Big hospitals and hospital chains have wailed, with considerable justification, since the outbreak of the coronavirus pandemic about financial damages they have suffered due to costly shortages of desperately needed health staff. But the institutions fostered this staffing crisis, with profit-ravenous suits in executive suites boosting hospital bottom lines in flusher times by slashing one of the biggest expenses in the business — frontline health care workers.
To see this up close, let’s zoom in on the experiences of Ascension, one of the nation’s largest chains, to see how hospitals plunged themselves into an economic and medical care mire, the New York Times reported:
“Ascension …spent years reducing its staffing levels in an effort to improve profitability, even though the chain is a nonprofit organization with nearly $18 billion of cash reserves. Since the start of the pandemic, nurses have been leaving hospitals in droves. The exodus stems from many factors, with the hospital industry blaming Covid, staff burnout, and tight labor markets for acute shortages of staff. But a New York Times investigation has found that hospitals helped lay the groundwork for the labor crisis long before the arrival of the coronavirus. Looking to bolster their bottom lines, hospitals sought to wring more work out of fewer employees. When the pandemic swamped hospitals with critically ill patients, their lean staffing went from a financial strength to a glaring weakness.
“More than half of the roughly 5,000 hospitals in the United States are nonprofits. In exchange for avoiding taxes, the Internal Revenue Service requires them to offer services, such as free health care for low-income patients, that help their communities. But The Times this year has documented how large chains of nonprofit hospitals have moved away from their charitable missions. Some have skimped on free care for the poor, illegally saddling tens of thousands of patients with debts. Others have plowed resources into affluent suburbs while siphoning money from poorer areas. And many have cut staff to skeletal levels, often at the expense of patient safety. At a single hospital in Northern California, the sprawling nonprofit hospital chain Providence laid off dozens of medical staff in 2017 and 2018, resulting in long waits for crucial care. At a Washington State hospital that is part of CommonSpirit Health, another giant nonprofit chain, years of belt-tightening reached a breaking point in October when an overwhelmed nurse called 911 dispatchers, who sent the fire department to help care for patients.”
The newspaper zeroed in on Ascension and what its leaders described as their corporate efficiency efforts in its 139 hospitals:
“As recently as 2019, Ascension was trumpeting its success at reducing its number of employees per occupied bed, a common industry staffing metric. At one point, executives boasted to their peers about how they had slashed $500 million from the chain’s labor costs. In the years before the pandemic, they routinely refused requests to hire more medical workers or fill open jobs, according to current and former hospital administrators and employees. The yearslong effort — a combination of widespread layoffs and attrition — rarely attracted public attention. But it left Ascension flat-footed for Covid. During surges in the coronavirus, Ascension repeatedly reduced its capacity by more than 500 beds nationwide because it did not have enough workers. In Michigan alone late last year, the chain had 1,100 nursing vacancies. The head of an Ascension hospital in Baltimore last year blamed staffing shortages for the emergency room being dangerously overcrowded.”
The corporate campaign to chop down staffing costs had dire consequences for patient care, the newspaper said, reporting that it found this as it reviewed thousands of pages of logs kept by nurses, and interviewed dozens of knowledgeable parties involved:
“Patients lingered for hours on gurneys with serious, time-sensitive problems. Surgeries were delayed. Other patients developed bed sores — gaping wounds that for frail patients can be deadly — because they were not repositioned often enough. ‘You feel awful because you know you’re not turning these patients,’ said Jillian Wahlfors, a nurse at Genesys [an Ascension hospital in Michigan]. ‘You know they’re getting their meds late. You don’t have time to listen to them. They’re having accidents because you can’t get in fast enough to take them to the bathroom.’”
Chain spokesmen denied that patient care suffered due to health worker shortages, arguing that the Ascension employee-to-patient ratios are strong compared with peers. The newspaper noted that such claims are difficult to assess because hospitals decline to make public hard data on staffing — information the institutions consider to be highly sensitive, proprietary, and competitive.
Still, through the chain’s own documents and interviews with current and former executives and frontline health workers, the newspaper portrays Ascension’s aggressive pursuit of profits as leading it to cutting thousands and huge costs with an industry-emulated zeal.
