One of my first jobs out of nursing school was in Louisiana in a busy pediatric Emergency Room. We had very few resources and were very busy. For our whole 36-bed unit, we had two monitors and they were at least 42 inches square. They were so old, they did not print rhythm strips. One day I was standing at the bedside of a congenital heart patient and noticed two things: the patient was having PVC’s and periodic oxygen desaturation down to 50%. The monitor never alarmed. There was also no central monitoring station, so if you put a patient on the monitor you had to watch it all the time at the bedside to see what was going on.

We started realizing that they never alarmed. Given how short-staffed we were standing at the bedside watching heart rates and oxygen saturation levels on patients that were not so ill they needed constant care was not feasible. This, along with several other perceived patient safety issues prompted me to organize the nurses. We wrote a letter outlining our concerns for patient safety and requesting a meeting with hospital administrators to present possible solutions. All the nurses signed it, doctors also looked at it and voiced their support. We sent it to the top nursing administrator and copied the CEO, all the Vice presidents, and the president of the Board of Trustees.

Now this was New Orleans, and if you are not familiar with the “laissez le bon temps roulez” culture let me just say that in general, New Orleans is not known for being a culture of progressive change or process improvement. Needless to say, the nurses worked to create ideas for how to improve problems with staffing, suggested purchasing monitors and a central monitoring system, and looking at procedures for triage. We presented to the nursing administration and waited.

Shortly after the presentation, they tried to discipline me for poor clinical judgement for something that was completely bogus. Knowing they didn’t have a leg to stand on given my level of documentation, I asked them to put their concerns in writing so that I could respond appropriately, rather than calling me into meeting where they threatened and questioned my judgment. Needless to say, my documentation saved me and they never substantiated their claims or put anything in writing.

I felt that they were punishing me for organizing the staff, spearheading the letter and the presentation. I was so discouraged since I had tried so hard to make sure everything we did focused on illuminating the problem while providing positive suggestions for nurse-led improvement efforts. The intention of our work had always been about patient safety and I could not understand why they rejected me.

On the up side, 12 new monitors were purchased and the unit was wired for a central monitoring telemetry station. It took 8 months for that to be installed, and in that time, I was so depressed and discouraged that I left New Orleans (about 4 months before Hurricane Katrina).

5 years after those efforts, I ran into a nurse in Georgia from that pediatric E.D. in New Orleans. We talked about the hospital where we work now and how there are so many resources compared to where we worked previously. Where we work now seems posh and luxurious with great staffing ratios, all the best equipment, social work support, child life, etc. I told her that I had been so discouraged by how the treated me there after we did the presentation, but now that I had been away I felt as though we had done much good for the patients we served even without any resources.

She understood and said, “If you hadn’t done that, we never would have gotten any of that equipment, and we’d still be working with two monitors. They would still have nothing, at least we got what we got.” All these years, I felt like I had failed to make a difference there. Now, through her eyes I saw that I had made a difference. I may have paid a price for my actions, but I feel now that a purpose was served and change happened even though it took five years for me to see the result.

I was surprised when I returned to graduate school in nursing after 6 years at the bedside to find that my classmates were often fresh out of undergraduate nursing school with no work experience. Aside from feeling like an old lady, I wondered how they would define the nurse practitioner role without having worked as Registered Nurses. In addition, I felt that my experience shaped my desire to work as a nurse practitioner and gave me a strong background in basic assessment and treatment.

The biggest thing that I learned working as a nurse was just how much I didn’t know. And that was a good thing, because I learned that I needed to ask a lot of questions. I also learned that being aware of the limits of your knowledge made you a great nurse. Sometimes I drive my coworkers crazy with all my questions about why would you order that medication and not this other one. But the truth is that there is so much that is not taught in school. Even if you work your whole life at the bedside, you will still not know everything. That is why you have to be able to think critically and ask questions to be an excellent nurse. It is not always what you know that makes you excellent, it is asking about the things you do not know.

Bedside nursing is hard work and many people who choose nursing as a career do not want to do bedside nursing. I understand that, but sometimes my fellow students seem to think they know everything they need to know. Sometimes a lack of respect for experience comes across. I think it is unintentional, but it sure ruffles my feathers. This is what was innocently said to me one day: “I think it will be harder for you to be a nurse practitioner because you will not be able to break out of your RN mindset. Since I never worked as an RN, I will not have that problem and will adapt better to the Nurse Practitioner role.”

We had some nurse executives speak to our class about leadership, ethics, and other current issues in nursing. One student expressed frustration that no one wanted to hire her as an advanced practice nurse because she did not have any nursing experience. She wanted to know why so many employers wanted experience when she felt her education gave her all the qualifications necessary to do the job. The nurse leaders responded by saying they understood her frustration, but that in advanced nursing roles one needs credibility and that credibility comes from experience.

