BY LAURA McKINNIS, MSN, NP-C
Illustration by: Katarzyna Bogdańska
The world seems out of control. We are in a global pandemic, unemployment has not been this high since the 1930s, wars and political rancor make listening to the news a fast track to a panic attack. In the midst of this chaos, I decided to leave my job and open my own health care clinic. Just when I had arrived at a place of confidence and influence in my career, I jumped ship and swam in a new direction.
I have worked in emergency medicine for 20 years. Over the last 10 years, the health care environment has continuously declined. I could no longer work within the status quo of our broken system. My patients kept telling me about the terrifyingly high cost of care. People in need of medical care are worried about the high cost of care and surprise bills. Patients often delay seeking help because of the financial risk they may face. Of all the scary things happening in our country, the health care system is one of the worst. I began thinking of Psalm 139:12, "Even the darkness will not be dark to you; the night will shine like the day, for darkness is as light to you." Is that even true? How can there be light in such times of darkness? How can a little nurse practitioner in Wisconsin make any of this better?
I left emergency medicine because I felt that the care I was able to provide was declining. One of the hospitals I worked in continued to make cuts to both supplies and staffing. For example, in one ER shift I simultaneously managed four unstable patients in the intake hallway of our ER because no beds were available in the main department. I had to tell a patient that she had a subdural hematoma (a bleed in the brain) while her bed was parked behind a curtain in the hallway of a busy department. I had to deliver sensitive news about diagnoses to patients seated in hallways within earshot of the waiting room because there were no private rooms. I found this unacceptable. The problem was not because of overwhelming numbers of sick and injured patients. Instead, it was due to the fact that the balance between profitable elective procedures and unprofitable chronic or emergency care had shifted. It put an ever-increasing stress on an overwhelmed ER.
Health care is an important issue for all Americans. It affects every economic class, especially the middle class and the poor. "Half of U.S. adults say they or a family member put off or skipped some sort of health care or dental care or relied on an alternative treatment in the past year because of the cost," according to a Kaiser Family Foundation article.1 While we have the most advanced health care technologies and treatments, these improvements have come at the cost of people's ability to afford them. According to the Economics of Healthcare, medical costs consume 18% of the gross domestic product of the United States.2 This also places a burden on the cost of doing business. The Kaiser Family Foundation also published statistics stating, "despite the nation's strong economy and low unemployment, what employers and workers pay toward (health care) premiums continues to rise more quickly than workers' wages and inflation over time. Since 2009, average family premiums have increased 54% and workers' contribution have increased 71%, several times more quickly than wages, 26%, and inflation, 20%."3
The possible solutions to these problems have been reviewed and studied endlessly. But all the attention and study has improved the situation precious little. Our predicament is reminiscent of Charles Dickens' cautionary tale, Bleak House. Dickens was writing about the legal system of that day, "which so exhausts finances, patience, courage, hope; so overthrows the brain and breaks the heart; that there is not an honourable man among its practitioners who would not give — who does not often give — the warning, 'Suffer any wrong that can be done you, rather than come here!'" Our health care system has become a similar quagmire for many in our country.
I needed to leave. I needed to do something different. But how do you do better than a $3.5 trillion dollar industry? How could one nurse practitioner do any better? What tools did I have to make a difference? Where should I even start?
Stones. I had a sling full of stones.
I wrote letters to department and hospital leaders and peers. They would listen to me but nothing changed. I joined committees to improve patient flow. I sat on an ethics committee to learn how principles of faith and care could be applied to complicated end-of-life situations. I offered opinions in committees to improve the clinician experience within our own physician group. I wrote and spoke about clinician burnout and tried to support my clinical staff.
Nothing changed. The giant would not listen.
I felt like young David preparing to meet Goliath. I was naïve in the ways of business and finance. I was unprepared for the complexity of a such a monstrous system. I was unwise, unprepared and weak.
But I had learned how to care. I had been a nurse for seven years and a nurse practitioner for 12. I could not stop seeing the needs of my patients, community and peers. And like David, I had been training in the field for years.
In the book of I Samuel, David explains his training this way, "But David said to Saul, 'Your servant (David) has been keeping his father's sheep. When a lion or a bear came and carried off a sheep from the flock, I went after it, struck it and rescued the sheep from its mouth.'"(17:34-35). Nurses are trained to monitor vital signs, make assessments, watch for indications of worsening disease. I had been training in the field of nursing for two decades. The signs that our system is breaking are everywhere.
David had been fighting things that were big, bad and scary his whole life. Nurses are used to being in the battle as well. We care for the sick and wounded and we jump into situations that can be scary. We face down death every day. The question for me became how to apply the skill of caring to this challenge of improving a failing and complex health care system.
