Editor's Note -
The following clipping is what represents progress in the USA!
I guess you take what you can get.
😡
-SPC
New Rule on Surprise Billing Aims to Take Patients Out of the ‘Food Fight’
Neutral arbiters are given guidance on how to settle disputes between insurers and medical providers.
by Sarah Kliff - NYT - October 6, 2021
The Biden administration released a rule Thursday that addresses one of the most fought-over provisions of a coming ban on surprise medical bills.
The rule details how a new class of medical billing arbiters will decide the fair price for emergency medical care, one of the largest sources of surprise bills. The rule received a positive reaction from consumer advocates and some legislators who drafted the law, but it “disappointed” emergency physicians, who fear it will lead to unreasonably low rates.
The ban on surprise medical bills was passed by Congress and signed into law by President Donald J. Trump last winter, but it is the Biden administration that has been fine-tuning the policy — amid intense lobbying from insurers, medical providers and advocates.
In a dispute between an insurer and a provider over an out-of-network bill, the rule directs the arbiters to focus first on the median price that other doctors and hospitals in the area have negotiated for that service.
This was the second major rule the Biden administration released on surprise billing this year, before the law takes effect in 2022. Taken together, the two regulations detail how the federal government will end what patients, academics and legislators often describe as one of the most exasperating practices in American medicine.
“We’re taking patients out of the middle of the food fight, and we’re also providing a clear road map on how you can resolve that food fight between the provider and the insurer,” said Xavier Becerra, secretary of Health and Human Services, in an interview.
Surprise medical bills happen when a doctor or other provider who isn’t in a patient’s insurance network is unexpectedly involved in a patient’s care. Patients may go to a hospital that accepts their insurance, for example, but get treatment from emergency room physicians or anesthesiologists who don’t — and who then send patients big bills directly.
Millions of Americans receive these type of bills each year. As many as one in five emergency room visits result in such a charge, and the rate of surprise billing is similar for women giving birth. Some coronavirus patients have received exceptionally high surprise bills. That includes a Pennsylvania woman who was unconscious and intubated when an out-of-network air ambulance transported her between hospitals. She was billed over $50,000 for the service.
Patients like that are essentially caught in the middle of a dispute between a doctor and an insurer, who disagree on the fair price for a given medical service. The new rule released Thursday lays out how newly hired billing arbiters will decide who, in those fights, is right.
Under the federal law, both the insurer and the doctor will tell an arbiter what they believe the appropriate price for the service should be. The arbiter will then look at a variety of factors to decide which of the two rates to pick.
The law that Congress passed has six factors the arbiters can consider. The rule released Thursday, however, directs the arbiters to focus on one of those factors as their starting point: the median prices that have been negotiated in the area for the same medical service.
The arbiter “must begin with the presumption” that this is “the appropriate out-of-network rate,” the rule states. They may consider other factors listed in the law, such as how sick the patient was or whether the hospital or doctor had made good faith efforts to join insurance networks, if they receive “credible information” from either party involved in the dispute on those subjects.
The administration on Thursday also opened applications for organizations to become arbiters. Applicants must have experience in “billing and coding” and “arbitration and claims management.”
The rules on how arbiters settle billing disputes are seen as especially important because they will determine whether the ban on surprise billing ultimately saves money for consumers, insurers and the federal government. The Congressional Budget Office estimated last year that the surprise billing ban would save the federal government $17 billion and reduce private insurance premiums 0.5 percent to 1 percent.
Most experts expect that starting from the in-network prices will ultimately lead to lower reimbursement rates. The Biden administration stated in the rule that the decision “will aid in reducing prices that may have been inflated due to the practice of surprise billing prior to the No Surprises Act.”
Trade groups representing health care providers, including emergency room physicians and hospitals, had generally urged the Biden administration to do something different: ensure that arbiters use all six of the factors listed in the law when they make up their minds. They argue that Congress intended for arbiters to have that broader deliberation, and that focusing on median in-network rates will lead to lower prices that are untenable.
“We’re pretty disappointed because this is entirely against congressional intent,” said Laura Wooster, senior vice president for advocacy at the American College of Emergency Physicians. “I’m not seeing how small physician groups will be able to work with this, and keep their doors open. Now is not the time to take away resources from emergency physicians.”