The ripple of ghastly exclamations practically reverberated through the class. I think there should be opportunities for people who go straight through undergraduate to graduate programs. On the other hand, my experience working also indicates that nurses are very aware of nurse practitioner experience levels. Many nurses say that they can see a big difference between the skills of nurse practitioners who have worked at the bedside and those who have not. I’ve heard nurses who feel that experience at the bedside makes nurse practitioners better also say that it doesn’t take many years of experience to make the difference. One or two years working as a nurse is usually enough for them to see increased competency in nurse practitioners. Whether all nurses agree with that in an idealistic sense, that reality exists. Credibility from experience matters. Even if you choose not to get experience before obtaining an advanced degree, I would encourage you to think about the importance of respecting experience. Recognizing that nurses with experience might know and understand things that you do not will go a long way towards those nurses wanting to work with you.

Which Comes First, Health Care Cost Containment or Access:

Comparing the Health Plan Policies of John McCain and Barack Obama

Either John McCain or Barack Obama will become the next president of the United States in January 2009. According to a recent poll by the Kaiser Family Foundation, “one in four Americans cite paying for health care as a serious problem.” (Kaiser Family Foundation, 2008) Beyond the challenges of American individuals struggling to manage rising health care costs, insurance companies, hospitals, and employers continue to adapt their policies to attempt to decrease the economic burdens of health care. As these stakeholders have responded to rising costs by attempting to shift the cost burden to other stakeholders, the burden that is shifted back on the individual has contributed to increases in the number of uninsured Americans. The recent economic downturn and associated rise in the unemployment rate is associated with an increase in the number of uninsured individuals by a factor of 1.1 million new uninsured for every 1% rise in the unemployment rate. (Kaiser Family Foundation, 2008) The presidential candidates have both articulated health care plans and policies that address health care reform in terms of cost, quality, and access to varying degrees.

Barack Obama and John McCain’s foundational philosophies about health care reform are vastly different. Where Barack Obama aims to reform health care and create affordable, quality health insurance accessible to all Americans, John McCain’s approach is to reform health care by focusing on cost containment measures that will be market driven. While Obama does not articulate his plan as a plan for universal health care, the idea that health care is a human right appears to be the foundation of his plan. Obama’s rhetoric focuses on increasing access through increasing the role of the government in providing insurance along with investments in research, technology, and public health. McCain articulates a philosophy of change that emphasizes shifting control of the system to the individual consumer. In McCain’s health care reform paradigm, shifting control and cost burden to the individual consumer will optimize cost containment. According to McCain’s plan, the notion of moral hazard in our current health care system, where the consumer is shielded from the cost and therefore has no incentive to be cautious in their utilization of services, is a contributor to rising healthcare costs. In comparing the underlying principles without reference to the specifics, one must evaluate whether reform of health care is best accomplished by increasing access or containing costs first. Where Obama’s plan lacks clarity on cost containment, McCain’s plan does not significantly address the issue of access. In terms of the many details of their plans for increasing quality, the candidates are in agreement.

Access

The road to increasing access to insurance for all people is clearly defined in Barack Obama’s plan. Obama’s plan will create a national health plan that people who do not have access to insurance through their employer, cannot afford private insurance, or have not been eligible for coverage can purchase. Obama’s outline indicates that all premiums, co-pays, and deductibles will be “affordable.” According to the outline, those individuals who do not qualify for Medicaid or SCHIP but cannot afford the premiums of the national plan will be eligible for subsidies to offset individual costs. Other aspects of Obama’s plan that are designed to increase access include expansion of eligibility for Medicaid and SCHIP, mandatory coverage for children, creation of the National Health Insurance Exchange as a means of regulating the private insurance market, and inclusion of portability as a component of the national health plan.

While Obama’s plan does not mandate coverage for adults, it does appear that more Americans would have access to insurance through the creation of the national health insurance plan. One area that seems unclear is how well the subsidies would offset costs for families that would qualify. Obama does not dismantle the private insurance system, but would require employers to either provide insurance or contribute towards the costs of the national health insurance plan. The integration of public and private insurance under Obama’s plan makes it appealing, and less likely to evoke strong resistance on the part of big business than a true universal health care plan. In terms of access, Obama’s plan appears to be a true reform, but the implications of this plan for cost control in health care are problematic.

McCain contrasts sharply with Obama over the issue of increasing access to healthcare for Americans, though he has never articulated commitment to universal health care. McCain’s plan does state that they will make insurance more available to individual Americans by lowering costs and increasing portability. According to his outline, he will use tax credits to make insurance more affordable. He will eliminate the employer tax exemption on health care and provide families with direct tax credits they can use to pay for insurance. The idea here is that families will search for the lowest cost plans and this will drive competition in the industry. Employer-based plans are still an option, though. Bob Lazewski has analyzed McCain’s plan and notes, “With the average cost of employer-provided family health insurance at $12,000 a year, a $5,000 tax credit will often come up way short—especially for higher age people and those who don’t have the benefit of an employer contribution.” (Lazewski, 2008) In addition, if an employer pays a portion of the costs, families would now pay taxes on that benefit. In this sense, McCain’s tenet is that he will make health insurance more affordable, which will give more people access. The challenge here is that it is not clear who will benefit from this plan. It depends on how much one earns and the ability to find coverage. (Kaiser Family Foundation, 2008) In addition, there is no requirement of coverage. The McCain plan also emphasizes the use of Heath Savings Accounts, national plans that are portable, and a Guaranteed Access Plan for people who are otherwise ineligible for insurance. The mechanism of the GAP is not well-defined.

