Brave New World, Again

How the ACA is restructuring care and nursing itself

RoseAnn DeMoro, Executive Director, NNU

By: RoseAnn DeMoro, Executive Director of National Nurses United

With all the clamor over website woes during rollout of the Affordable Care Act, much less attention has been paid to changes in the delivery of healthcare that will have far-reaching, adverse effects on healthcare quality and access long after the signup problems are a distant memory.

As we have said, some components of the ACA are clearly welcome, especially the Medicaid expansion in those states where the governors are not standing with pitchforks in the door to block health coverage for the working poor. Yet there’s plenty of trouble in the fine print, especially on the care delivery side.

For RNs, these changes are achingly apparent. Just ask Kaiser Permanente RNs who have spent much of the fall protesting cuts in hospital and patient services that Kaiser executives paint as the face of future healthcare. Much of this latest wave of hospital and healthcare restructuring was, of course, wreaking havoc before enactment of the ACA.

However, financial incentives buried deep in the new healthcare law add a whiff of healthcare restructuring on steroids. The ACA rewards hospitals and insurers for shifting care delivery out of the hospital, regardless of patient need, stepped-up use of labor- and skill-displacing technology, gimmicks like patient satisfaction surveys, the transfer of more costs onto patients and workers, and other worrisome trends.

To get the full picture, I strongly encourage those who are able to attend one of our educational offerings, “What Does the ACA Mean for RN Patient Advocacy? The Bedside From the Bottom Line,” “RN Patient Advocacy in an Ecological Context,” both now open for registration on the NNU website, or one that will start soon, “Keeping Sight of Patient Protection: Insurance & Patient Care After the Affordable Care Act.”

Like those bad Halloween movies, the worst abuses long associated with managed care are back. Private health insurers, and hospital chains like Kaiser that are also insurers, or hospitals that form their own integrated networks through the new Accountable Care Organizations (ACOs) have an economic incentive to restrict care.

Other insurers simply pass along their financial risk to providers, who then, to boost their own revenues and profits, shift the burden onto patients through steeper co-pays, require cash up front before administering care, determine if patients are a payment risk using medical credit scoring, and hound patients for payment afterwards.

Hospitals also set cost reduction targets by limiting patient access to hospital care, increasing out-of-pocket expenses for patients, and targeting RNs.

The latest wave of the restructuring emphasizes two interrelated objectives: eroding the patient advocacy role of RNs through deskilling, displacement, and division, weakening the ability of RNs to act collectively.

Fewer patients are admitted, held in “observation units” up to 24 hours then sent home, and pushed out the door prematurely to lesser-staffed, lesser-regulated sites or home.

Kaiser, for one, has reduced its average daily census by 11 percent the past four years. They’re not alone. Henry Ford Health System in Detroit had a 6 percent drop the first seven months of this year, Modern Healthcare reported in August. Health consulting firm Sg2 predicts a national 3 percent drop in inpatient admissions the next five years, coupled with a 17 percent growth in outpatient services.

Hospitals overall, note our researchers at the Institute for Health and Socio-Economic Policy, have profit margins of 35 percent for elective outpatient services, compared to just 2 percent for inpatient care.

Kaiser, a national model, is seeking to move 1,000 RNs out of hospital care to other settings in Northern California alone, thus dispersing RNs and undercutting their ability to act together to fight for patients, while closing hospital services in a number of facilities, as seen in an array of cuts which have outraged seniors in Manteca, Calif. and the closure of pediatric care in Hayward, Calif.

In a 2012 Health Week presentation in Copenhagen, former Kaiser CEO George Halvorson said that in the near future, “for most people the home will be the primary site of care” dominated by in-home monitoring, self-care, and increasingly “cheap.”

That will increase the burden on families, especially women. A Gerontologist study in 2012 predicted an up to 15 percent likelihood of adverse events for home care patients in drug side effects, falls, and equipment malfunctions, and a huge increase in levels of stress and strain for the new home caregivers.

For RNs, the restructuring wave hits in multiple other ways as well. Technology is used to displace, not enhance, professional skill; to increase surveillance of nurses; and to routinize care by chopping it up into discrete, factory assembly line-type parts.

If managers can fragment and standardize the nursing process, they can automate it with technology, and intensify the workload with speed-up and short staffing. Sound familiar?

NNU RNs are heroically challenging these trends, and it is a major reason why we continue to campaign for a more humane healthcare model, not based on maximizing profit, but on ensuring a single standard of excellence in quality care for all. But it is going to require all of us; everything we represent is at stake.