Open letter to Charles Babington...

This is an open letter to Charles Babington, writer for the Associated Press, whose article in the Minneapolis Star Tribune on August 3rd made me wonder if he was interested in shedding light on the health care debate or merely adding to the heat. He asks that we check the facts, and then goes on to offer us his five insights on “the facts” as he sees them.

I offer a personal and a professional perspective as a nurse with 34+ years experience in the American health care system. I see our elected officials struggling to manage the macro-economics of health care yet failing to recognize, let alone understand, the micro-economics that confront each of us as citizens and consumers every day. I confess that my opinions are shaped by what I’ve seen over the years and read in documents like the Rand White Paper (1), Living Well at the End of Life, which lays out the costs of disproportionately using our resources to stave off death.

My bias is that our health care system is mostly an “illness care” system, prepared to tackle our health problems only after they have become huge obstacles in our lives. There is little about it that offers us wisdom on preserving health, managing minor illnesses well or making thoughtful decisions about the quality and length of our lives. The data, in some cases, are out there (smoking contributes to cancer and heart disease; exercise prevents many chronic illnesses) but our health care system is poorly set up to move the public health of our nation toward genuinely healthy decisions. Intervention comes a day late and a dollar short for most of our citizens. The rest of us just shake our heads and tolerate it. Oh, and by the way, we pay for it, too.

Mr. Babington hits on some important issues and offers us good arguments but no direction. Here are the five facts he points us toward:

1.THE FACTS: The House bill would require Medicare to pay for advance directive consultations with health care professionals. But it would not require anyone to use the benefit.

I agree with Mr. Babington, advance directives are intended to lay out a patient’s wishes for life-extending measures. Generally, these documents are constructed in consultation with health professionals, not government agents. Will Americans pursue with more vigor the construction of their own advance directives simply because a law permits payment for the consultation? Few people bother to write out their wishes now. Worse, even fewer emergency departments and first responders have access to these documents when important and immediate intervention decisions arise.

Jones (2 ) indicates that by 2007, only 41% of Americans had created living wills. However, for the advance directive to be an effective tool, far more of us need to subscribe to the premise that we want and need such a tool to live our lives thoughtfully and ethically, especially at the end of life.

Will paying for consultation lead people to take advantage of the opportunity to make their wishes known? I have my doubts. Perhaps instead, the law should require (at least for members of any “public plan”) that we must write out an advance directive. For me, I’ve done that, but in addition, I intend to have Do Not Resuscitate tattooed over my sternum, where hopefully, anyone attempting to save my life with CPR should find it.

2.THE FACTS: The proposed bills would not undo the Hyde Amendment, which bars paying for abortions through Medicaid, the government insurance program for the poor. But a health care overhaul could create a government-run insurance program, or insurance "exchanges," that would not involve Medicaid and whose abortion guidelines are not yet clear.

Since we don’t have any final language, I’d hate to see us dismiss the first serious U.S. health care reform in my adult lifetime on language we haven’t even read yet.

I’m a person of contradictions and paradoxes. I’m Catholic, so you know that my bias about abortion leans seriously against it. I’m also pro-choice, so while I admit I couldn’t choose to have an abortion, I am grateful that my government no longer criminalizes a woman’s choice to consider it. That said, if what we’re interested in is lowering the COST of healthcare, we have to think about the amount of futile care that goes on at the two ends of life – near birth and near death.

Our arguments about abortion get so loud that we forget to even discuss the topics that we should, like America’s infant mortality rates. If we want to talk about the wellbeing of babies, that’s the place to start. We forget all about PREVENTION and the modest expenditures required to bring most children into the world safely. Krisberg (3), writing for The Nation’s Health, alerts us to data “released in October 2008…the Centers for Disease Control and Prevention’s National Center for Health Statistics ranks the United States 29th globally in infant mortality in 2004.” It is a sad commentary on where our values lie.

In America, we rely on neonatal intensive care units (NICUs) to preserve the children who, with a little prenatal care, might have stayed safely in the womb until full term.

Lantos (4) reminds us, “Neonatal intensive care is one of the triumphs of modern medicine. Babies who inevitably would have died a few decades ago routinely survive today. But the success of NICUs should not lead us to see them as the only solution to infant mortality or as an adequate moral response to our children's health needs. We should constantly remind ourselves that the need for so much intensive care for so many babies is a sign of political, medical, and moral failure in developing ways to address the problems that sustain an epidemic of prematurity.”

That’s where our attention must be focused, on that epidemic of prematurity. Yet we insist on getting hung up on the abortion issue, and miss all the opportunities prevention could offer.