McCain’s plan may make health insurance more affordable for some, but the shift from the employer-based system to an individual purchaser system will undoubtedly be a bumpy road. The plan does not address how the uninsured poor will have more access to insurance, especially since the degree to which the costs will be driven down is unknown.

Cost

McCain’s plan is rooted in cost containment. In this sense, his plan does not require significant new expenditures that need to be funded by tax increases. His tax credit will essentially be funded by ending the tax exemption on health insurance benefits. Looking at how his plan impacts stakeholders, it appears as though his plan to drive down costs through competition would decrease costs for some stakeholders to some extent. By placing the burden on individuals, there would be some relief of cost burden for employers who may stop providing insurance and subsidize their employees’ individual purchases. At the same time, McCain’s plan does not articulate a clear mechanism to deal with the impact of the uninsured on hospitals and providers, who then pass the cost of providing care of the uninsured to private insurers. Unless there is flow of new capital into the system by way of more purchasers of insurance or some other means, the cost burden on the private insurers may increase, and then increase costs to individuals whose salaries do not rise at an equal rate. McCain does articulate other cost containment strategies such as: lowering drug prices through reimportation and increased generic availability, emphasizing preventive care and disease management strategies, greater use of information technology as a cost-saving measure, increased use of walk-in clinics in retail outlets, tort reform, and Medicaid and Medicare payment reform. In terms of cost containment, McCain’s plan does have a cost benefit in so far as the implementation of the plan will not produce significant new government expenditure; however, it does not clearly articulate who will have lower heath care costs and to what extent the costs will be lower. The extent to which low-income uninsured will benefit from tax credits depends on several specific details about tax credits that are not stated in McCain’s Plan. (Kaiser Network, 2001) McCain’s plan also does not demonstrate that the cost containment strategies he will implement will be equal or greater to the cost burden of 47 million uninsured on the system.

With respect to cost, Obama’s plan requires extensive government spending to be implemented, estimated at 50 to 65 billion dollars per year according to his campaign website. This cost will be passed on to individuals through the repealing of Bush’s tax cuts. In all fairness, those tax cuts have been noted to primarily benefit the wealthiest Americans. Essentially his plan will infuse cash into the system that will cover many uninsured and increase the number of insured. On the other hand, his other cost containment strategies are not well-defined and are similar to the McCain plan. Obama’s plan also emphasizes cost control through use of information technology and lower drug costs, though he does briefly discuss regulation of unjustified price increases by big business. Ultimately, if the cost of health care itself cannot be reduced through decreased utilization of the system and reduction of administrative costs, covering the uninsured will not be feasible in the long run with tax increases. The bottom line is that Obama’s plan will cover the uninsured which will help reduce the cost burden on hospitals, providers, private insurance companies, and the privately insured, but does not provide well-articulated strategies for controlling costs within the system.

Quality

There are few significant differences between Obama and McCain’s ideas about improving the quality of health care aside from the implications of access or as quality indicators. Both support initiative for preventive care, public health, research, increased use of information technology, and federally supported outcome measurement initiatives. Obama provides more specific examples of the types of quality initiatives he supports, but they are really not espousing vastly different quality improvement strategies other than the ways they relate reform of access and cost issues to issues of quality in health care.

Nurse Practitioners and the McCain and Obama Plans

McCain is the only candidate that gives some reference to utilization of nurse practitioners as a mechanism of improving access and quality when he discusses the use of walk-in and retail clinics, though he does not explicitly state that nurse practitioners constitute a component of the approach. The physician lobby is fairly powerful and both candidates are most likely aware that if they want support of their plans, they will need the blessing of the physician lobby. Even though increased use of nurse practitioners as providers has the potential to decrease costs for Medicare, Medicaid, and the insurance companies, McCain and Obama are not likely to state this in their plans.

Obama’s plan has potential to impact Nurse Practitioners favorably by virtue of increasing the flow of revenue into the system in the form of more insured patients. If nurse practitioners can position themselves as lower cost yet effective providers, they have the opportunity to create jobs for more nurse practitioners and have more money flowing into their pockets. Many nurse practitioners feel that the health of the population is adversely affected by the number of uninsured individuals.