Congressional Democrats quickly applauded the new rule.
“Today’s rule implements the No Surprises Act just as we intended,” Senator Patty Murray of Washington and Representative Frank Pallone of New Jersey, who lead health committees in each of their chambers, said in a joint statement. “It establishes a fair payment resolution process between providers and insurers while finally taking patients out of the middle.”
Secretary Becerra said he expected the rule to generate “a lot of animated discussion on the part of the stakeholders in the industries” but felt the Biden administration had created a way to settle billing disputes that was straightforward and fair. “It will give patients some peace of mind that they don’t have to stand the chance of going bankrupt just because they had to go out of network,” he said.
Republican reaction to the rule wasn’t immediately available. Stakeholders are still reviewing the 521-page rule, and the administration will accept comments on it for the next 60 days. Given the relatively short timeline — the surprise billing ban is set to start in three months — major changes are not expected.
Sarah Kliff is an investigative reporter for The New York Times. Her reporting focuses on the American health care system and how it works for patients.
A version of this article appears in print on Oct. 2, 2021, Section A, Page 17 of the New York edition with the headline: New Rule Steers How Arbiters Settle Disputes Over Surprise Medical Bills. Order Reprints | Today’s Paper | Subscribe
https://www.nytimes.com/2021/09/30/upshot/surprise-billing-biden.html?
Maine Voices: We must hold hospitals, government accountable on health care costs
We’ve won the right to know prices – now we need robust enforcement, meaningful penalties and full disclosure.
We’ve won the right to know prices – now we need robust enforcement, meaningful penalties and full disclosure.
Since ancient times, one of the primary tenets of medicine has been that physicians should “first, do no harm” to our patients. Today, we also need to add “do no financial harm.” The best way to do that, and to protect our patients’ finances, is through complete price transparency.
The ability to see and compare prices would usher in price competition, which would bend the cost curve down for a change, allow patients to shop for the best value for their health care dollar and slow the unhealthy trend of consolidation in the health care industry.
Thankfully, as of the first of this year, a new hospital price transparency rule went into effect, giving Americans the right to know the price of their health care up front.
The problem is that many hospitals throughout our state are not complying with the federal law. A report released last month by a national nonprofit organization showed that the vast majority (94.4 percent) of hospitals, including most of those in Maine, were not following the rule.
They claim that they cannot comply because the information is not readily available, which insults the intelligence of the average Mainer. All these hospitals have multimillion-dollar billing systems that can, and do, generate bills to patients and insurance companies on demand. We all see the prices in the explanation of benefits we receive – after we get health care we cannot return. Obviously, they know the prices but are unwilling to disclose them. There is no reason that, upon request, hospital billing personnel couldn’t enter the procedure code of a particular service (called a CPT code), and display the price the hospital charges in advance. If hospitals really cannot do this, perhaps there should be intense audits of their accounting systems.
Although doctors are often blamed for rising health care costs, I assure you, we want what patients want. We want to know prices, too, but hospitals and insurers also keep us in the dark. That has always been unethical, and now it is criminal.
I have written to Maine Attorney General Aaron Frey asking him to help enforce the law and hold hospitals accountable. To do that, our government needs to dramatically increase the financial penalties imposed on hospitals that don’t follow the rule. Currently, the penalty is only $300 a day. Worse, the government has yet to fine a single hospital for not complying with the government’s own rule. What good is a law with no teeth? The fine should be 10 times that, or $300 a day per hospital bed, and be robustly enforced. We also need to eliminate the loophole in the rule that allows hospitals to simply provide estimates, not guaranteed prices. By their complacent inaction, government is sending the message that these hospitals, most of which are nonprofit, so don’t pay taxes, are above the law. Perhaps the state of Maine should re-examine the tax-exempt status of any hospital system that doesn’t comply with this very important consumer protection.
We have a long way to go to fix our broken health-care system, but demanding what is rightfully ours, the right to know the cost of care before getting a surprise bill, is an essential step. Mainers deserve nothing less and should demand nothing less.
