Here’s an opinion piece submitted by John L. Shirey, an adult inpatient clinical social worker at Mission Health who says that Jan. 12 was his last day on the job. “Please know that I have not been fired, I am not under duress, and I am leaving after a five-week notice that I completed on good terms,” he writes. In the opinion piece below, Shirey is referencing the pending sale of Mission Health to HCA Healthcare, a for-profit healthcare company based in Tennessee. 

I’m sure you’ve heard: Mission is going for-profit, there will be a foundation, they’re going to pay taxes, it will be good for the community, and the foundation will be the largest in Western North Carolina. I’m sure you have even wondered, how will this effect me? Or maybe, why should I care?

Well I can give you one of the many inside perspectives. I have kept silent till now, worried about my job, turning a blind eye to what is happening inside an institution that I believed in, an institution I loved. I completed my graduate degree with a nine-month internship at Mission. I loved the compassionate nature of all the professionals that I worked with, the care for the homeless, the care for the down trodden, the community good, the organization that made you feel like they cared about you, and give you a mission that is worthwhile.

A year ago (1.5 years after graduation with my degree), I got the chance to return. I won’t lie – it was hard. Ten-hour days, low person on the pole, and exhausted. Things had changed, the opiate crisis was in full swing, and the caring professionals were struggling with an appropriate response. I was on the bleeding edge of how a major health system would respond (and is still responding) to this crisis. Regardless, I was excited. I was making a difference. I was helping, and it was worth the sacrifice. That’s when the wheels fell off.

I came into one of our frequent meetings announcing that the board along with the CEO had officially entered in to some agreement that we would sell to HCA. The propaganda was intoxicating. We will get the lowest cost medication for our patients, there’s going to be this huge foundation, our mission will not change, for-profit organizations pay more, the hospital will pay taxes, etcetera, bull hockey, and other crap.

I made it known at the time that I was not comfortable working for a company that was OK with the prospect of making a profit off of people’s suffering (my first job out of grad school was working for a for-profit methadone clinic that left a very bad taste in my mouth.) I began immediately looking for other work, and continued to do my job to the best of my ability.

I should mention here that I had a year’s experience working with a for-profit hospital in a rural area. Occasionally I would be required to hospitalize a participant in my service who was expressing suicidal ideation. Should this participant be insured, they might spend a night in the psychiatric evaluation area (PEA). Should the unfortunate soul not be insured, they would languish in the PEA until either they stopped expressing suicidal ideation, or could be transitioned to a local (you guessed it) not-for profit facility.

Initially, nothing changed with my job. It was the same old same old, patient care didn’t suffer, and we were doing the best with the extremely limited resources we have in Western North Carolina (that’s a whole article in itself). After a while I began to drink the Kool Aid. Eventually, I stopped looking for another job and thought, maybe this won’t be that bad.

Just as soon as I had stopped looking for another job, the wheels fell off. HCA was there “looking at our books” and the changes started. Suddenly, people needed to be out the door yesterday. Homeless, medically fragile, complex social issues, get them out as soon as you can convince a doctor that they will not come back in 30 days. (If they come back with in 30 days, Mission doesn’t get full reimbursement on their medical bills.)

I was taken off salary, and placed on hourly, because thats what HCA does. I was also told it was so I could get paid for overtime, get surge pay, and access holiday pay. What happened was my co-worker couldn’t go to her doctor’s appointment for her pregnancy without using her personal time off (that she desperately needed so she could get paid during her maternity leave). In addition, I was scheduled to work all the major holidays (hoping for some of this promised time and a half). Then I was sent home as soon a possible (just like our patients), and charged personal time off for the privilege.

So let’s come back to you. How does all this behavior affect you, the hospital customer. Two words: “bundled payments.” This is the new insurance buzz-phrase that was started in an effort to improve care by Medicaid.

The concept is simple: the insurance pays a set rate to the hospital for a certain procedure. Say you’re getting a bilateral knee replacement and Medicaid pays the hospital $60,000. That’s all the money they get for that surgery, whether you’re in the hospital one day or two weeks. Obviously, if you’re only in for one day, the hospital makes a tidy profit, and your recuperate at home (good for everybody). But what happens if there are complications, such as  a post-operative infection, and you’re in the hospital for 10 days? Well, the hospital foots the bill, and you’re unhappy.

So quality of care should go up, and the hospital is motivated to seek the best outcome. If we were working with the not-for profit Mission, I would agree, and confidently report that the hospital does the right thing 99 percent of the time. Unfortunately, we’re talking about working with a for-profit organization that’s making money for stockholders, beholden to stockholders, and committed to profit above people.

Your bilateral knee replacement suddenly becomes a huge profit maker, and the surgeon is pressured to do as many as possible. Maybe you get a post-operative infection, and the hospital pushes you out to a skilled nursing facility, and you do not receive the same stellar care that you were getting in the hospital.