Conclusion

While the lack of cost containment policies in Barack Obama’s plan is a concern, the expanded access that it will provide to uninsured Americans makes it a better plan than John McCain’s plan. I do not think the shift towards a consumer driven insurance market is going to aid the uninsured or be a real cost containment measure unless the shift is coupled to heavy regulation of the insurance industry. Given John McCain’s principles, it is unlikely that he would support increased regulation. Even though Obama’s plan is more costly, I support the repeal of the Bush tax cuts to pay for it and also believe that decreasing the numbers of uninsured will serve as a cost containment measure. Once access is expended, efforts to contain costs can be more focused and refined with the removal of the financial cost of caring for the uninsured. Without expanding access, I do not believe costs will be contained. While expanding access has a cost, it is a cost that also serves the health of the population, which is important. I also happen to support the idea that health care is a human right. Given the current state of the economy, I fear that McCain’s plan will only increase the numbers of uninsured as individuals struggling to make ends meet will be forced to use any tax credits to offset other necessary costs. If that were to happen, the cost burden could continue to be shifted back on the insured anyway. In do not believe the net cost effect on the average insured American differs that greatly between the two candidate health plans. While we may pay in the form of taxes for Obama’s plan, I believe McCain’s plan will probably cost us some employer-provided benefits that will not be made up by increased wages as well us cause increases in hospital costs to cover the uninsured. By failing to address the access issue for uninsured Americans, I believe hospitals and private insurance companies will continue to deflect the cost of care to the uninsured onto the privately insured. The costs associated with either plan are essentially equal in that I believe any health reform will cost me. But my belief that health care is a human right leads me to support Obama’s plan.

References

1. Bodenheimer, T. S. & Grumbach. (2005). Understanding health policy: A clinical approach. Stanford, CT: Appleton& Lange.

2. Kaiser Family Foundation (2008) New Analysis Shows Effect of Rising Unemployment on Health Coverage, Medicaid and SCHIP Spending and Enrollment. Retrieved on 7/13/08 from http://www.kff.org/medicaid/kcmu042808pkg.cfm

3. Kaiser Family Foundation (2008) Tax Subsidies for Health Insurance: An Issue Brief. Retrieved on 7/16/08 from http://www.kff.org/insurance/upload/7779.pdf

4. Kaiser Network. (2001) Presentation Transcript from 4/6/2001: A Briefing on Extending Health Coverage- Tax Credits, Public Program Expansion and Combination Approaches. Retrieved on 7/17/08 from http://www.kaisernetwork.org/health_cast/uploaded_files/kff040601.pdf

5. Lazewski, Bob. (2008) A Detailed Analysis of Senator John McCains’s Health Care Reform Plan. Retrived on 7/12/08 from http://healthpolicyandmarket.blogspot.com/search/label/McCain%20Health%20Plan%20Analysis

6. McCain, John. (2008) Straight talk on health Care System Reform. Retrieved on 7/10/08 from http://www.johnmccain.com/Informing/Issues/19BA2F1C-C03F-4AC2-8CD5-5CF2EDB527CF.htm

7. Obama, Barack. (2008) Plan for a healthy America. Retrieved on 7/10/08 from http://www.barackobama.com/issues/healthcare/

This essay originally written for my advanced practice nursing class on Health Policy and Finance July 23, 2008 at Emory University.

I’m worried about what will happen when one aspect pay for performance in Medicare and Medicaid is implemented this fall. The need for effective cost containment strategies in health care is evident. Neither hospitals, providers, consumers or public and private insurers can afford to continue shifting costs around the system in a financial game of Russian roulette. The government as a public payor via Medicare and Medicaid plans to cut costs by stopping payment to hospitals and providers for treating conditions deemed “reasonably preventable.” Sounds like a good idea, right?

When you read the fine print and then look at it in context with the state of our health care system today, this is another health care cost containment measure that will not really contain costs and will potentially result in hospitals losing money to the extent that they will close. My primary concern is that the hospitals that will not be able to meet these standards are those operating in areas with limited resources, such as those in medically underserved areas.

The six conditions included in the list of reasonably preventable conditions are:

1. Pressure ulcers

2. Catheter-associated urinary tract infections.

3. Staphylococcus Aureus septicemia (really hospital acquired venous access infections)

4. Air embolism

5. Blood incompatibility

6. Object left in patient after surgery

I think that some of these are no brainers. If you have a hospital whose surgical staff has problem leaving objects in patients, they need a serious wake-up call. Likewise, if the hospital continual gives patients the wrong blood type, theses are safety standards that MUST be met at a minimal level and no one but the hospital should pay the bill resulting from that error.

On the other hand, probably more morbidity is associated with catheter associated urinary infections, pressure ulcers, and line infections, but they are harder to prevent. It is also hard to prove causality for these events. Any patient with an indwelling catheter is at high risk for getting an infection, even if the staff does everything within their power to prevent infection. Hospitals will test patients for the presence of these conditions on admission and if any of these conditions are present on admission Medicare and Medicaid will pay for the treatment. If a patient did not have a UTI on admit and gets one during the course of treatment, Medicare and Medicaid would not pay.