Editor's Note -
Dr. Ciampi, author of the preceding letter, is right to state that patients and doctors should know the prices of the products and services they use. What he does not seem to realize is that the current system is designed to obscure or conceal prices He doesn't seem to understand that there is no such thing as "a price". There are many prices for the same services, depending who the patient is, what insurance company they use, and many other extraneous factors.
Even if accurate prices were available in advance, there is still the question of whether the products or services were appropriate for the patient's disorder or were necessary at all. How do you know your doctor is acting on your behalf, and not succumbing to the pressure being applied by their employer to benefit their bottom line in our for-profit system?
The patient really doesn't have the knowledge necessary to make that judgement. "Consumers" (we used to call them "patients") have no power, and more and more institutional "providers" (we used to call them doctors, nurses and hospitals) even if they are nominally non-profit-are behaving like for-profits.
If consumers have no power, markets cannot function.
That's one of the most important reasons markets do not, have not and will not ever work in healthcare. Only in America would the notion of markets applied to healthcare have anywhere near the credibility it enjoys in the America. A French friend of mine once made the statement "When it comes to healthcare, Americans are suckers".
Regretfully, I agree.
-SPC
While Democrats bicker, our unacceptable health-care status quo continues
For all of Americans’ political divisions, on some issues there is more agreement than many of us may realize. Medical care is one such area. A majority of Democrats, Republicans and independents want the federal government to negotiate with pharmaceutical companies over prices for prescription drugs covered by Medicare, polling this summer shows. Here’s another point of agreement: Most U.S. adults think Medicare should offer dental coverage.
Simply put: We need both. The United States is the only first-world country that does not negotiate or regulate what Big Pharma can charge for its offerings. Not surprisingly, Americans pay more for pharmaceuticals than citizens in other nations. Public Citizen reported this week that Americans shell out more for the top 20 bestselling prescription drugs than the total paid by every other nation on the planet combined.
As for dental care, the surgeon general warned back in 2000 of “a silent epidemic” of dental and oral diseases afflicting many Americans. A 2012 survey published in Health Affairs found that about half of all people on Medicare hadn’t seen a dentist in the preceding year. The issue was almost certainly cost. Those who had dental insurance were more likely to have sought care. As of 2020, at least 20 percent of adults reported delaying or skipping necessary dental care within the previous two years. Dental health is not a vanity issue — people with gum disease are at higher risk for heart attacks and strokes.
Despite public support for expanding coverage and limiting health costs for consumers, it’s quite possible Americans will remain stuck with the (unacceptable) status quo. The blame for such an outcome does not accrue only to the Republicans seeking to block President Biden’s agenda every which way they can. The other culprit is the corrosive role that special interest and corporate money plays in our politics, which is to say in both major parties.
Consider: Three Democratic members of the House Energy and Commerce Committee — Reps. Scott Peters of California, Kathleen Rice of New York and Kurt Schrader of Oregon — voted down a provision this month that would allow Medicare to negotiate drug prices with pharmaceutical companies. Good-government types pointed out that the trio themselves have collected about $1.5 million in campaign donations from Big Pharma.
The three, I am obliged to note, have denied that corporate money influenced their votes. They say that the legislation they voted against would lead the pharmaceutical industry to spend less on innovation and development. (Somehow, almost no one parroting this argument ever explains why the United States should bear the brunt of this financial burden.)
Instead, Schrader and Peters are championing a bill of their own, one that would permit government bargaining over prices of a significantly smaller number of drugs. Is this less-effective effort going anywhere? Well, Sen. Kyrsten Sinema (D-Ariz.) has told the White House that she can’t get behind any of these proposals to rein in the pharmaceutical industry.
Absent a negotiation provision — which the Congressional Budget Office has estimated would save the federal government $456 billion over 10 years — it’s quite possible that Medicare dental coverage won’t happen. That would certainly make the American Dental Association happy. The association has been fighting the proposed expansion, fearful that its members — that is, dentists — would not get paid enough by the federal government. (It is instead promoting a fig leaf of a plan that would offer dental coverage only to indigent and nearly indigent seniors.)