The scenario assumes a well-insured patient. Just imagine how there going to treat an indigent patient, a homeless patient or an uninsured patient.

My hope is simple: call, write, or fax the North Carolina attorney general and advocate to stop this sale.

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6 Comments

  1. David D. Duncan says:

    Big Al, you’re certainly right about single-payer, and government -subsidized healthcare. Every man, woman, or child should walk in the hospital with the same insurance card as everyone else. Rich or poor, white, black, red, or yellow every person in the richest nation in the world should receive the highest quality healthcare in the world. If it’s necessary to raise taxes, so be it. Those with incomes over, let’s say $500,000 should pay a sur-tax of, let’s say for the sake of argument, 5% – 15%, on all the income over the $500,000. This would be in addition to the tax that they are already paying. This system has been employed in our tax structure in years gone by, and once people understand it, then it simply becomes a part of their thing. (Obviously I’m not in possession of the Federal budget, to the extent that one’s produced anymore, and it isn’t. Therefore, the floor and the rates would change from mine.

    Your comment about the need for a “sugar daddy” is most interesting. There are numerous wealthy people in this area who have included Mission in their wills. They have two choices. Leave it as it is, and their money goes to the somewhat questionable Dogwood Trust, or change their will to send that money to another not-for-profit organization. If it goes to Dogwood it’s not going to help the hospital provide one cent for patient care. Dogwood is looking to spend millions of dollars for “innovative” programs that have some tangential possibility of helping improve the health of people in HCA’s area of coverage. In other words, all the value of our current system is no longer available for improvement of patient care.

    Mission, like any other NPO isn’t making large profits. But HCA will pay income taxes on their profits (and they will make a profit), property taxes to the county’s in which the various facilities and located, and finally, as with any for-profit corporation, they will be beholden to their shareholders to help the value of the stock increase, and to pay dividends.

    The idea that HCA will provide better care at a lower cost, and that the Dogwood Trust will be a great thing for our area, is, in my opinion, the biggest shell game since we cut taxes on million, and were sold the bill-of-goods that it would be good for lower income and middle income.

    Just a quick closing, the idea of bundled payments is crazy, because every case in every hospital is different from any other case. That concept needs to be eliminated on the basis of good sense.

  2. With more elderly and underinsured patients in its’ 14-county catchment area than other regions that have more diversity in age, employment and health, Mission relies much more on Medicaid and Medicare reimbursement. Both reimburse much less than private insurance and as such, Mission is bleeding money. It needs a “sugar daddy’ to survive and that means a non-profit. Nobody likes it, but until single-payer, government-subsidized healthcare becomes a reality, or until Asheville becomes something other than a retiree village and tourist trap, there is no other alternative.

    • Oops, major faux pas, I meant to say “It needs a “sugar daddy’ to survive and that means a FOR_PROFIT entity”.

  3. Irene Martinez says:

    You’re also obviously an advocate for health care as am I. My good friend sent me this article. I hope you find another job where you are badly needed by the poor and homeless but where you can also be appreciated by the people you work with. Maybe if you wrote a grant to set up an organization to do what you were previously doing, you could be in charge on how it is run policy wise.

  4. Thank you, John and Jason, for this glimpse of what’s in store for local healthcare if the HCA sale is completed. As a physician who retired early from medicine in response to an earlier phase of industrialization (2001–corrupting effects of BigPharma initiatives and also an NC decision to privatize community mental health services), I’m as aware as John that the downsides he lays out for patient care are just the tip of the iceberg.

    Rather than adding to his list though, I’ll simply underline the fundamental driver John mentions. For-profit organizations value the welfare of shareholders and executives above that of their “customers.” For them, welfare is measured in profit/financial terms. The game is to maximize and privatize profit while externalizing (socializing) liabilities. To state it crudely: Give us your money; we’ll spend as little of it as practicable on the good or service you bought, and if you should have a problem with it, that’s probably your problem.

  5. Michael Hopping, MD says:

    Thank you, John and Jason, for this glimpse of what’s in store for local healthcare if the HCA sale is completed. As a physician who retired early from medicine in response to an earlier phase of industrialization (2001–corrupting effects of BigPharma initiatives and also an NC decision to privatize community mental health services), I’m as aware as John that the problems he lays out are just the tip of the iceberg.

    Rather than adding to his list though, I’ll simply underline the fundamental driver John mentions. For-profit organizations value the welfare of shareholders and executives above that of their “customers.” For them, welfare is measured in profit/financial terms. The game is to maximize and privatize profit while externalizing (socializing) liabilities. To state it crudely: Give us your money; we’ll spend as little of it as practicable on the good or service you bought, and if you should have a problem with the product, that’s probably your problem.

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