Minor Thoughts from me to you

Ken Bavier recently wrote about Michigan's new plan to retrain unemployed workers as nurses. He's not thrilled with the idea.

I wrote a response to his thoughts.

I'll respond as someone who works in health care IT, but not in the actual delivery of health care. I'd consider myself an educated observer of health care but not really a participant in the health care field. (And my HIT experience is on the billing side, not the clinical side.)

I'll post my economic thoughts since I don't really have any clinical thoughts. I think a lack of true financial incentives are strangling the field. I don't see any viable alternative explanation. You mention several causative factors: underpaid teachers (leading to a lack of teachers), lack of money to expand nursing training, nurses who don't have the influence to change their work environment, and a lack of nurse / physician collaboration. Those are all economic factors that show up when incentives aren't aligned properly.

In her recent State of the State speech, Governor Granholm talked about a waiting list of people who want to become nurses and a shortfall of actual nurses. That's really an amazing statement. Organizations are desperate for nurses. People are eager to become nurses. But nothing's happening. Where's the dam in the river? Why isn't the water flowing downhill here? Why are teachers underpaid even when there's a desperate need for training? Why is there a lack of money to expand training for the very workers that are desperately needed?

The only rational explanation I can see is that health care organizations either don't believe they'll profit from increasing nursing staff or don't believe their allowed to take the actions necessary to properly increase their nursing staff.

Most of the businesses that we're familiar with hire friendly, competent, well trained staff for a very good reason: a customer that feels insulted is likely to leave for a business that makes them feel welcome. Good employees are an asset to these businesses. They serve both to increase customer trafic and to retain customer traffic. This increases profitability. Good employees are good for the bottom line. Bad employees drive customers away and keep customers away. This decreases profitability. Bad employees are bad for the bottom line.

But I don't think this is true in health care. In the U.S., people have a choice of 1-3 health plans offered by their employer. These health plans provide a very limited number of options for outpatient and inpatient clinical care. (Warning: this part is from the patient perspective. It may or may not match reality as seen from the provider's perspective. And, that's kinda the point.) Do you feel insulted by your doctor? You can request another one -- if he has openings. But he's employed by the same organization that hired th first jerk. Do you feel that your nurse is slacking off? Good luck getting another one. Want to move to a different clinic or hospital? Well, you can, if you want to pay for it entirely out of your own pocket.

Patients have very limited choices. This leads to limited (non-existent?) competition and limited incentives for improvements. Sure, health plans compete for members. But they're mostly interested in getting access to premium paying healthy people. Nobody's really competing for patients to walk into their waiting rooms. Few organizations are truly competing to have the best physicians and nurses. Few organizations truly believe that the quality, friendliness, and diligence of their providers drives their bottom line profits.

So much for my view of the profit side of the problem. What about the regulatory side? Here I'll just have to throw out questions. What qualifications are necessary to open a nursing school? What qualifications are necessary to teach nursing? What prerequisites are necessary to enter nursing school? What would prohibit (or discourage) a health care organization from providing training? What would prohibit (or discourage) other organizations from providing training? What existing regulations make it difficult for graduates to find jobs? What existing regulations make it difficult for graduates to learn on the job in a controlled, manageable way? What types of jobs do nurses do that could be done by someone less credentialed and less well trained? How many of those lower skill positions are limited to nurses even when a nurse's qualifications aren't necessary to do the job well?

I don't know nursing well enough to answer those questions myself. But I've read enough about the health care field to believe that those questions have answers and that those answers would reveal a lot about the current nursing shortage. I think the only way that the shortage will truly be alleviated is if organizations clearly profit from better nursing and are free to act in a way that will maximize their profits.

There, Ken. I think I've written something that may anger people just as much as your original post.

Originally posted as a comment by jmartindf on Nod If You Can Hear Me using Disqus.