A Free Market in Childbirth
Recently, my wife and I celebrated the birth of our fifth child in twelve years. Over that stretch of time, we have seen hospitals adapt to the wants of the consumer: future mothers and fathers. Some of the changes we have witnessed have been subtle, mere nuances, while other changes have been quite dramatic. Together, these changes lead me to two conclusions: I love the free market; and, I would love a truly free market in healthcare. FULL ARTICLE
Comments (14)
As a nurse I appreciated your comments regarding your and your wife's recent hospital experience. I do think, however, the customer can be easily swayed by the cable tv, smiling faces, etc. This is important, but what you should be looking for in a hospital is cleanliness, staffing ratio, ancillary staff, wait times for diagnostic tests that may be critical to the patient's diagnosis and treatment. In my experience and from comments made by patients, for profit hospitals often have a greater patient to nurse ratio, fewer ancillary staff and longer wait times for tests. Fewer ancillary staff mean dirtier rooms (not obviously dirty but not sanitary, higher infection rates and overstressed nurses who are more likely to make a mistake. But the rooms look good, the hospital looks like a hotel and the staff are trained to talk a great game.
The not for profit hospital I work for trained us on customer service and what not to say when questioned about staffing. We were told to never say we are short staffed but we are very busy today. We are trained to be very polite and push customer service. However, sometimes infection protocols are ignored due to ancillary staffing issues, patients being admitted to semi private rooms with a roommate that may have an infectious disease and really should not have a roommate due to the potential to pass that disease on to the new patient. The hospital will lose money by not using that empty bed, etc. Management is so focused on customer service that nurses have lost the power to tell families they cannot bring small children on the unit or that they must obey infection control protocol. We have no power to insist that patient who is at risk for injury or an infection risk stay in his room. The consumer must look beyond the obvious - the cable TV, computer access, physical plant and look at the infection rates, nurse to patient ratio, wait times for diagnostic tests, policies, etc. Just because someone is being polite and the building looks great and you have great cable TV does not mean you are getting good medical care. But you are right in the sense that hospitals must compete and that this will foster improvement. They must compete on the basis of the things that are important. I realize the general school of thought is hospitals compete on the basis of what consumers want but consumers should be focusing on wanting the things that are important. Wouldn't it be great if we could have it all. Congratulations on your new family member.
Published: April 23, 2007 10:20 AM
Also, it would have been in your wife's best interest if you had worn a gown in the delivery room because your clothes are a potential vector for infection. Remember the days when women died from childbed fever? Balance is needed between satisfying the consumer and protecting them by delivering quality medical care in a safe environment even if this means not giving them everything they want. Consumers have to be aware of the need for this balance. Sometimes the consumer wants things that are not necessarily in their best interest. Children coming to visit sick people - not in the child's best interest but the public is demanding it. Consumers need to continue to educate themselves.
Published: April 23, 2007 11:01 AM
It always simply staggers me when I read articles from the US pushing the greater use of state intervention in health care. The cure would be to invite Hillary Clinton, if it is possible that this goddess could ever suffer from some kind of a medical defect, to come over here to the UK and use our proto-communist NHS (National Health Service) to sort it out. If she didn't die from MRSA first, and could stand waiting six months in line, I'm sure she'd "Do a Madonna" and fly straight back to the US instead to use your semi-private medical system, despite its evil semi-capitalist nature. You may still have many problems with your health guilds, particularly the licensing of medical schools by the AMA and all the other restrictive practices designed to enrich privileged medical professionals, but if you've ever used a public bathroom in a British NHS hospital, you will know which side of the Atlantic your health bread is buttered on.
Published: April 23, 2007 6:13 PM
I do not think your ideal hospital could survive if free market forces were truly given full reign. Privatized medical insurance is being slowly destroyed by moral hazard and stratification into affordable plans for healthy people, and unaffordable plans for unhealthy people. Yet our glorious consumer society thinks nothing of bombarding the public 24/7 with advertisements to eat food that we all know contributes to poor health, but we eat it anyway because it is tastier, cheaper, and there is no clear punishment for this until much later when our lives depend on affordable medical care.
Surveys have found that many personal bankruptcies were triggered by unexpected health expenses -- when a family that is barely making ends meet is suddenly put many thousands of dollars into debt, how does anyone seriously expect them to get out? The answer is not to admonish them to save, when real wages stagnate and general price inflation is much worse than the official numbers pretend. America has ceased to be the land of opportunity with risks shared by all, and has become the land of demanding not to pay for others' risks but expecting to be rescued from the perils of one's own. Everyone is guilty, from the union worker struggling to afford a rent increase, to the bankrupt corporation lobbying for a bailout.
