Providers of Health Care and Market Medicine

QUESTION:  Take the nursing shortage we are now experiencing. Isn't it a simple market situation where salaries have to increase to attract more nurses in to the field. Why see any more in it? 

In the first place the situation has been incorrectly labeled as a "nursing shortage" (which is more the effect than the cause). It would be more accurate to call the crisis one of "understaffing". Consider the following data from mid 2001 data (research study conducted by Peter D. Hart research associates on behalf of the Federation of Nurses and Health Professionals).



Fully 50% of current nurses say that, within the past two years, they have considered leaving the patient care field for reasons other than retirement. Nurses who have spent at least 10 years in the field (52%) and those in clinical specialty areas (54%) are the most likely to have considered leaving for nonretirement reasons, but even among primary care nurses (47%) and those with less experience (45%) substantial proportions indicate that they have considered departing the field. Fully 54% of current nurses under age 50 and 41% of those age 50 and over have thought about leaving the patient care setting to do something else.

QUESTION:  But still nurses must be leaving the field due to low salaries. So still that must be the root cause of the nursing shortage and it will be corrected by the market soon enough, right?

Individual nurses leave patient care for many reasons, but the biggest cause for their departure is the stressful working conditions, especially as they relate to understaffing. Nurses are leaving patient care because, too often, the conditions they face today are intolerable .



The top reason (56%) why nurses have considered leaving the patient care field for non-retirement reasons is to have a job that is less stressful and less physically demanding(research study conducted by Peter D. Hart research associates on behalf of the Federation of Nurses and Health Professionals). Together with wanting a more regular schedule and regular hours (largely also an effect of understaffing), fully 78% of the reason given for wanting to leave nursing would be "understaffing" related. That is three and a half times more than all the other 3 reasons given combined which are not very related to understaffing. Furthermore for former nurses leaving in late 1990's the number who left because of intolerable stress was three times greater than for nurses who had left the field in the early 1990's or still earlier - coinciding with the rise of "managed care".

QUESTION:  Okay so there are other conditions that need to be adjusted in the nurse-employment market, but the adjustment is well underway already why worry?

By 63% to 9%, current nurses say that the overall situation facing nurses where they work has been getting worse rather than getting better (research study conducted by Peter D. Hart research associates on behalf of the Federation of Nurses and Health Professionals). Current nurses also report a low level of morale among registered nurses at their health care facility, with only 31% who rate morale as excellent (5%) or good (26%) and 68% who say it is fair (42%) or poor (26%). There is a striking difference, however, in the level of job satisfaction between those who left the direct patient care setting during the late 1990's (47% satisfied, 53% not satisfied) and those who departed before that (73%, 25%).



Former and current nurses agree (70% affirming) that managed care has a had a negative impact on the profession. Sixty-two percent of current and 71% of former nurses say that helping patients and their families is the most enjoyable aspect of being a nurse. Nurses say that improved staffing and lessening paperwork & administrative duties would be the two greatest future changes that would encourage them to stay in the profession. Therefore, unless we abandon the market medicine system these problems will not be addressed.

QUESTION:  But the crisis is especially severe for the more highly trained registered nurses (RNs). Is there any evidence that anything other than salary and benefits needs to be addressed in adjusting the registered nursing shortage?

Current nurses were asked to select from a list the one or two biggest problems with being a direct care nurse (research study conducted by Peter D. Hart research associates on behalf of the Federation of Nurses and Health Professionals). Nearly 8 times as many chose Understaffing, Stress/physical demands of the job, Not receiving support from administration, Unpredictable work & schedule/long hours, those who chose Low pay and poor benefits (on average twice as many chose one of the four former reasons as "biggest reasons" as chose insufficiency of pay). Clearly this indicates that the problem is poorly described as a nursing shortage due to market forces.



The top 5 reasons listed by RNs as severe problems with their work situation were Staffing: patient load, Staffing: acute care*, Time with patients, Time for paperwork, Physical demands. All of which were rated severe by more than half all current nurses (average of 62% of all nurses so rating).



In a 2002 report^*1 it was found that each patient added to a nurses' workload increased patient mortality by 7%. In 2003^*2 it was reported that nurse workload and the hospital's educational composition of the nurse workforce are equally important in their association with mortality rates following common surgical procedures.  Here is a problem costing American lives, raising medical errors and malpractice premiums and endangering all patients, so that hospitals can be run for profits and to stay ahead with insufficient reimbursements from insurers (taking out their huge profits).  Surprising that nurses have become discouraged?

QUESTION:  Isn't a large part of the problem in financing health care today the enormous salaries that physicians are commanding?

If health insurance CEO's can put away tens of millions individually each year, why shouldn't someone highly skilled and directly responsible for saving many lives make a quarter or half a million dollars in our capitalist system?  And why should large shareholders in insurance companies, pharmaceuticals and equipment companies be individually extracting hundreds of thousands of our health care dollars without providing any service at all?  Shouldn't these questions be answered first before we consider problems with what a physician might be earning? 

It should also be mentioned that when one of us has to go into the hospital for a 6-8 hour operation, like heart surgery or advanced stage cancer debulking and when its just one of many such surgeries that surgeon is performing that week (in addition to other duties in the clinic), we might rejoice in the fact that the surgeon has been induced to stick with a very stressful job.  And also that he/she can get some totally relaxing time-off and not have to worry about personally mowing his lawn, or fixing his plumbing. We might be glad they come in to the Operating Room refreshed on Monday.

See other questions on physician salaries in the FAQ section on Financing UHC (questions 6, 7)

QUESTION:  Okay, even allowing that there are greater abuses of some CEOs, it's still true isn't it that there are physicians earning several times what a reasonable high salary should be

Yes. Some physicians are earning more than is probably necessary or even as indicated by their training, sacrifice and commitment. Excessive salaries (excluding physicians serving as corporate CEO's) are mostly within certain medical specialties. A greater financial problem than the high salaries even within those specialties is probably that there are too many specialists. Often these are specialties serving the most affluent neighborhoods also.

Communities with more primary care physicians have lower mortality rates, according to a new study, confirming the advantages of wide access to primary healthcare services. Communities with a greater proportion of specialists did not have a measurable, positive effect on U.S. health status compared with other industrialized countries. And such disparities in primary care­specialty physician distribution is likely to lead to even wider gaps in health status and outcomes relative to other countries.

Except for the US, the number of visits to generalists "greatly exceeds" the number of visits to specialists. "It appears that it is the relative roles of primary care physicians and specialists rather than their number that makes the difference in health outcomes. Evidence of this is the three-fold difference between the United States and the United Kingdom in the percentage of people seen by a specialist in a year" according to the study. For overall mortality, a 20% increase in primary care physician per 100,000 population yielded a reduction of 34.6% in deaths per 100,000 Ref-3.