Then, when we do care for a child in NICU what criteria are we using for the treatment we insist on doing? It is usually not statistics (which can be grim). Hack (5) and colleagues remind us that the mild and moderate handicaps associated with preterm and low-birth-weight babies include asthma, attention-deficit disorder, visual problems, cerebral palsy, and the need for special education. These outcomes can drain a family financially, physically, emotionally, and spiritually. Clinicians, families and most in our society share a built-in bias to treat newborns aggressively.

But, we also owe it to these parents to help them become well informed of the potentially long-term struggles in raising a child with special needs. Health care providers should not tell them what to do, but counsel them fully so they are not surprised or saddened by the outcomes of their decisions.

3.THE FACTS: The proposed legislation would not require people to drop their doctor or insurer. But some tax provisions, depending on how they are written, might make it cheaper for some employers to pay a fee to end their health coverage. Their workers presumably would move to a public insurance plan that might not include their current doctors.

Wow – news alert, you may have to change providers! Every time your employer picks a new insurer you run that risk. If you lose your job you may lose your provider. And, if you have to change cities to get another job, you’ll probably have to find a new provider, too. This isn’t news. Primary care provider (the person you see for year-to-year preventive care) numbers are dwindling at break-neck pace, and they’re aging too. So, honestly, if you live a good long life, you’ll have to find a new provider from time to time.

Again, I agree with Mr. Babington when he offers his next set of facts.

4.THE FACTS: Millions of Americans already face rationing, as insurance companies rule on procedures they will cover.

And rationing goes even further into our healthcare choices and decisions:
•When healthcare facilities cut nursing staff, access to needed care goes down accordingly. The length of time from pressing the call bell to receiving a response, that’s an access issue too!
•When cities and towns cut back on first responders and ambulance crews, that’s an access issue as well.
•When drug costs soar out of the reach of common citizens, guess what? That’s an access issue.

Rationing happens! We just don’t want to admit that it does, and always will. Rationing isn’t wrong, but it shouldn’t be thoughtless or haphazard. We all ration, every time we examine our own personal budget. Personal rationing asks, how much will I spend on this or that? Will I make healthy choices for myself, or careless ones, hoping there’s enough money to pay for the damages they will cause?

The issue is WHO should be determining how public rationing occurs? In my opinion, it should be a layered discussion and decision. First, for simple things, the patient, family and provider should handle matters. After that, within a “public option” and for more complex issues, states should have an expert committee made up of healthcare professionals, community members, ethicists and clergy who help determine the tough issues.

There will always be rationing; our technological advances make it so. We’ll always have more tools available than we have time, people or financial resources to use them. And, just because we CAN provide a particular healthcare intervention, does not mean we should!

5.THE FACTS: Obama's pledge does not apply to proposed-spending of about $245 billion over the next decade to increase Medicare fees for doctors. The White House says the extra payment, designed to prevent a scheduled cut of about 21 percent in doctor fees, already was part of the administration's policy.

Mr. Babington tells us that the White House and Democratic lawmakers are talking about creating a powerful new board to root out waste in government health programs. He suggests that it's unclear how that would work.

Well, I have some ideas. The new American health care system should:

-- Require advance directives and the conversations they initiate. Write out your health care wishes, update them regularly, let family, friends and your physicians know about them and above all, be informed about what end-of-life care means. Be careful what you ask for!

-- Focus on prevention. Make preventative health care a RIGHT not a privilege so that we begin to level the playing field for all of our citizens. Immunizations cost less than the diseases they prevent; check-ups catch early signs of disease when it is more treatable; information about healthy choices offers us choice about our long-term health care goals.

-- Change providers thoughtfully. Consider a new provider when you’re approaching 65 especially if your physician is too! Consider a new provider when you’re not getting access to information about national guidelines designed to drive best health care practices. Consider a new provider when your provider fails to treat you as a partner in your own care!

-- Ration rationally. Think again about how we use our intensive care units and emergency services (of all sorts) so we’re not spending the bulk of our dollars on the final year of life, but on the early years when a healthy start can make a world of difference.

-- Help the government root out waste! Report fraud and certainly don’t engage in it (like lending your insurance card to an uninsured family member). Don’t steal – no, the towels, pillows, sheets, and extra supplies in your hospital room are NOT YOURS to take with you.

Don’t ignore the signs of illness and neglect to take appropriate action. The life you save may be your own!