This concept is great from the standpoint of the need for quality improvement in care to reduce risks for these conditions. There is not greater incentive for the hospital to get busy with their staff to reduce these theoretically preventable conditions than hitting them with a financial consequence. At the same time the a nursing shortage and a primary care physician shortage make it very difficult for hospitals to reach levels of quality that depend on their staff being able to do everything they should do to provide the best quality care.

Pressure ulcers are preventable when nurses and auxillary staff turn at-risk patients every two hours and ensure that nutritional intake is optimized. When I work as a bedside nurse I am obsessed with turning my patient every two hours to prevent pressure ulcers. But I’d be lying if I said there were not times when staffing was so low or other types of care had to be prioritized first that I was not able to do this on every patient every two hours. Is that my fault? Yes and no. If I have 6 patients to care for that all require a high level of care and the auxillary staff called in, I am forced to prioritize care and do the things that are most important first. Now working under those conditions and not being physically able to do everything I want to do for my patients feels horrible. But what other choice do i have? If I have four patients and have support from other nurses with similar patient loads and support staff, I can provide the best care. I feel great when that happens. The reality is that there is a nursing shortage. Nurses will tell you over and over again that they are so short-staffed that they cannot do everything they need to do. Nurses in this situation will also tell you that they ask for help from their administrations constantly. Some hospitals deal with the shortage better than others, but in some geographic areas there is no relief. Will those hospitals be able to meet the quality standards at the same level as other hospitals? Is a hospital in New Orleans suffering from a severe loss of staff and an increase in patients after Katrina be able to make quality improvement at a high enough rate to prevent loss of revenue from treating these catheter-associated infections without reimbursement?

If they cannot, and they have to close, how will that serve the New Orleans community? If you think about the types of hospitals that will have more trouble with this mandate it is important to realize that hospitals with lower quality are often hospitals that serve in areas of high need with few economic resources.

I know that there are many errors that are unacceptable, including some on this list. There are some errors on this list that are less black and white. Preventing those errors falls heavily on the nursing staff that is already overtaxed with responsibility. In areas faced with high shortages and other barriers to making the desired improvements, these mandates will potentially have a large financial impact. I have great concern about the who and where of this financial impact as an indicator of vast disparities in health care along socio-economic lines.

Sometimes when I am caught up in the political arena at work or frustrated about something we need to do, something happens that takes me right back to why I am here in this job. That something is often in the form of a 5 year-old boy, who I think is a very old soul.

He has blond wispy hair now that stands on end and brown eyes. When I first met him, he had no hair because he was in the middle of chemotherapy to treat relapsed Acute Lymphocytic Leukemia . This child has a way of setting me right when I least expect it.

One day I was taking care of him and he was having negative side effects from the treatment I was giving him. I was very concerned and was in and out of his room checking on him, calling the physician, and apparently fluttering around him. His blood pressure was running low and his heart rate was elevated. He was not febrile, but he was shivering. As I was taking his blood pressure for the 8th time, he looked at me intently and gently said, “I’m O.K. I promise. You worry too much.”

I was never sure that he was really just referring to my concern over his reaction to his treatment. His statement seemed more of a global assessment of my personality as opposed to his reaction to my vigilance in that instance. Needless to say, he received the rest of his treatment and was fine.

A few months later I returned to work from maternity leave and I was having some challenges getting back into the swing of things. My buddy came in asking for some numbing cream to put over the spot where his port-a-cath would be accessed. Many of the kids have rituals and preferences when it comes to exactly how we do these things, and the nurses have to keep mental track of who likes which dressing. I remembered that he liked a special dressing over his numbing cream because he feels it is easier to get off. I pulled out the dressing and as I was putting it on, I suggested that we fold the corners of the dressing down so he would have less sticky stuff to take off. He looked at me with a big grin and sighed, “You’re awesome.” He was not trying to be overly cute or sweet, but was simply very grateful for this small gesture that made him a little more comfortable. That reminded me why I wanted to be there.

One of my most treasured possessions is a sign this little guy gave me that says, “I heart you, you are kqut. Love, P.” The day he made that for me, we had visited the treasure box and he had carefully chosen a bracelet with some clip-on earrings which he immediately wore. A little later in the day, he was still wearing his jewels, as he called them, only he had further accessorized with an orange feather boa. He reminded me that you just have to be yourself, without pretense, as much as possible.

The thing about this kid is that every single person in the clinic where I work has a story or two about how this child really made them stop and think for a moment.

While we are trying to fix him, he manages to fix us all somehow.

Have you ever heard the saying by Ghandi, “Be the change you want to see in the world”? If we apply this idea to the need for change in our country’s healthcare system as it relates to how people who work in the healthcare industry are insured, we have an interesting set of issues that are readily visible. Many healthcare institutions bemoan the effects of uninsured or under insured patients that flow through their doors because of the money they lose. There is an opportunity for these institutions to examine the effect of their insurance plans on their employees to understand how their policies may contribute to the numbers of uninsured, under insured, and insured but still in debt.

The following examples are food for thought.