Notably, the dental benefits for seniors in the $3.5 trillion reconciliation package wouldn’t begin until 2028. That doesn’t help seniors in the here and now, so it’s hard to see how it would make for a winning campaign issue in 2022. Conversely, it’s easy to imagine that this timing would allow opponents to regroup, peddle false information about the plan and attempt to stop the benefits before they could take effect.
No one would need to write the playbook for this — it’s what happened with the Affordable Care Act.
This back and forth over popular reforms — ones that are urgently needed to improve Americans’ health and well-being — points to a bigger problem looming over our politics and the Democratic Party. Donald Trump pledged to “drain the swamp” — which, of course, he didn’t do. Biden’s pitch to Americans was that his long-term relationships with Republicans and with political and business power brokers would pay off for all of us.
But there’s a warning implicit in Democrats’ infighting over the president’s agenda. If Biden can’t wrangle enough members of his own party to deliver on initiatives as popular as cracking down on prescription drug prices and adding dental coverage to Medicare, it undercuts a huge selling point of his appeal. Will voters be patient? Or, disillusioned, will they turn to others who promise they can corral Washington and corporate interests — and deliver in a bottom-line way that improves peoples’ lives?
Letter to the editor: Mainers deserve equitable health care system
In August, the Commonwealth Fund issued a report comparing health care in the U.S. to 10 other high-income countries. The U.S. compared dismally, ranking last in health care affordability and health equity. The U.S. health care system also has the highest rate of infant mortality and deaths that would have been prevented with good health care. Although Maine’s infant mortality and overall mortality rates are lower than the U.S. average, they are still significantly worse than the other 10 countries.
The report’s authors note, “Four features distinguish top performing countries from the United States: 1) they provide for universal coverage and remove cost barriers; 2) they invest in primary care systems to ensure that high-value services are equitably available in all communities to all people; 3) they reduce administrative burdens that divert time, efforts, and spending from health improvement efforts; and 4) they invest in social services, especially for children and working-age adults.”
It is long past time for us to improve our inequitable and overpriced health care system. Maine Healthcare Action is a group of dedicated Maine residents who are working on a ballot initiative, demanding that the Maine Legislature implement a publicly funded, equitable health care system for all Maine residents. Please sign their petition to put health care on the ballot in 2022. For more information, visit mainehealthcareaction.org
Julie Keller Pease
Topsham
Ban on 'surprise' medical bills to take effect Jan. 1
The Biden administration on Thursday put final touches on consumer protections against so-called “surprise” medical bills. The ban on charges that hit insured patients at some of life's most vulnerable moments will take effect Jan. 1.
Patients will no longer have to worry about getting a huge bill following a medical crisis if the closest hospital emergency room happened to have been outside their insurance plan's provider network. They'll also be protected from unexpected charges if an out-of-network clinician takes part in a surgery or procedure conducted at an in-network hospital.
The rules released Thursday detail a key part of the new system: a behind-the-scenes dispute resolution process that hospitals, doctors and insurers will use to haggle over fees. When an insurer and a service provider disagree over fair payment, either side can initiate a 30-day negotiation process. If they still can't come to an agreement, they can take the matter to an independent arbitrator.
There's also a new way for uninsured people and certain patients who pay their own way to get an estimate of charges following an emergency procedure.
“We’re hoping to give folks a sigh of relief, who have been blindsided by billing,” said Health and Human Services Secretary Xavier Becerra.
Surprise medical bills have been a common problem for people with health insurance, all the more irritating because most patients might have thought they were protected. Charges running from hundreds to tens of thousands of dollars came from doctors and hospitals outside the network of patients' health insurance plans. It’s estimated that about 1 in 5 emergency visits and 1 in 6 inpatient admissions triggered a surprise bill.
Although many states already have curbs on surprise billing, federal action was needed to protect patients covered by large employer plans, which are regulated at the national level. A 2020 law signed by then-President Donald Trump laid out a bipartisan strategy for resolving the issue, and the Biden administration filled in critical details.
The idea was to take patients and their families out of the financial equation by limiting what they can be billed for out-of-network services to a fee that’s based on in-network charges. That amount gets counted toward their in-network annual deductible.