References cited:

1. The Rand Health White Paper, WP-137, (2003). Living Well at the End of Life. Accessed August 3, 2009 from: http://www.medicaring.org/whitepaper/

2. Jones, C. (2007). With living wills gaining in popularity, push grows for more extensive directive, Crain's Cleveland Business, August 20, 2007. Accessed August 3, 2009 from: http://www.highbeam.com/doc/1G1-167959744.html

3. Krisberg, K. (2009). U.S. lagging behind many other nations on infant mortality rates: Healthy behavior, healthier babies. The Nation’s Health (February 2009). Accessed August 3, 2009 from: http://www.apha.org/publications/tnh/archives/2009/February09/Nation/BabiesNAT.htm

4. Lantos JD. (2001).Hooked on neonatology. Health Aff (Millwood). 2001;20(5):240.

5. Hack M, Taylor HG, Drotar D, et al. (2005). Chronic conditions, functional limitations, and special health care needs of school-aged children born with extremely low-birth-weight in the 1990s. JAMA. 2005;294(3):318-325.

School Daze II

School is starting this very week and I feel like a prisoner of my own choices. I’ve chosen to go back to school to pursue this post-master’s FNP certification. I’ve committed my time, my energy, my schedule and risked the significant relationships in my life toward the completion of this graduate work. Yet, right now, I feel as though I may very well have chosen poorly, and that is most discouraging. Some dreadful confusion has led to our not having an instructor in place for one of my courses. The tempus is fugit-ing and so far, all we (students) know is that the school is “working on the problem”.

This seems to be happening everywhere. Just last week I was trying to help another school sort out a similar faculty difficulty. That school was scheduled to bring 8 senior students (BSN program) to my workplace, and they found themselves at the 11th hour without a clinical instructor for the student group. I got pulled into the problem-solving because our Education Specialist was out on medical leave. In the end, the school found someone to teach the clinical section. Who knows what her credentials are, and whether she’s ever seen patients like those we serve every day. She’ll have no rapport with the staff here and no familiarity with the curriculum the students are studying. A lovely way to begin the semester!

In the long-run, this fall’s difficulty will disappear from my memory. I will accomplish my goal and like all unpleasant experiences, this one will dissipate and become a thing of the past. For me, this is merely annoying.

For my fellow students, and especially for those undergraduates who are set to begin their clinical instruction at my hospital next week, I find this situation reprehensible. My colleagues in graduate school are mostly young women (okay, there’s one guy). They either have jobs that function on shift-work or student loans that will bury them for years to come. They have young children and aging parents to care for, and spouses who probably have less tolerance for nursing graduate school than mine (with two PhDs) does.

We (hubby & I) were having a conversation just last evening reminiscing about our fond memories of graduate school. His experiences were in the 1950s and mine in the 1970s, which seems like eons ago. We remember faculty members who liked their work, faculty who liked students and were committed to our success. We remember faculty who mentored us, encouraged us and set each of us (twenty years apart) on paths that would launch us on meaningful careers of life-long learning. What are my school colleagues getting out of their graduate experience? And, perhaps even more importantly, what are today’s undergrads experiencing in their educational programs? Will they even WANT to consider going on for more schooling? If the undergraduate experience is discouraging, why would anyone sign up for more?

This is, I believe, the 21st century challenge in higher education: to recruit, hire, support and retain high-quality teachers. How do you do that, especially with a reward system so skewed, especially in the healthcare fields, toward being out in a practice setting, rather than in higher education? Out in the work-world of healthcare, the practitioner can earn at least half again as much each year as the professor who taught her. Its sad, but true.

That I am in nursing gives me only one perspective and limited insight, but I have to believe that the situation is similar in all the healthcare careers including medicine, the rehabilitation therapies, dentistry and social work, each of which are requiring increasing levels of graduate education for practice. As we continue to require more years of education, we tax the faculty we have and we probably dissuade the practitioner from teaching, given the financial burden he or she has accumulated during the preparatory educational process.

This time around, getting graduate education in the 21st century, I find myself discouraged. If asked by a colleague, “should I go back to graduate school?” my answer might not be the rapid and automatic “yes” that it would have been before my most recent experience. No one is, at this moment, mentoring me as a student. I have to wonder if my younger colleagues, who do not have the nostalgic memories of graduate school of long ago, are even more discouraged than I am.

What should graduate education be?
To my mind it should definitely be:
-- An exciting encounter in which the learner is stretched and challenged by the information, not by the logistics of learning.
-- A reinforcing, supportive place where the learner gains a new vision of his or her own professional possibilities, a time to imagine an ever-opening future.
-- An opportunity to hone those generalizable skills like reading comprehension, analysis, synthesis and problem-solving that will complement anyone’s lifetime of experience.
-- A place where learners meet faculty who are excited and positive about their work, connected to the current trends in their field, happy in the work that they’ve chosen, rewarded for their ability to teach well and impart wisdom as well as facts.
-- An environment where faculty are also supported, encouraged, mentored, enlarged and connected to each other and the practice world into which they are charged to launch the students.

Wishful thinking? Probably.
If only I could see my way clear to be part of the solution, instead of just a prophet in my own land.