I agree that we need to discourage "welfare queens" but it is also wrong to think that the free market will continue to provide life-saving services that are uneconomical, which many of them now are but everyone is in denial over how badly we have squandered our national wealth. I suppose the hospital itself could provide the health insurance, but wouldn't this just create a vertical monopoly situation, with its own tendency towards abuses?
Published: April 24, 2007 1:26 AM
The hospital I work for recently bought a new robotic surgery gizmo (which cost millions of dollars) but we're 800 people short of nurses, nursing assistants, CNAs, etc. I'm not seeing a properly run business here. I say staff up so the building will be clean, infection rates well managed, patient's attended to. Perhaps consumers need to become better shoppers. What if you have that high tech surgery but post surgery you're one of 7 patients being cared for by one nurse. Private ly owned hospitals don't do much better, infact statistically worse with staffing, to increase their profit margins.
Medicare is a joke. Since the government announced cutbacks, I've seen a trend. Old people who used to stay in the hospital are now "treated and streeted". Conditions they come in with are not being treated aggressively. Of course that opens up another discussion on medical ethics. Does that 94 year old really benefit from chemotherapy?, etc.
Insurance runs everything. They issue DRG - Diagnostic Related Grid. They deem, for example, pneumonia should be treated in 3 days. After 3 days they don't reimburse the hospital. If the patient requires 5 days, the hospital eats 2 days of the cost. So, I don't know what the anwer is. Don't get sick?
Published: April 24, 2007 3:29 PM
Anonymous nurse,
I think that the key piece of the puzzle, the one question that you and everyone else should be asking is this: why does medical care cost so much?
Just think about that question there for a moment. Why does it cost me $75 and nearly two hours of my time to get a paid professional to examine me for less than two minutes and then sign off on an prescription for a cheap antibiotic for my eye infection? This is clearly not an industry that is forced to compete freely on the basis of quality of its service. Any person of average intelligence could be trained within a few minutes to recognize the symptoms I was exhibiting and recommend a remedy. Heck, I knew exactly what was wrong with me from the description in a layman's medical guide that I read fifteen years ago.
The problems with medicine are the result of deliberate market interventions by the government, acting through the AMA. I'm not saying that all medical procedures would become cheap, just that it is silly to assume that just because heart surgery requires expensive facilities and extensive training, all medicine should carry the same relative costs.
The lack of quality that you see is a result of artificially reduced supply. The large profits to be made in medicine stem from this, and it is the reason that poorly-maintained hospitals continue to run. This is not a trite observation but a fundamental, universal economic principle. The free market would gladly provide us with more doctors and nurses, but the AMA won't allow enough of them to practice.
Published: April 24, 2007 4:00 PM
Soviet medicine may be flawed because of it's own internal problems. Walter Reed is not flawed. After months of investigation I wish I could have had my knees replaced using their excellent doctors and nurses. Unfortunately, the glut of unplanned war wounded stopped that decision. The problems at Walter Reed were in the after care 'holding' wards for the wounded. These wards were run by profit driven subcontractors, politically connected to the current Busch administration. Check out their Halliburton ties.
Childbirth is such a short term, well spaced medical event it is easy for the customer and kin to be bamboozeled by smiley faces and cut corners. If you had to be emeshed in the three or four week hospital situation of a loved one mangled in an auto accident it would give you an entirely different picture--nurses soldiering on through their own pain and the patient's pain--going through the hundreds of medical rules that insure patient safety.
Published: April 24, 2007 5:04 PM
Anonymous nurse wrote: The hospital I work for recently bought a new robotic surgery gizmo (which cost millions of dollars) but we're 800 people short of nurses, nursing assistants, CNAs, etc. I'm not seeing a properly run business here.
In my work experience, every project, and every company for that matter, is woefully understaffed based on some industry atandard. Yet, the employees always seemed to produce very marketable products.
That's not to say that there aren't failures, but what makes you think adding 800 employees will achieve any good for the consumer?
Wouldn't that simply add to the expense and force individuals to make the hard decision to forego needed medical attention. Remember scarcity.
There are a host of problems with healthcare, yet a free market would solve as many of those problems that are truly problems in the eyes of the consumer. The market will not solve issues that are problems solely in the eyes of the employees, that is typically a mark of a government-run entity.
Note public K-12 education where the employees cry for more, and the political bosses tend to comply.