The new protections are aimed at:
— Protecting patients from surprise bills arising from emergency medical care. Protections apply if the patient is seen at an out-of-network facility, or if they are treated by an out-of-network clinician at an in-network hospital. In either case, the patient can only be billed based on their plan’s in-network rate.
— Protecting patients admitted to an in-network hospital for a planned procedure when an out-of-network clinician gets involved and submits a bill.
— Requiring out-of-network service providers to give patients 72-hour notice of their estimated charges. Patients would have to agree to receive out-of-network care for the hospital or doctor to then bill them.
Before the ban on surprise billing, patients usually had to take the initiative themselves to work out unexpected charges. In many cases the hospital or doctor would go back and forth with the insurance company until they reached an agreement. But there was no guarantee that would happen, and patients were at risk of being placed into collection proceedings in situations they had no control over.
Health workers know what good care is. Pandemic burnout is getting in the way
Yuki Noguchi - Twitter - October 2, 2021
The desperate and frantic pace of hospital work in 2020 in New York, the epicenter of the U.S. pandemic at the time, was more chaotic than anything intensive care nurse Matthew Crecelius had ever seen. "It was like watching a bomb go off in slow motion," he says.
He was caring for double the usual number of critically ill patients and navigating hospital halls that looked more like construction zones, with giant fans and plastic tubing blowing a deafening level of extra ventilation. He couldn't hear his patients, or see them through the giant wooden doors of the negative pressure chambers.
"You shout out to somebody, 'Hey, can you check on my other people?' " he says. " 'I can't even see a monitor; I don't know how they're doing.' "
Once, while Crecelius tended to one COVID-19 patient, another ripped off his oxygen mask, triggering a heart attack. Alarms blared. Crecelius rushed to the room, swathing himself in a new gown, to try to revive the man -- who died clutching a photo of his daughter. As other nurses rushed in to help, other unattended patients started to crash.
Crecelius says he can recall numerous moments like this one, when the crush of work and burnout among health care staff had a direct impact on patient care.
"That plays out again and again, day by day, at many hospitals, and in my opinion, I think it's getting worse," says Crecelius, a traveling contract nurse who has worked in a dozen hospitals since the pandemic began.
Many health care workers surveyed say they feel burnt out and that is impacting patient care. The prolonged battle against COVID-19 has left many doctors, nurses, medical assistants, respiratory therapists and others on the front lines of care exhausted and overwhelmed, fueling greater levels of burnout that were already high. The advent of vaccines against the coronavirus sparked hope of a return to normal — only to be dashed by the latest surge of cases, driven primarily by people who aren't vaccinated.
Burnout is a common term many associate with sheer exhaustion. But the World Health Organization says it's also characterized by greater cynicism and reduced effectiveness at work. It was a huge problem in health care long before the pandemic. But now the short staffing and the crushing and unpredictable workload is contributing to epidemic levels of burnout.
"It's not good for their mental health; it's not good for the work environment. There's increased chance for mistakes, medication errors," says Ernest Grant, a specialist in burn care and president of the American Nurses Association. Many fellow nurses he talks to say they're at the end of their rope, which Grant says presents a hazard for any patient needing urgent care right now. "There is no health without nurses," he says.
Caregivers under extreme stress
But just how much burnout affects patient care is very hard to gauge. Multiple studies have linked burnout to lower quality of care. But many of those studies rely mostly on subjective measures, such as patient surveys and self-reporting by nurses and doctors. So drawing a cause-and-effect connection isn't easy.
What happened to Carolyn Dewa in California illustrates why.
After her father was hospitalized in April with cancer, Dewa had a hard time reaching his physicians. Pandemic-related restrictions at the hospital limited when family could visit, and the sheer volume of patients left the staff no time to call the family with updates or to explain treatments.
At one point, doctors treating Dewa's father halted his anti-stroke medication, thinking his throat might be too constricted to swallow the pills. "No one asked me," says Dewa, who had been taking care of her father before the hospitalization and knew he was still able to eat and swallow.
As doctors rushed between patients, she says, they were relying more than usual on numbers and charts to make decisions about how to care for each person.
A short time later, her father died of a stroke.
A painful irony that only adds to Dewa's grief: As part of her work as a professor at the University of California, Davis, she studies the effect of burnout on medical care. "I know what good care is supposed to look like," she says.
