The impending collapse of the US health care system

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meIt’s four in the morning and you wake up with chest pain. Your family calls 911 and paramedics arrive and diagnose a cardiac event. They tell you they have to transport you forty-five minutes away because your two local hospitals have closed over the past few months. Even when you arrive at the hospital, it is overcrowded and they tell you that there are no ICU beds open for you because fifty percent of the beds in the cardiac unit are “brown out” due to staff shortages . This nightmare is an all-too-familiar post-pandemic reality of health care delivery in our country. This is not what the public expects in health care delivery in one of the world’s wealthiest countries that has been at the forefront of health care innovation in the last century.

The cause of this post-pandemic nightmare is multifaceted. The pandemic changed how healthcare professionals are valued and how they see themselves. At the height of the pandemic they were heroes who risked their lives to help the community. But now things look different.

About 7,000 nurses are on strike in the New York City nursing strike as a symbol of the dire situation. Nurses, who are essential to the emergency work of every hospital, deserve not only fairer compensation and benefits, but ultimately safer staffing ratios in all settings patient care. The irony is that the strike will force these health care systems to replace employed nurses with temporary staff nurses, exacerbating their financial problems, and ultimately, the lines their lowest. Until we invest in people and their value in healthcare, we cannot see light at the end of the tunnel.

Every day we read about hospitals across the country losing millions if not billions of dollars every year. Hospitals are closing critical care, obstetric, pediatric and other services to try to survive. One of the main causes of this crisis is the lack of workers. Post-pandemic hospital staffing has been severely depleted with increased reliance on temporary locum workers. Hospitals and clinicians no longer have regular staff who can build professional and patient relationships; instead, they rely on locum workers with short-term contracts to provide such services. These locum providers are at all levels of the professional ladder from physicians, mid-level providers, nurses, respiratory therapists, and radiology technicians. This staffing model has led to many issues both professionally and financially.

On the professional level this massive drop in staffing and reliance on temporary workers has created an urgent issue in the patient care field. Hospitals and clinics have closed services in all essential patient services. It is not uncommon to hear that health care systems have closed Pediatrics, Psychiatry, Obstetrics, and ICU. Other health care systems have gone to the point of closing entire hospitals due to staffing issues. Another important feature of the crisis is that outpatient services have reduced hours and days. It is obvious that this reduction in services has had a significant impact on access to health care. Individuals have the ability to receive timely appointments, x-rays and tests. In many communities, it is the defenseless who have paid the greatest price in terms of receiving timely care.

Hospitals have also had to close operating rooms due to staffing, thus delaying elective and emergency services. Critically ill patients boarded in the emergency department have also spent long hours or days waiting for patient beds due to a lack of trained staff even when a bed is available. Even when they may be ready for hospital discharge, patients have long waits to find rehabilitation and skilled nursing facilities because short staffing has also affected them. This inability to transfer patients to appropriate facilities does not contribute to the short supply of patient beds.

During the pandemic, it was not uncommon for older providers with health issues to retire rather than enter the workforce. People who went to work worked long hours and had increased stress levels. After the pandemic, many of these people did not receive a financial reward: they saw the COVID-19 relief funds go to renovating facilities, building new buildings, and other non-employee rewards. This obviously changed the relationship between bedside providers and hospital leadership.

Adding to this disruption for many were city and state vaccination mandates. Many believed that they had been working hard with limited resources and knowledge against COVID-19 and now the value is losing your work over your own ability to make health care decisions . Another important issue is the lack of individuals who want to become health care providers. Many people and families saw how hard it was necessary for health care workers to work and work while other professions and jobs could work from home.

One of the most important aspects of the movement was the introduction of large numbers of temporary workers during the pandemic which continues today. Temporary workers (commonly known as Locums) are a major contributor to staffing issues. As regular hospital staff learn about the financial benefits of locum providers, it doesn’t lead to more people questioning, “why am I still working here?”.

Locum providers may receive double or triple the hourly rate of pay, and in some cases, free housing, rental cars and food allowances. This is not a good model for employee satisfaction where an individual is working through the pandemic with all the stress and now training someone who will make multiple folds of their salary with additional benefits that do not have loyalty to the resource. In some areas of the country locum health workers can be from the hospital down to the street. Staff from hospital A go to hospital B and then to hospital C without travelling.

Also at the heart of this conversation are the pre-pandemic high levels of burnout and attrition among providers that further destroyed the supply of health care providers available going into the pandemic. Addressing this issue is critical to the continued supply of providers across the US

Widespread use of locums also affects the way and quality of care provided. In the complex environment of health care delivery over the past few decades, we have learned that the best care is provided by individuals working as teams caring for cases or special problems. Prime examples of this are operating rooms and ICUs. Here, providers know each provider’s individual knowledge and skills and protocols and guidelines needed to care for specific situations. You can easily see how this will generate the best care. With short-term locum providers, the use of this system falls into a world where people do not know how to manage, where to supply, the needs of individual providers and what each person brings to the table. What also suffers is the ability to run through simulations and learning situations as workers are temporary. Many of us will see an increase in complications and poor outcomes in the next few years due to breakdowns in the health care team.

The massive financial drain caused by staff shortages and locum use has led to many health care facilities reaching the point of financial instability. Daily reports of large quarterly losses by both international and local hospitals where billions of dollars are being lost in an industry that was already operating on a slim margin lead to the closure of many additional facilities. This has affected not only rural hospitals with slim operating margins, but larger urban healthcare facilities as well. The loss of such important services in hospitals and outpatient facilities will affect the care of our communities for generations to come.

So, if the hospital and all the health care facilities close, where will we get our care? The answer is grim. If we are hit by another pandemic where will the care be delivered, where will the beds be? This financial crisis will affect other businesses as well. Medical technology companies can’t sell advanced ventilators, monitors and imaging devices to facilities that don’t have cash flow. Aging medical infrastructure cannot be repaired, upgraded or replaced in this financial environment.

As a backdrop to this growing crisis, we wonder why this isn’t headline news. Why are our local and national leaders addressing this issue?

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