When I worked for a nonprofit children’s hospital in New Orleans, our health insurance covered no well visits. Most children only see their pediatricians for well visits which include immunizations. These visits were not covered by insurance. Can you believe that a hospital whose mission is to serve the health needs of children did not provide a health insurance policy to its employees that covered well visits? Imagine how the employees who worked there and did not earn a living wage fared with this insurance policy. For immunizations, employees were encouraged to visit a free immunization bus that traveled around the city. While this would allow everyone to have their children immunized, it did not provide for well visits with a pediatrician to screen children and provide anticipatory guidance to parents.

Many businesses are now encouraging their employees to open Health Savings Accounts for their health insurance. I understand the idea behind such accounts, but I think they are a potential disaster for people with lower incomes. I am concerned about how employers are encouraging people to enroll in these plans as if they are less expensive for everyone. The system is complicated enough that we all need to carefully weigh the costs and benefits associated with various plans, the propaganda about these plans is misleading, in my opinion. If I were to change to this type of plan, I would not have sufficient cash to start the account such that if I had a catastrophic illness before I had put several thousand dollars in the account, I would have a serious financial problem.

Similar problems can occur with PPO plans. These were also touted as better than HMO plans because they have lower premiums and you have more choices. You also have a much higher deductible. I had this type of plan at one time. When I needed a minor surgical procedure, I ended up paying about $800 between my deductible and some other fees not covered by the plan. It was very difficult for me to pay this much cash, even though I have a very good income. Imagine what happens to people who make less than I do.

I do not believe that it is fair for the housekeepers upon whom we depend to keep our facilities clean pay the same premiums for healthcare that we do when those premiums will constitute a significantly higher proportion of their incomes. If I made minimum wage, I do not believe that I would enroll in the health insurance plan my employer provides because it would be financially implausible for me to have health insurance and pay my bills. This phenomenon has been noticed by forward thinking living wage advocates who have advocated for a living wage ordinance in Los Angeles. This is a description of the rationale for their efforts to include health insurance premiums in their living wage calculations.

If we want more Americans to have the befit of health insurance, we may look to the practices of our own employers and start the dialogue about how we are insured. Contact your Human Resources Department and ask them to investigate how many of their employees are uninsured and why. Also ask them to investigate what proportion of their employees require public assistance to be insured. Remind them if we want to change the flood of uninsured that come into our facilities, we need to look at how their own practices contribute to the numbers of uninsured in their area. I would advocate researching the costs and benefits of instituting a sliding scale of insurance premiums for employees that would set the cost of the premium at a proportion of your income.

In the meantime I devoutly enroll in my HMO plan during benefits renewal every year, until my employer or the insurance company decides that it costs them too much money. I may need a referral or a PCP, but I choose not to pay 10% of my hospital bill.

If you haven’t seen this movie by Michael Moore yet, I highly recommend it. This movie does an excellent job of showing the state of healthcare today in human terms. I mentioned that I had watched the movie to some fellow nurses. Many people commented that “socialized” medicine had terrible consequences. I found these comments interesting given the terrible cost of capitalist medicine in this country for the average insured person. As a nurse, patients often express their anxiety about getting their bill or comment that their insurance company has denied their claim. We are all aware that some of the people we care for will simply not be able to pay their bill. I think we sometimes forget that these are not people who are among the uninsured. There are many people WITH insurance who will be financially destroyed because of their medical bills. These are the people Michael Moore chronicles in this film.

Another striking point of the film is that the American people have been fed a steady stream of propaganda about the terrible state of healthcare in countries with universal health care. As I watched this sequence I had the sinking feeling that our politicians are not representing their constituents (the people), rather the constituents they represent are those corporations able to write checks large enough to fund their reelection campaigns. My $50 or $500 dollar contribution to the campaign of a politician I support pales in comparison the $500, 000 check someone with deep pockets can contribute. Do we honestly think that we will be equally represented by that politician?

We have to confront the reality that our system is designed for businesses (read: insurance companies) to make a profit. It is in the best interests of these businesses to spend as little on us as possible. Healthcare in other countries that provide coverage to everyone probably is not perfect, but the system is not set up so that a business will profit from your illness by denying your claim. I cannot tell you how many times I have had an insurance company refuse to authorize the treatment prescribed by one of the physicians I work with.

The process goes something life this: 1) Dr. X writes a prescription to treat Johnny’s chronic illness. 2) The insurance company denies the claim when Johnny tries to pick up the medication. 3) Johnny calls the physician’s office to tell them what happened. 4) The nurse calls the insurance company to find out why the medication is not covered. 5) The insurance company has some reasons that makes no sense, medically. 6) the physician submits a letter of medical necessity. 7) the insurance company still denies it. The physician or nurse talks to a physician for the insurance company to explain why the treatment is necessary. 9) Hopefully, it gets approved eventually.

This process takes days or weeks. Think Johnny’s health is improving in this time period? See how that your insurance company has a lot to do with how your physician determines your treatment plan?

