeing if my brain works.” Then I don’t remember anything for a while.

Well, we know that those of us who work in health care can be odd, not to say difficult patients. In spite of that – or perhaps more because of that – I am grateful for the nurses who have taken care of me. Now, I’ll admit that as a child I wasn’t as immediately grateful for the nurse’s care as I became. However, from the nurse who fought my childhood fever with an ice bath to the nurse who just this week gave me an absolutely painless flu shot, nurses have taken care of my health and met my needs, and I appreciate that.

Or, should I express my appreciation as a colleague? Ministers, and especially chaplains, sometimes get called “doctors of the soul.” However, I have long contended that we have more in common with nurses than with doctors. In general, we don’t diagnose; we assess. We aren’t looking as much for pathology as for holistic function. We are concerned with the whole person, and not specialized for isolated systems. No, clergy are much more nurses of the soul than physicians.

I’m especially conscious of that as a chaplain. Chaplains work more closely with nurses than with any other professionals in health care. The biggest reason for that is that the nurse is truly the care coordinator. In a sense doctors direct care, determining goals of treatment and writing appropriate orders. It’s still the nurse who coordinates care, both in the direct care she or he provides and in how she or he guides and coordinates the care of others, including chaplains. And there is another reason. Uniquely among our colleagues in health care, it is nurses who share our concern about a patient’s spiritual needs. As a chaplain I can’t be everywhere at once. God can, but I can’t. I depend on the wisdom and the holistic perspective of the nurses I work with to help me be with the patients and families, and the staff, who most need my care. I can hardly tell you how grateful I am for that.

Or, perhaps I should express my gratitude as an Episcopal priest and as Director of Spiritual Care in an Episcopal hospital. You know, when you came as students you were not most of you part of the Episcopal tradition, but you were soon aware it was an Episcopal hospital. I’m sure many of you remember chapel attendance with Chaplain Beachy. Nor perhaps are you members of the Episcopal tradition now. However, you share with the Episcopal tradition a commitment to health and wholeness, and to respecting the dignity of every human being.

You quickly became aware that you shared in that with the Episcopal Church as you trained in an institution started and led by Episcopalians. However, you probably weren’t aware of many ways in which the Episcopal Church shared with you that commitment to ministries of healing. We have long had, for example, a Standing Commission for Health for the Episcopal Church. I have the honor of serving on it.

More important, at least for an Episcopalian, it shapes our worship. Like some other churches, the Episcopal Church remembers in worship those who have been heroes and heroines of the faith. You know, I’m sure, that we remember Saint Luke. Indeed, Saint Luke’s Day and Saint Luke’s Week are just around the corner, when the hospital and the health system celebrate the ministries of chaplains. But, perhaps you didn’t know that Florence Nightingale is also in the Episcopal Calendar. Vincent De Paul is in the Episcopal Calendar. So are the Mayo and the Menninger families. And there are those known less well. There are the Martyrs of Memphis, who died providing care at the bedsides of yellow fever victims in Memphis, Tennessee. There are Damian and Marianne of Molokai, who served to the end patients suffering with leprosy. There is Innocent of Alaska, an Orthodox bishop who served among the Aleut and saved many lives when he convinced them to accept smallpox vaccination. They were not all Episcopal either, but they all shared, and shared with us, a commitment to the health and wholeness of those they served. So, perhaps as a chaplain and Episcopal priest, and as the Director of Spiritual Wellness at Saint Luke’s Hospital I can offer you thanks.

Really, all these perspectives are important. We can express appreciation for the nurses you were as new grads and for the nurses you became in your careers. We can be grateful as patients you served and as colleagues you served with. We can offer our thanks as individuals, and as members with you of that community across years of history and lines of tradition that is committed to service and health and wholeness. The fact is that you are deserving of our thanks and of our appreciation; and I am honored with this opportunity in some small way to express our gratitude. So, for all you have offered and all you have been as nurses, and for the many ways that you have cared for us and honored the hospital and the school where you began: thank you. Thank you very much.