Speaking from a personal perspective, Dewa adds, she does feel burnout cost months of her beloved dad's life. But she also recognizes the extreme stress his caregivers were under. It would be very hard, she says, to pinpoint objectively how much that burnout contributed to his death.
"Medicine is a team sport," Dewa says. "So can you attribute it to one clinician? How many clinicians need to be experiencing burnout until we see an effect on quality?"
Not enough staff, no empty beds
Clearly, one huge problem is a shrinking field of seasoned professionals in medicine. Since the pandemic's start, some health care workers have retired early and many say they're considering leaving the field.
Crecelius, the traveling ICU nurse, says that increasing reliance on less-experienced health workers can hurt patients. At the small Michigan hospital where he works now, he recently discovered that a nurse on a previous shift had inadvertently put a heart attack patient on the wrong medication.
"She's a newer nurse and doesn't know this is completely inappropriate. Had someone more experienced been here, we would have been able to catch that," he says.
Crecelius says he used to think of such incidents as teaching moments. These days, he has no time or energy to mentor. He just complains to his colleagues, about his colleagues.
That shortness of time, staff and fuses can fuel still more burnout.
Recently in Indianapolis, for example, a combination of the latest surge in COVID-19 cases and a dire shortage of staff meant all the acute-care beds across the region were full. Lindsay Moore-Ostby, a family doctor in the city and member of the advocacy group Physicians for Patient Protection, says one doctor dealing with that crisis tried to transfer a patient, personally calling every hospital within several states — around 40 hospitals — she recalls.
This doctor was "trying desperately to find a bed for a patient who needed ICU care," Moore-Ostby says. At that point, the doctor told her: " 'Now I'm spending time trying to make this transfer happen — so, what if I can't provide the care I need to the other patients who need me?' "
"It's really a game of dominoes," adds Moore-Ostby, "where the doctor is just emotionally devastated because they can't fix it."
A few months into the pandemic, Moore-Ostby started her own concierge practice, cutting back on her roster of patients. She did so, she says, primarily because having no time to talk to patients robbed her of what had led her to the profession in the first place.
"That little bit of time connecting with the patients — that's what they like, that's what they need and deserve," she says. "And it's what I love about medicine."
Solutions are in the details
As the problem of burnout multiplies, some health care systems are trying to find solutions – discovering they often are found in the small details of the work.
For much of this summer, Tampa emergency doctor Damian Caraballo couldn't staunch the flow of unvaccinated COVID-19 patients coming in. Nor could he stop the stampede of co-workers — nurses, EMTs, and lab techs — who kept leaving, making the pace of work more frantic for those who remained.
"Even things as simple as registration; we're short registration people, and that puts a delay on everything," Caraballo says. The average waiting time in his ER ballooned to over 10 hours. "So it has a downhill effect."
On balance, the pandemic has made all the normal bureaucratic hassles of the medical system that much more grating, Caraballo says. But he can also point to recent changes that have made a difference: His hospital started allowing remote monitoring of some COVID-19 patients.
"I've been able to send people home" if they have sufficient internet connectivity, says Caraballo, who is a member of patient-advocacy group Physicians for Patient Protection. Florida also recently relaxed rules about where patients could receive IV infusions of monoclonal antibodies to treat COVID-19, a move that also eased Caraballo's patient load. "All those things would take stress off the hospital because we wouldn't have to admit these patients."
Certainly, chronic short-staffing and overwork are huge factors intensifying burnout. But better management can also help alleviate it, even under extreme conditions, says Christina Maslach, a psychologist at the University of California, Berkeley, whose Maslach Burnout Inventory is the basis of the World Health Organization's definition of the workplace syndrome.
"We have to get past this notion that the job is what it is and you can't fix it, you can't change it, you just have to deal with it no matter what," Maslach says.
Often it is a collection of irritants at work that make people feel undervalued, disregarded and eventually burnt out, she says: "Little stuff. What are the chronic pebbles in your shoe?"
She says the fixes, therefore, are often small and targeted.
One of the most common complaints health care workers talk about, Maslach says, is a perfect example: not having a functioning copier.