“Across its network of hospitals, Ascension set individual financial targets, and executives whose hospitals did not achieve their goals would not get bonuses, according to three former executives. Keeping staffing low was one of the easiest ways to get paid, since labor costs make up about half of a hospital’s expenses. Ascension also closely tracked the number of nurses on duty relative to how many patients were treated in each hospital unit. Managers felt pressure to require fewer nurses to handle more patients. Some had to show they were hitting productivity targets before they could hire more workers, according to current and former Ascension employees … In Michigan and Illinois, Ascension lobbied against legislation that would have required minimum nurse-to-patient ratios. The measures never became law. In the following years, staffing levels at Ascension hospitals in those states were routinely below what the bills would have required, according to nurses at those hospitals.”
As the pandemic broke out and then wore on, hospitals across the country were overwhelmed and exhausted and short-handed health workers — even with early adulation and then with various attempts at financial and other awards — began to quit in numbers. The newspaper reported that Ascension kept positions unfilled, demanded that existing staff take on more duties and longer hours, and the chain tried to use robots and remote health monitors to make up for big nursing shortages.
Frontline personnel told the newspaper that these kinds of measures worsen not only their working situation but also the care that they can provide to patients:
“Nurses in nearly every unit at the [Michigan] hospital [the newspaper zeroed in on] said in interviews that they were regularly required to care for more patients than allowed under their contract — restrictions that are supposed to ensure the safety of patients. ‘You just try to do damage control your whole shift,’ said Stephanie Atchley, a Genesys nurse. ‘It just all snowballs into very poor care.’ Dr. Dale Hanson, a physician who treats patients at Genesys, said that most days, there are not enough nurses, resulting in prolonged hospital stays for his patients. Some get marooned in the emergency room because of nursing shortages in other parts of the hospital. Dr. Hanson blamed Ascension’s aggressive cost-cutting, which he said has resulted in ‘miserable’ conditions for patients and staff.”
Not good. In my practice, I not only see the harms that patients suffer while seeking medical services, but also the clear benefits they can reap by staying healthy and far away from the U.S. health care system. It is, according to research conducted in pre-coronavirus pandemic times, fraught with medical error, preventable hospital acquired illnesses and deaths, and misdiagnoses.
As patient advocates look at ways to slash at medical costs that bankrupt patients, they have put hospitals squarely in their sights, as these institutions have become a major driver of spending, taking up roughly 1 of every 3 dollars spent in this area (~$1.2 trillion in 2018 alone).
Sure, hospitals and the people in them need to make a reasonable return. The institutions and the people in them can provide remarkable care. Many have become beacons of hope during the dismal times of the pandemic. Still, grinding down their own frontline health workers to fatten their shareholder returns and mistreating patients and their families by hounding them for every penny is a poor way for any enterprise to treat staff and customers.
The New York Times report on how hospitals like Ascension helped to create their own staffing nightmares also does not mention how critics have assailed the institutions’ hiring in far less stressful and flusher pre-pandemic times. This blog reported in 2018:
“As the Axios news site has pointed out in one of its recent newsletters, health care employment keeps booming and is providing one of the US economy’s major job engines, with more than 1 million workers added since January in nursing home care alone (see chart above). Indeed, in the overall economy, as a Los Angeles business columnist has noted, the hiring situation has grown so tight that ‘employers will do almost anything to find workers to fill jobs — except pay them more.’
If you follow trends in health care hiring, however, you might see that administrative and support jobs, including for high-paid managers and executives, are the areas that are booming most. The New York Times reported that America leads the world in the cost of administering its health care system, devouring 25% of hospital spending on an accounting for an expense that the newspaper headlines as ‘astonishingly high.’ Employment of those who provide direct patient care, meantime, is growing but lagging behind the paper pushers, including a big and growing number of increasingly specialized workers focused on billings.”
We have much work to do to ensure that health care in the wealthiest nation in the world is a right not a privilege for a select few. We must ensure that the medical services we have are affordable, accessible, safe, efficient, and excellent. If hospitals cannot make a priority of patient care versus excessive profits, their patients, the public, lawmakers, and regulators must step up and step in.