ASGOgator
03-15-2013, 07:42 PM
Lets take an example of a well known national corporation that owns multiple hospitals in Florida. Each one of these local hospitals applies to the state for a Certificate of Need, which in essence allows the hospital the permission to own and build facilities with a number of beds for that local area. Hospitals covet these CON's, and aggressively fight other rival facilities from obtaining CON in their area, because in essence it provides them the exclusive privilege of serving that area. Some might call this a monopoly protected by the government.
Now imagine hospital chain that is granted a CON to provide a service to that community, builds the facility, but finds it more profitable to understaff the facility. So it has a CON for 150 beds, but only hires enough nurses to staff 100 beds. Instead of having nurse to patient ratio on a medical floor of 1 nurse to 5 patients, they closed off 25 beds or an entire floor, and increase the ratio to 1 to 7 patients. As patients come into the Emergency room and are admitted they are placed in hallway beds "waiting for a room upstairs" in the ER. These patients are still charged for an inpatient room.
Instead of needing 60 nurses on a given day to operate the hospital, they are able to do it with 40 nurses and ancillary staff.
How does corporate accomplish this? Let's say that they provide a nice bonus for each one of the midlevel managers and the human resources director if they get through the quarter under a certain budget. That means they don't hire staff, they eliminate overtime, don't use agency help. They then tell the physicians, patients and the general public that corporate has not authorized the local hospital to hire additional nurses to fill the beds which have previously been authorized with the certificate of need.
So, hypothetically speaking, at this point the medical staff is frustrated to a boiling point. Patients are not getting beds, orders are not being carried out, meds are not being given, patients are laying on stretchers (as opposed to hospital beds) for days at a time, and of course there is the occasional patient that has an adverse outcome from lack of care. (hypothetically a patient who may have passed away with no monitor, found 6 hours later) None of which will be attributed to lack of the nursing staff.
The medical staff (meaning the physician leadership) arranges a meeting with a corporate VP. During this meeting it is determined that months ago Corporate authorized 20 nursing slots to be filled, however the authorization was never carried out. With a wink he simply explains to those present "you should do the math where the problem lies. Corporate has authorized the nursing positions, the Human Resource director is directly bonused for staying under a certain budget, and no one beyond the level of the HR Director and the CFO are aware that there has been an allocation".
For the hospital here is where the bonus comes to play.... The area Primary Care Physicians admit their patients directly from their office. This represents about 5% of hospital admissions. The Primary Care Physicians (PCP) are told that there are no beds available and that the patient will need to be brought through the emergency room. In some instances the direct admit orders are hidden so that the ER has no idea this is a direct admit. There is an additional charge to the patient and insurance for a ER visit that was unnecessary. Of course it was generated because the hospital did not fill it's allocation of hospital beds with personnel.
So whats left to do, patients can't go elsewhere because the certificate of need ensures there is limited competition for their services.
Winners
1. Corporate- no competition, higher profit margin, higher stock price
2. Individual hospital CEO- Higher admissions rate, lower over head, no competition from neighboring facilities.
3. Midlevel managers- rewarded/bonus checks for staying under budget.
Losers
1. Patients- receive poor care, long waits, worse outcomes because they have no choice.
2. Nurses-They get 25-35% more work with no compensation. When there is a bad outcome because they are trying to manage too much, no one will stand up for them to explain that they have been placed in a position to fail. They will be solely responsible for the bad out comes. Ask any nurse that works in a hospital unit if she has ever been forced to care for a patient in a situation that was not safe.
3. Physicians- They will also bear the brunt when a medical error occurs and when their patients have bad outcomes. Since they are not for the most employed by the hospital they have very little to say about about the process. ER physicians are stuck managing in patient cases that are in the ER for days, Hospitalists are managing patients that should have been discharged except for the inability of the nurse to manage the tremendous workload they are trying to bear.
4. The community-they are stuck with a hospital that really doesn't care about the community. Let's consider this, if it was up to the manager or hospital CEO to properly staff the hospital or loose his $30k bonus, which do you think they would choose?
5. The taxpayer----is footing the bill for ER visits (each one of these visits is likely in the $3000-6000 range) which aren't necessary, for prolonged visits.
So my question is this.... How is this hypothetical situation not fraud? How are hospitals allowed to create strained situations then profit from them. It's like paying a fireman for putting out the fire he threw gas on?
I would also like to add that I'm not a right or left guy. This corporation is obviously looking after the interests of it's shareholders, although at the expense of the community.
If the CON didn't exist and there was deregulation, fair competition would exist and this would result in another business having the ability to compete directly with this corporation and this behavior would cease.