Published: April 24, 2007 10:42 PM
In response to Jim Fedako's comment. Due to the shortage of 800 employees the nurses are now passing food trays, processing paperwork that could be delegated and wait times for diagnostic tests (including lab work xray, cat scan ultrasound mri, etc.)have increased. Not the same as waiting at WalMart or waiting for your diswasher repair person. If your nurse is busy passing trays to other patients she/he has less time to pay attention to your vital signs or pain. Medications may be late or a nurse may miss a change in patient condition that could result in a longer stay for the patient or his/her death.
I don't know what industry Mr. Fedako is employed in but only in the health care industry can a patient die from a nurse not being available for the patient due to being pulled to other duties. Things can get out of control very fast and once a patient starts going down, sometimes they keep going down.
What about that patient with right sided weakness waiting for a cat scan to diagnose whether he's having a hemorrhagic or thrombolic stroke. The treatment is different but can't start until a proper diagnosis is made.
Yes the shortage of 800 employees (includes nurses, xray techs, lab techs, phlebotomiosts, food service workers, nursing assistants, secretaries, house keeping staff, and many more) in a very large hospital does indeed make a difference. I feel it most definitely. I would like to focus on my paient and the consequences of not being able to do that are more than having a disgruntled patient. It might include having a dead patient.
Published: April 26, 2007 12:53 PM
Your points are well-taken, anonymous nurse, but what I see screaming from between the lines of your description is not "profit!" but "inefficiency!" From your description so far (and without being able to alter your staffing budget), I would suggest that your hospital is overstaffed--with nurses!
I'm guessing that the hospital could employ two or three food service workers or nurse's assistants for every nurse they let go. Wouldn't it be better to have a few less nurses on staff so that the remaining nurses can focus on their correct jobs? The ones they get paid good money for?
What you are describing doesn't sound like a well-run business that responds to the market, but simply a bureaucratic mess. Paying people $25+/hour to deliver food isn't profitable, it's stupid.
Published: April 26, 2007 4:07 PM
Mr. Scott D:
I appreciate your comments however the fact is no nurses were let go. I already take care of 6 patients on a medical surgical unit. Nursing assistants and other ancillary staff aren't applying for the jobs. They can make more money at Burger King, etc. without the legal liability. Plus the food service jobs are easier (so they tell me). Currently there are studies that show that greater patient to nurse ratio leads to increase lengths of hospital stay and increased mortality rates. Yes it is inefficient for nurses to get paid big bucks to pass trays but someone has to do it. I think the "experts" are saying that on a medical surgical unit the ideal ratio is 5 nurses to 1 patient. And I really don't know what the answer is. I just know when I come home at the end of a shift I am beat. It's the physical work - turning patients, cleaning them, plus the stress - it takes a lot of mental work to do the job. You have to remember lab values, vital signs, medication schedules, patient history, comorbidities and the list goes on and on. Unless you've experienced the job I don't think you could understand what it entails. It's tough. It's very serious. There are reports and studies available on the web if you're interested.
Nurses used to take care of an average of 8 patients on a medical/surgical unit but the mortality and length of stay rates have improved with lower nurse to patient ratios. Unless you're having a baby no one is admitted to the hospital these days unless they are having surgery or extremely sick. The insurance companies won't pay for it. Anyway I appreciate your comment but speaking for myself and my fellow nurses - we're just about as efficient as we can be under the circumstances. Perhaps people who qualify for the jobs need a market adjustment to entice them to the healthcare business. Also additional food service workers, etc aren't going to know what to do if your heart stops beating. But nurses do!! Take care!!!
Published: April 27, 2007 11:28 AM
Mr. Scott D
I'm sorry I meant the ideal ratio on a medical surgical unit is five patients to one nurse - not the other way around. Take care!!
Published: April 27, 2007 11:34 AM
Enterprising entrepreneurs have been birthing children for most of history. You don't mention midwifery at all. Out of our 4 kids, the midwife led home birth was by far the most relaxed, genuinely pleasant experience we could want. We wore normal clothes. When the baby was born I was able to grill my wife a fat steak dinner to enjoy in the comfort of her own bed. The midwives were well trained and conscious to my wives needs.
The next baby we were back in the hospital because insurance won't pay for a home birth and it is a lot more expensive. It wasn't too bad. I was able to fend off the needle and goop wielding staff and we made it out in under 24 hours. Despite the expense, we will be going the home birth route again next time. The market provides and we are thankful for our freedom of choice in these matters.
I think a lot of people don't even consider home birth a possibility these days. It is safe, relaxing (as much as the situation will allow), and most of all comfortable. As the father, I appreciated my ability to be of use, and not just in the way. Good times.
Published: May 1, 2007 9:02 PM
ps, I actually only have one wife. Just to clarify the typo.
Published: May 1, 2007 9:03 PM