That might seem minor, she says. But what makes the broken Xerox so toxic is that it taps into a simmering rage that health care staff universally bemoan: The byzantine paperwork and insurance forms that suck up their after-hours and weekends. So having to hunt down a copier that isn't out of ink or jammed doesn't just make the patient backlog worse, it ignites an existing fury within.
Maslach says she's seen huge morale boosts just from hospital management buying a new copier. In addition to making the work faster, "it gives people the sense they are being listened to, that they're being taken seriously," she says.
And she says combating burnout means identifying and tackling these kinds of problems that plague the workplace.
"People keep saying, 'What is the one thing we can do?' " she says. "There is no one solution. There are many."
Implementing staff ideas for fixes
Often the best suggestions come from those who do the work.
Massachusetts General Hospital realized that early in the pandemic.
As the nation's supply of rubber gloves ran critically low, a triage nurse came up with an idea for a plexiglass wall at a patient's bedside. It had arm holes cut into it, where a set of sleeve-like rubber gloves could be attached. That way, caregivers could slide their arms through and adjust a patient's oxygen line or check a pulse — it was quicker and safer and didn't require a new pair of gloves.
"I thought it was a great idea, so we implemented it very quickly," says Ali Raja, executive vice president of emergency medicine at Mass General. "And the triage staff absolutely loved it."
One of the things they loved about it, Raja says, is that adopting staff ideas gave them a sense of agency over their work lives. "Implementing as many ideas as possible — especially if they're not very expensive — can definitely not only acknowledge the staff's expertise and what they're going through, but quite honestly can give you some really good solutions that the leadership just won't have thought of, because they don't have boots on the ground."
He says staff came up with other ideas: to set up a COVID triage unit outdoors in the ambulance bay and to give iPads to patients, so they could more readily communicate with staff, who then didn't have to suit up in personal protective equipment.
Another critical way of fighting burnout is addressing the mental health challenges that come with it. Officially or unofficially, many hospitals and workers talked about the importance of camaraderie.
Some hospitals converted waiting rooms left vacant because of visiting restrictions, into staff lounges or to be used for peer counseling. Talking about the difficulties of managing work and life sometimes led to staff volunteering to cover for one another in family emergencies.
"I've been asking my friends for help when I've needed it," says Raja, and his co-workers urged him to seek therapy for the first time. "That's not something I would've been willing to do, but the fact is, so many of my colleagues have acknowledged that same burnout and told me how much that helped."
ER doc Damian Caraballo says he encourages the same at his hospital in Tampa: "Offer moral support for them. In the short term, I think that's the best we can do."
For the most part, there are not too many quick ways to solve burnout, he says. It doesn't help knowing the crush of work these days is largely preventable; two-thirds of patients he sees are people with COVID-19 who didn't get vaccinated — even though they could have — often young people. That fact, combined with staff shortages, " it just creates this really tough environment that makes burnout even worse," Caraballo says.
Losing passion for the field
The worst part, say health care workers like traveling nurse Crecelius, is that burnout is robbing them of their sense of purpose — making it harder to care about the work itself.
"Last year this time, I had a greater sense of 'This is kind of my duty,' " says Crecelius, who says he's always had an instinct to run toward disaster — wherever help is most needed. While working in the hotspots during the early months of the pandemic, he says, he told himself: " 'I'm able, I'm young; I can make a difference. Let's go and see if we can put this fire out.' "
In those days, he donned a kind of emotional armor, he says — muscling through shifts during which he lost patient after patient, then prepared them for the morgue.
Then, on a road trip this summer in an RV he built with his wife, Crecelius was standing in line at a grocery store, waiting to buy bananas and yogurt, when he glanced at a tabloid with a cover story about the pandemic.
"And it had a picture of someone loading zipped-up bodies onto a truck," he remembers. "I lost it."
He trembled as he looked at the picture, flooded with memories of volunteering to load bodies into the morgue. He thought of the families he'd helped say goodbye, holding a phone to the ear of his patient.
The work feels different to him now, Crecelius says. Though he's a fifth-generation nurse, he is looking to switch careers.
"Now that there is a vaccine, people aren't getting it," he says. Nursing has changed for him. "I'm not interested anymore."
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