“The most common way people give up their power is by thinking they don’t have any.” ~ Alice Walker.

I was a bedside nurse in the 1980s, a time when the way the government reimbursed hospitals for patient stays was upended completely.  Prior to this time, any patient whose insurance was paid for by the government (mostly Medicare), after they were hospitalized, the bill would be submitted and paid in full.  No questions asked.  This was abused pretty recklessly, and physicians were seen as cash cows, admitting older patients for convenience (family wants to go on vacation? No problem!), or for diagnostic testing.  You would frequently have Medicare patients admitted for four or five days to undergo barium enemas and upper gastro-intestinal studies.  Mind you, this was not necessarily a bad thing, since the prep alone often caused dehydration and/or falls on the way to the bathroom. 

It also meant that, as a nurse, within your patient load you would have some sick patients who actively required your care, along with others who were ‘up and about’, merely needing vital signs and an occasional medication.  Then came the ‘DRGs’,  a system which linked categories of diagnoses and standardized the payments to hospitals.  Studies had gone on for years, identifying reasonable costs and length of stays associated with many diagnoses, adjusting for geography (costs could not be the same for an inner city hospital as a rural one), and allowing for more complex situations.  It was expected that a patient with heart disease and diabetes who needed hip surgery would require more care and a longer recovery than one who was basically healthy.

When the new payment system was implemented (after much training had gone on, and whole new teams of employees were hired to monitor and educate) there was a lot of pain.  Based on the patient’s diagnosis, the hospital stay should not exceed a certain number of days and a fixed dollar amount.  Anything in excess of either would be absorbed by the hospital.  Physicians were opening their patients’ charts to see letters with a countdown of how soon the patient had to be discharged, or by how much they had already exceeded the amount the government would pay. Naturally this also caused a lot of resistance and anger.  I recall one physician saying ‘No one complained when I was bringing this hospital hundreds of thousands of dollars, now they want to tell me how to do my job?’

There was a steep learning curve, and hospital administrations had to find ways to be more cost effective.  No longer were patients admitted the night before surgery to make sure they were prepped properly, and had a good night’s sleep.  The Finance team looked for more and more ways to save money.  The nursing payroll was always a big ticket item.  Nursing care is also the largest aspect of healthcare that is not a reimbursable item.  Respiratory care; physical therapy; occupational therapy etc., all charge for services, so the payroll for those disciplines is balanced by billable items.  Nursing care is included in the room charge.  In other words, the cost to stay in an ICU bed can be three to five times higher than the cost for a stay on a medical-surgical floor.  But there is no line item that says: ‘Nursing care’.  Along with the trimming of the unnecessary admissions came the onset of far sicker patients, with more aggressive nursing care required.  And the need for nurses to be more efficient and accurate, in order to make sure these sick patients got better in a timely manner, without incurring any preventable complications that would challenge the reimbursements. 

When the private and commercial insurances saw what the government was doing with their payment plans, many of them decided to implement a similar process.  At the same time, advancements in technology meant that procedures could be done through minimally invasive incisions, and same day surgery centers opened up all over the country. 

For nurses, the question became how you can deliver care safely while the patient load was increasing, and the acuity of the patients also increased.  For administration the question was how can we save money on the nursing payroll?  When I moved from the bedside into nursing management, we were introduced to a newly hired expert, an Efficiency Engineer.  One of my sons informed me that at his university, they referred to students in those programs as ‘Imaginary Engineers’.  This was a man with wonderful ideas for improving nursing efficiency, but no clinical knowledge, so we paired him with an expert nurse in the hopes that she could match his ideas with reality.

He started by suggesting that we staffed the Emergency Room each day based on the number of ER visits the previous day.  Any ER nurse knows that that can’t work.  When our efficiency expert visited the labor and delivery area and saw three nurses sitting at the nursing station while one woman was in labor, he wanted to send home two of the nurses, and have them wait by the phone (a landline in those days) to be called in if more patients were admitted.  Oh, and they would not be paid while they waited.  He didn’t last long.

The other way that administration tried to make nursing more efficient was by hiring consultants to try to quantify patient care.  This way patients could be ‘weighted’ to indicate how many nursing hours of care they required each shift.  For weeks nurses would be asked to mark on a chart what time they entered a patient’s room, what nursing care they delivered, and what time they left.  Whether they were starting an IV (which may take five minutes or forty-five, depending on the patient), hanging a blood transfusion, or changing a complex dressing, they should indicate start and end time.  Unfortunately, that system only works if the nurses always remember to enter their times, and most nurses are interrupted so many times in a shift, keeping a time log often fell off the list of priorities.

This long walk down memory lane is really an attempt to show how challenging it can be to take complex situations (like the health care of human beings) and render them more efficient, more cost effective.  In the case of the DRGs, it took years of studying data and statistics from across the country to come up with a fair way of categorization and reimbursement.  And even then mistakes were made and adjustments had to be made.  There was waste, there was abuse which needed to be addressed.  But there was a method to the implementation.

In the past six weeks we have been enduring a completely different way to address alleged waste and abuse in the government, at tremendous cost to the citizens of this country.  We have also watched as attempts to rewrite history are taking place before our eyes.  The Navajo Code Talkers were a group of soldiers who evaded Japanese spies by using their language to devise a code to send information about Japanese troops in World War II.  Our government, deeming this information somehow a product of the now apparently illegal Diversity, Equity and Inclusion program wiped out this information, along with information about such heroes as Jackie Robinson, deleting thousands of pages referring to anyone deemed part of DEI.  Thanks to the public outcry, those pages have now been restored.

There are so many egregious things taking place at present, that it is hard to address them all.  Last weekend I enjoyed the company of a diverse group of individuals at a joyous wedding.  As I looked at the multi-ethnic gathering, a melding of cultures and dance moves, I could only think ‘This is US’, this is what the United States can be.  A cross-cultural exchange of positivity; a blending of families and races; a citizenry with a shared and often painful past, that has the potential to see the best in each other, and build each other up. 

This weekend I hope we can see the humanity in each other, and withstand the calls for divisiveness and otherness.  I hope we can also recognize the power that ‘We the People’ have, and can continue calling out the disruption, the cruelty, and the distractions.  It may take a lot more effort than we wish, but we shall overcome.

Have a wonderful weekend, Family!

One Love!

Namaste.