We have to change our healthcare system. We have to find a way to make it impossible for anyone in this industry to make money off keeping people from getting well in the best way possible. Look at the healthcare plans the current presidential candidates are proposing and ask yourself if these plans take the profit for private corporations out of the equation.

Nurses have a responsibility to participate in advocating for this change along with other medical providers. We are on the front lines of healthcare and have the ability to convey the impact of the current system on the health of our patients. We can tell these stories, write letters to our representatives, think when we vote, and be sure to tell our friends and families what we know. See Sicko and start talking about what you know.

Most nurses are female. Given that women have babies it is reasonable to think that many nurses will have a baby or two at some point in their career. It would seem to make sense that the Nursing profession would be very supportive of women and the challenges of being a working mother, right?

Before I had my baby, I always supported the mothers I worked with by covering their patients while they pumped if they were breastfeeding or by letting them leave if they had a sick child or some other childcare issue. Since I had my first child, I have been supported by my colleagues in turn, but realized just how systematically unfriendly the nursing profession can be to working mothers.

When it came to pumping breastmilk while at work, I found that we were often so short staffed that pumping had to be delayed to the point that my milk supply and ability to provide milk for my baby was compromised. As supportive as my colleagues were, they had to assume care of lll my patients for 15 minutes every three hours so I could do this.

Furthermore, there was no physical place for me to pump. I had to search for an empty hospital room, occupy the bathroom, or hope some administrator with an office was not at work that day. When I did pump in a patient room, I prayed no one would ignore the sign on the door and come in.

When it came to juggling childcare, as a part-time employee it was not practical or economically feasible for me to have full time day care, as a result I needed a basically set schedule in order to be able to work and have child care. My manager told me that I needed to have complete availability and she was not able to accommodate my child care schedule. In the preceding 6 months I was one of the highest rated nurses in the department by this same manager. In addition, several working mother had vacated their positions because their child care needs limited their availability on certain days of the week. This was very difficult for all of us because we all loved our jobs and had been as flexible as humanly possible. At the same time, we were replaced by younger models with no children and a lot less experience.

I understand how difficult making a schedule can be when people have limitations, but the nursing shortage will only worsen if attempts to work with the needs of working parents are not included in our strategy for retaining nurses. I had even found a nurse who would job share with me so we could each work set days of the week, but that was not enough for the administrators. I attempted to have complete availability for a while, but I was spending so much time trying to juggle my schedule and have make sure I had childcare. In addition, my manager would release the schedule about a week before it started and coordinating child care at the last minute is near impossible. So I gave up my part-time job in favor of part-time PNP school and working PRN. I have a set schedule and child care but miss my job and they have a job vacancy it will take them months to fill.

On September 17th, 2007 I became a mother. After working as a pediatric nurse for almost 6 years, I had “educated” so many people in the pediatric ER about basic baby care from how to suction a stuffy nose to what to do when fever occurs. I remember being shocked at how little people seemed to know about basic infant care.

Then motherhood happened to me. I forgot everything I had been teaching others and became an insecure, frightened parent when it came to my own child. During those first weeks home I called my pediatrician because my baby had not pooped for 24 hours. If I had triaged that phone call from myself, I knew what I would have said: not something to worry about as long as baby is eating well and having at least 6-8 wet diapers a day. But the new mom in me was terrified that something was wrong. The terrified mommy wins over the rational nurse every time. I remember going to my pediatrician when Molly was 1 month old and asking her not to tell anyone that I was a pediatric nurse.

In my defense I have been doing pediatric hematology oncology for the last three years so even my knowledge of well baby stuff was rusty. But still. I was disgusted with myself and embarrassed at my complete loss of composure over taking care of my own child.

The addition of mommy doubt and anxiety to my life and my new identity as a parent gave me a new understanding of what parents of sick or well children might need from their health care providers.

Parents need to know that we are listening to their concerns first, diagnosing and treating with those anxieties and fears in mind. How often do jaded health care providers dismiss the seemingly overanxious parent and tell them not to worry about something without having actively listened first and then provided basic education. My own experience with this occurred when Molly was 3 months old. She seemed to be sleeping much more than normal. The new mommy in me called my pediatrician and they told me to bring her in. So I did, even though the rational nurse in me knew Molly was OK, anxious mommy alter ego was in the car 5 minutes later. Once there, Molly was fine of course, but I didn’t feel that I had the chance to explain why I was worried. My pediatrician saw the nontoxic looking 3 month old in front of him and we were out the door in 5 minutes. I did not get what I needed because I still did not fully understand why she was acting so differently.

Healthcare providers do not spend enough time providing developmental guidance and assistance with basic childrearing issues. Most pediatric well visits are brief and do not afford parents the chance to really check in with how parenting is going. Most patients will initially say that everything is going well the first time they are asked. But parents need us to provide more support, especially since people are more isolated from each other but are able to Google almost any health topic and educate themselves. There is a great deal of information out there in the internet, but one must be discerning about information. Pediatric healthcare providers have the opportunity to help parents sort through this information.