Socialized medicine also has it's share of the blame in all of this. Those receiving government sponsored medicine are the absolute worst offenders for coming to the emergency room for routine problems, thereby clogging up the system. They have no co-pay, there for there is no reason for them not to come to the ER first. Even worse manipulation of the system will allow these patients to worsen their presenting complaint so that they are seen first. Chronic back pain turns into abdominal pain and chest pain.
Now imagine hospital chain that is granted a CON to provide a service to that community, builds the facility, but finds it more profitable to understaff the facility. So it has a CON for 150 beds, but only hires enough nurses to staff 100 beds. Instead of having nurse to patient ratio on a medical floor of 1 nurse to 5 patients, they closed off 25 beds or an entire floor, and increase the ratio to 1 to 7 patients. As patients come into the Emergency room and are admitted they are placed in hallway beds "waiting for a room upstairs" in the ER. These patients are still charged for an inpatient room.
Instead of needing 60 nurses on a given day to operate the hospital, they are able to do it with 40 nurses and ancillary staff.
How does corporate accomplish this? Let's say that they provide a nice bonus for each one of the midlevel managers and the human resources director if they get through the quarter under a certain budget. That means they don't hire staff, they eliminate overtime, don't use agency help. They then tell the physicians, patients and the general public that corporate has not authorized the local hospital to hire additional nurses to fill the beds which have previously been authorized with the certificate of need.
So, hypothetically speaking, at this point the medical staff is frustrated to a boiling point. Patients are not getting beds, orders are not being carried out, meds are not being given, patients are laying on stretchers (as opposed to hospital beds) for days at a time, and of course there is the occasional patient that has an adverse outcome from lack of care. (hypothetically a patient who may have passed away with no monitor, found 6 hours later) None of which will be attributed to lack of the nursing staff.
The medical staff (meaning the physician leadership) arranges a meeting with a corporate VP. During this meeting it is determined that months ago Corporate authorized 20 nursing slots to be filled, however the authorization was never carried out. With a wink he simply explains to those present "you should do the math where the problem lies. Corporate has authorized the nursing positions, the Human Resource director is directly bonused for staying under a certain budget, and no one beyond the level of the HR Director and the CFO are aware that there has been an allocation".
For the hospital here is where the bonus comes to play.... The area Primary Care Physicians admit their patients directly from their office. This represents about 5% of hospital admissions. The Primary Care Physicians (PCP) are told that there are no beds available and that the patient will need to be brought through the emergency room. In some instances the direct admit orders are hidden so that the ER has no idea this is a direct admit. There is an additional charge to the patient and insurance for a ER visit that was unnecessary. Of course it was generated because the hospital did not fill it's allocation of hospital beds with personnel.
So whats left to do, patients can't go elsewhere because the certificate of need ensures there is limited competition for their services.
Winners
1. Corporate- no competition, higher profit margin, higher stock price
2. Individual hospital CEO- Higher admissions rate, lower over head, no competition from neighboring facilities.
3. Midlevel managers- rewarded/bonus checks for staying under budget.
Losers
1. Patients- receive poor care, long waits, worse outcomes because they have no choice.
2. Nurses-They get 25-35% more work with no compensation. When there is a bad outcome because they are trying to manage too much, no one will stand up for them to explain that they have been placed in a position to fail. They will be solely responsible for the bad out comes. Ask any nurse that works in a hospital unit if she has ever been forced to care for a patient in a situation that was not safe.
3. Physicians- They will also bear the brunt when a medical error occurs and when their patients have bad outcomes. Since they are not for the most employed by the hospital they have very little to say about about the process. ER physicians are stuck managing in patient cases that are in the ER for days, Hospitalists are managing patients that should have been discharged except for the inability of the nurse to manage the tremendous workload they are trying to bear.
4. The community-they are stuck with a hospital that really doesn't care about the community. Let's consider this, if it was up to the manager or hospital CEO to properly staff the hospital or loose his $30k bonus, which do you think they would choose?
5. The taxpayer----is footing the bill for ER visits (each one of these visits is likely in the $3000-6000 range) which aren't necessary, for prolonged visits.
So my question is this.... How is this hypothetical situation not fraud? How are hospitals allowed to create strained situations then profit from them. It's like paying a fireman for putting out the fire he threw gas on?
I would also like to add that I'm not a right or left guy. This corporation is obviously looking after the interests of it's shareholders, although at the expense of the community.
If the CON didn't exist and there was deregulation, fair competition would exist and this would result in another business having the ability to compete directly with this corporation and this behavior would cease.
Socialized medicine also has it's share of the blame in all of this. Those receiving government sponsored medicine are the absolute worst offenders for coming to the emergency room for routine problems, thereby clogging up the system. They have no co-pay, there for there is no reason for them not to come to the ER first. Even worse manipulation of the system will allow these patients to worsen their presenting complaint so that they are seen first. Chronic back pain turns into abdominal pain and chest pain.