I needed to know who I was fighting. Was it leaders, managers, CEOs, insurance companies, suppliers? I think I have found that it is the overly complex health care system that is the real Goliath. There are no truly bad people that I have encountered on this journey. Everyone seems to be doing their best within a job that often puts unhealthy constraints on their decision making. When limited resources are coupled with a broken reimbursement system, it is almost impossible to make effective change. I wasn't fighting a person or a company. It was the system that needed correction.
I started by looking to the business world for solutions. Actually, I tried to leave health care and join the field of sales and marketing. This did not work. It is not my skill set and I could not find spiritual fulfillment in it. I began an MBA program. If money had become the game, I wanted to understand it better. What I learned from business was fascinating. I studied the complexity of health care. I learned about the problem of a pricing system that is not transparent. I learned that insurance both protects individuals and causes costs to rise. Insurance reimbursement rates, especially from Medicare and Medicaid, are often significantly lower than the cost to provide services. This results in hospitals billing patients and insurers much higher than necessary in order to make a profit. This is the pricing game.
The health care system is tremendously difficult to understand. External forces can have a positive or negative effect on the health care market. In the health care industry, insurers or government payors may place positive pressure on providers and hospitals to provide lower cost care where reimbursement is tied to health outcomes. If the pressure is negative, however, it may actually increase cost by imposing unnecessary and burdensome regulations for providers to comply with these measures. Who do these measures benefit? Is it truly the patient or is it for the benefit of the insurer? Externalities can complicate the market. There is not a single buyer and seller. There is one, or many, additional parties seeking value in the transaction between provider/system and patient. The normal market safeguards cannot work. And who can afford the cost of care? Is it a right or a privilege?
One way to begin changing the health care system is to require transparency in billing practices. In the book, The Price We Pay, Dr. Marty Makary describes at great length the disparity in hospital billing based on private insurance, Medicare or private pay.4 It is a system clearly designed to recoup costs lost on Medicare/Medicaid by charging other payers more. This often leads to wildly high prices that are then negotiated down by commercial insurers. However, if you are underinsured or uninsured, you have no leverage to negotiate with the hospital. Many individuals pay the full marked up price and are taken into collections because of extreme medical debt. In fact, health care debt is the leading reason Americans file for bankruptcy. And the complexity goes on and on.
This is where my new journey began. Is there any way to simplify this process? Could I provide health care at a reasonable and transparent rate, provide excellent care and still make a living? I left the familiar hospital and clinic work and am trying something new. I started a company to meet the needs of my community and provide care that is both cost effective and convenient.
It is my vision to improve the community I live in by making health care access more convenient and affordable. I have a few "stones." These include price transparency, efficiency and the agility of a small business to change with the market. But in the end, it is the foundations of nursing that taught me about community assessment. Business refers to this as market analysis. Either way, it helps health care practitioners understand what their patients really need and how to provide this care. Unshackled from the way it has always been done, I intend to help.
I am hoping to use my nursing skills of listening, assessing and caring to make my corner of the world a little bit better. Only time will tell if this is an effective strategy. The phrase, "do what you can, with what you have, where you are" has been my mantra these days. It is a good way to approach overwhelming problems. So many things in our world seem daunting and frightening. It is easy to become paralyzed, hoping the problems will just go away. They won't. We have to apply our God-given skills to our particular areas of expertise and influence and find the solutions. My strengths have been cultivated for two decades in the trenches of emergency medicine. I have learned from my treasured friends who are doctors and nurses how to find creative solutions to difficult situations. I am hoping that this new way of providing care will make a difference.
"Even the darkness will not be dark to you; the night will shine like the day, for darkness is as light to you." There is hope in our time. We are not promised ease, wealth or simple solutions. But we do have hope. And we all have an important role to play.
LAURA McKINNIS is a nurse practitioner and owner of Oasis Healthcare in Grafton, Wisconsin. Oasis Healthcare is a self-pay, flat rate and low cost walk-in clinic serving patients for acute medical needs.
- Ashley Kirzinger et al., "Data Note: Americans' Challenges with Health Care Costs," Kaiser Family Foundation, June 11, 2019, https://www.kff.org/health-costs/issue-brief/data-note-americans-challenges-health-care-costs/.
- Economics of Healthcare, 2017, https://scholar.harvard.edu/files/mankiw/files/economics_of_healthcare.pdf.
- "Benchmark Employer Survey Finds Average Family Premiums Now Top $20,000," Kaiser Family Foundation, Sept. 25, 2019, https://www.kff.org/health-costs/press-release/benchmark-employer-survey-finds-average-family-premiums-now-top-20000/.
- Marty Makary, The Price We Pay: What Broke American Health Care and How to Fix It, (New York: Bloomsbury Publishing, 2019).