The decision by the United Nurses and Allied Professionals, the union which represents some 2,400 workers at Lifespan’s Rhode Island Hospital and Hasbro Children’s Hospital, to go on strike at 3 p.m. Monday, July 23, after a last attempt by federal mediators failed to bring the two sides together, should not have been a surprise.
One of the facts that emerged when Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health, held a news conference the morning of the strike was that Lifespan had been carefully laying the groundwork for a strike, beginning as early as six months ago to arrange for Rhode Island licenses for the replacement nurses.
Translated, management at Lifespan, the largest health system in Rhode Island, had been anticipating and planning for a strike since winter. Some might call such actions prudent, but it seems to beg the question about whether the hospital system had been negotiating in good faith.
Lifespan also invested $10 million in paying a consulting firm to pay for replacement workers – for three days of the strike and a fourth day of a lockout. Once the nurses go back to work, without a contract, it does not preclude a strike from occurring again. The question is: who is going to pay for those $10 million in costs – the hospital administration, the nurses in their next contract, or the patients in future bills?
The news media loves the human drama of a noisy, confrontational picket line at a hospital. It makes for great melodrama, with breathless, anxiety producing reporting, often reducing the events into easy-to-understand sound bites, “Are you for it or against it?”
But many of the underlying causes of the conflict do not fit easily into the standard news format of outrage and mayhem in 60 seconds.
- Nurses are the folks who run the day-to-day operations at most hospitals and outpatients’ settings, not doctors or administrators, caring for the patients. But they have not been compensated or rewarded with a portion of the shared savings that their work generates, particularly as the focus of most health systems shifts to population health management. They are the ones getting squeezed as hospitals attempt to rein in the ever-escalating medical costs of care.
- The old business model for hospitals – the hospital as hotel – doesn’t work anymore. The longer a patient stays in a hospital, the more money the hospital is likely to lose. Most hospitals and health systems are dependent on the two federal healthy insurance programs, Medicare and Medicaid, for roughly 60 percent of their operating revenue, which reimburse hospitals at a rate lower than expenses.
- The myth of an independent Rhode Island hospital system continues to be perpetuated, even if it really doesn’t exist anymore – the way that Rhode Islanders often give directions using landmarks that no longer exist. Whether you make comparisons to musical chairs or the board game of Risk, most of Rhode Island’s hospital system has already been colonized.
Here’s the scorecard: Westerly Hospital is now owned by Yale New Haven after going into receivership; Landmark Medical Center in Woonsocket, after five years in receivership, was bought out by a for-profit California hospital system, Prime, then “donated” to Prime’s non-profit foundation; Memorial Hospital, after being bought by Care New England, closed down this year; Roger Williams was bought out by Prospect Health, a California for-profit health system funded by private equity; Care New England, which includes Kent, Butler and Women & Infants hospitals, is in the process of merging with Partners Healthcare in Boston.
The only remaining unaligned acute care community hospital in Rhode Island is South County Health, whose president and CEO, Lou Giancola, is retiring in the near future, so it is possible that the future path of the Wakefield health system will be consolidation. Giancola was one of the few health care leaders who was willing to say publicly that maybe we pay too much for hospital administrators and doctors.
Hospitals are associated with some of the most profound emotional events: the birth of children, the death of loved ones, emergency interventions to save friends and relatives – the fabric of our lives.
Mourning the changes is an appropriate if not nostalgic response. But, in today’s corporate world of engulf and devour, it is a bit like mourning the demise of drive-in movies, Blockbuster rental stores for DVDs and video cassettes, and small independent cinemas and bookstores. It may work on Facebook, but it does not change the corporate bottom line.
Alas, it doesn’t solve the larger questions: who cares for the patient, who pays for the care, what is the most appropriate care, and what are the things that actually make us healthy?
The changes in Rhode Island are part of a larger national trend, where hospital consolidation has taken on the look of a shopping frenzy, accelerated by the passage of the Affordable Care Act. Bigger hospitals are swallowing up smaller hospitals, Hospitals are buying up hospitals, insurance companies are buying up hospitals, and hospitals buying insurance companies, and hospitals and insurance companies care buying up pharmacy benefits managers. What is the old Firesign Theater nugget: “It’s gotten so you can’t tell the ACs from the DCs.”
- The ever-increasing medical costs associated with the U.S. health care delivery system, which some, such as Dr. Michael Fine, the author of the forthcoming book, The Health Care Revolt, have described it not being a system but a market for wealth extraction, keep increasing.
A big part of that extraction market is what happens in the emergency room, one of the places that have consistently generated the most revenue for hospital systems – which also has the greatest lack of transparency when it comes to what patients are actually paying for in their bills.
Who has not heard the recorded message when calling a primary care physician’s office: if this is an emergency, hang up and call 911. The disliked reality is that too many people depend on the emergency room to treat things that could have been treated at a primary care physician’s office.
- The community health care center system in Rhode Island is one of the best, most effective, low-cost, high-outcome health care delivery systems operating in the state, serving more than a quarter of the state’s residents. The work by Blackstone Valley Community Health Care to create a Neighborhood Health Station in Central Falls, with a new facility to open in September, represents a different kind of model, one that bears watching.
It may not be the perfect analogy, but a recent analysis of how the behind-the-meter solar systems played a critical role in lowering peak demand on the electricity grid during the recent heat wave by New England ISO, lowering prices for consumers – challenges many of the most dearly held assumptions by utility companies about future power generation needs and the role that behind-the-meter solar systems can play.