I have read many books written by medical professionals about pediatric care, but I find the Touchpoints approach by T. Berry Brazelton to be a very holistic and comprehensive approach to how pediatric care providers interact with their patients. http://www.touchpoints.org/

Through my own experiences as a new mother, my ability to serve my patients as a Pediatric Nurse Practitioner has grown significantly. I have a much better understanding of parents. I understood a great deal about the textbook topics of pediatric nursing care, but had never lived the reality of caring for a little human being 24/7.

On the flip side I have to be Molly’s mom first and foremost and let the nurse go take a nap when it comes to my own child. That tired nurse gets some sleep for a change.

When I first went to Nursing School 6 years ago, I remember meeting so many idealistic nurses to be with dreams of taking their education and going to work overseas to make a difference in countries less fortunate than our own. Their experiences as Peace Corp Volunteers and NGO employees sounded so noble and exotic to me and I felt somehow inferior for having chosen to become a nurse without consideration for how my knowledge could benefit those living in areas without access to care at a fundamental level.

We undoubtedly have an incredible wealth of resources within our health care system from beautiful hospitals and clinics with multi million dollar architectural features to state of the art medical equipment, computer services, and highly educated medical personnel compared to health care systems in other countries. For example, it is unheard of in this country for a medical facility to have such a shortage of supplies that medical personnel would have no gloves available to wear when handling blood and body fluids or have to wash out the same pair of gloves repeatedly in between patients. When one considers how vastly privileged we are in this country, it is hard not to feel alternatively grateful for our own fortune and disgusted that we have so much when others have so little.

After 5 years of working as a Registered Nurse in pediatric and adult emergency rooms in New Orleans as well as in Pediatric Hematology Oncology at a nationally ranked pediatric hospital, I have come to understand how social, economic and cultural factors interact with one another in our health care environments that illustrate vast inequalities among patients within our own systems of health care.

The divide between the experience of the wealthy and the poor in this country is well documented. If you asked any medical professional if they treat all their patients the same regardless of their race, class, gender, or cultural background most would answer with conviction that they provide the same care to everyone. As individuals caring for patients, I know how deeply we believe that we treat patient equally. At the same time, if we acknowledge and examine all the ways in which the health care system is designed from corporate insurance policies to how our implementation of particular policies in hospitals and clinics may exclude patients who speak languages other than English, we would be forced to admit how our systems are defined to produce and affirm inequality that is defined by differences in race, class, and cultural background.
Too often we understand the concept equality to mean that everyone is treated exactly the same. This construct itself is what produces and supports inquality. Treating people the same way for the same conditions adheres to this notion of equality but in essence illustrates a failure to understand and address how differences in socio-economic and socio-cultural identities change the way people interface with social institutions such as health care. Imagine a pediatrician who sees two children on the same day in the same office, each wih a complaint of fever. Upon examination, the provider finds that both children have bilateral ear infections. Amoxil is prescribed. Two weeks later, one family returns with the same complaint and the provider examines the chil to find that his ear infections have not improved. The provider is concerned. It would seem that the second family spoke Spanish. The provider used an interpreter to explain the prescription the first time and cannot understand why they did not treat their child as he instructed. As it turns out, this family spoke only a little Spanish, they first language is a tribal Guatemalan dialect. In addition, they could not afford the prescription because they do not have insurance and are not eligible for Medicaid because they are in this country illegally. They did not tell the provider because they feared deportation. Finally, neither parent in this family completed education beyond 6th grade level in their home country.

Of course many providers address these issues successfully on a daily basis, however, there are numerous examples of how our awareness of these issues is not heightened until our attempt to treat patients the same fails. This is a process of trial and error in many provider experiences. If a situation is urgent enough or for cases of complicated management of chronic conditions, however, we may not have the luxury of trial and error. Also the difference economically for a family with access to insurance and without is crucial. Most providers have few options to provide the same treatment to families living below the poverty line who must bear the financial burden of treatment themselves. In effect, the differences between how these families and their upper middle class counterparts with insurance and large disposable incomes access medical care and treatment are astounding. Our health care system is designed to provide them the same treatment in theory, but not in practice.

In my own practice as a nurse, I have come to understand that even my best efforts to provide all children with the same care is severely limited within the health care system at times due in part to my own lac of understanding of the social, cultural or economic realities of my patients. I do believe that our resources are vast enough to decrease many inequalities, though complete elimination of inequality is perhaps unrealistic.

I propose that medical professionals must first define the scope of the problem through research. Let us begin to expand our studies of disease outcomes to include data about insurance status, primary language, family income, and cultural background.

Once such data is collected, we can begin to design interventions that will address the specific needs of families with different backgrounds. No doubt the need for health care policy change will be a highlight of such efforts, but we must also focus our interventions to find the most effective ways to treat, teach, and monitor families on the most basic level of how each provider interacts with each patient. We may find that shifting our thought processes away from notions of equal treatment and towards different treatments for different basic human needs is a philosophical shift that produces profound results.