Health care’s goal is in peril [PODCAST]

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“The U.S. health care industry has large challenges that can be overcome if we remember why our systems and services exist. We are here to help patients, and we must obtain the needed staffing capacity to drive throughput so patients can receive the care they need. Our system will cease to exist if hospitals are forced to close or begin to limit services offered due to financial concerns. As stated in the title of this paper, the ‘goal’ is in peril. However, by remembering and instituting key principles from operations, accounting, and with federal assistance, we can overcome the challenges worsened by the pandemic and build a resilient health care system that will be in place in this country for years to come.”

Vincent Roddy is an emergency physician.

He shares his story and discusses his KevinMD article, “The goal of health care is in peril.”

Reflect and earn 1.0 AMA PRA Category 1 CME for this episode.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Vincent Roddy. He’s an emergency physician, and he wrote the KevinMD article “The goal of health care is in peril.” Vincent, welcome to KevinMD.

Vincent Roddy: Pleasure to be here. Thanks for having me.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Vincent Roddy: Yes. I’m originally from Northern Virginia. I grew up right outside of the D.C. area. I was fortunate enough to go to Duke University, where I was an econ major, pre-med, many years ago. I’m not going to tell you the year I graduated, but I went to Duke and was able to go to Virginia Commonwealth University School of Medicine in Richmond, Virginia, for med school. I then matched in emergency medicine at Mount Sinai in New York City, so I worked between Manhattan, at Mount Sinai, and Elmhurst Hospital in Queens. That was for four years. I’m very proud, and I just had such a great experience in New York City. For the last several years, I’ve been working here in South Florida. I’m based in Miami. I’m an emergency physician full-time, and I’m also a medical director of our department. So that’s pretty much my story.

Kevin Pho: All right. We’re speaking toward the end of January. Tell us what you’re seeing in the emergency department today.

Vincent Roddy: I mean, we still see sick patients. We definitely still see sick patients. I would say that the Omicron wave is kind of on the downturn, but that’s not to say that you can’t still necessarily get sick with it. It wasn’t as bad as the Delta variant, and it was definitely not as bad as the first wave. But COVID still comes into the emergency department. Patients can still get it. The difference now is that the stay-at-home orders are no longer in place, and so it’s COVID patients mixed in with the regular type of presentations that you’d see in the ER, and that can sometimes obviously cause some throughput issues and some wait times.

Kevin Pho: So you mentioned you’ve been practicing emergency medicine for several years now, and you’re now medical director. What are some of the challenges that face emergency medicine?

Vincent Roddy: I mean, honestly, the challenges of emergency medicine are kind of reflective of the challenges of the overall health care system. The main ones affecting hospitals in the United States right now, and ERs around the country, are really just a lack of qualified staff. I mean, we do have physicians, obviously, but there are just really not enough nurses. There’s not enough ancillary support, like techs and, pretty much, nurses and techs. I mean, that’s the issue. And so you can come, and the physicians will be there to see you, but sometimes it might be a challenge having the support staff around the physicians to service the patients and to give the needed services the patients require.

Kevin Pho: So we talked more about that in your KevinMD article titled “The goal of health care is in peril.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why?

Vincent Roddy: Yeah, you know, I mean, “The goal is in peril,” that was the original title of the article, “The goal of health care is in peril.” I’m currently doing my MBA at Duke University, an executive MBA. In term five, we were taking two classes. We were taking managerial accounting, and we were taking operations management, and these topics are highly related to one another. The more I learned in those classes, the more I saw that what we were learning was related to what I do in the emergency department. Operations is throughput, and the managerial accounting aspect is really just the finances that people don’t really think about or know about in the background that allow the hospital to function.

Essentially, what happened during the pandemic was that stay-at-home orders went into effect almost overnight. When the stay-at-home orders went into effect in Florida, ER volumes dropped by 50, 50 to 60 percent. Now, you might not think that this is a problem, but it is, because the hospital is an organization that has a financial structure that has to be considered, and if patient volumes drop, you have to suddenly cut your staffing hours. So now suddenly we’re in a pandemic, and people are used to being paid and having hours on the schedule. You have to decrease nursing staffing hours, and you have to decrease physician hours, because the patient volumes have decreased so much. And that issue has persisted throughout the pandemic. I can tell you that in area hospitals in South Florida, volumes in some places have come back to maybe 90 percent or so, but in other hospitals, the volumes are still persistently decreased, 40 percent from what they were pre-pandemic.

And so this is a problem, because staffing hours have been cut, and the patients that actually do come to the hospital are still incredibly sick. So there’s less staff at the hospital waiting to greet patients when they come. We do the best that we can do, but patients might wait a little longer. Sometimes health outcomes can be put at risk as a result of waiting longer. And a lot of elective outpatient surgical procedures and other services have been decreased at the hospital purely because it’s just not the patients coming. I mean, the revenue that the patients would earn is no longer there, so they have to decrease services to kind of make themselves whole financially. That’s a problem.

Kevin Pho: So tell us a story about all of these statistics and numbers that you just mentioned. Can you tell us a story or case study about how a specific patient has been adversely affected by the lack of techs and nurses and some of the issues that you just described? How does this specifically affect a patient that you can remember?

Vincent Roddy: I want to be very clear. I mean, if you’re sick and you come to the hospital, we’re going to do everything that we can do to service your needs. But just what I’ve seen in my experience is that, for example, patients come to the hospital, and they might have to wait a little longer than they might have previously waited, purely because there’s just not staff there to service you. The best example I can use really is the stock market, and most people have probably seen this before in movies or in film or something like that. In the New York Stock Exchange, when they’re trading stocks, there are so many people there to take your order, right? I actually looked at this. I believe the New York Stock Exchange only operates at maybe 20 percent utilization, meaning that there are so many workers there that only maybe 20 percent of them are ever busy at any particular time, taking the orders and doing the things they need to do to help these financial transactions. In the hospital, people are at 100 percent utilization all the time. There’s just enough staff to actually meet the patient arrivals, and if you decrease staffing hours, despite the fact that patient arrivals have decreased, everyone is still at 100 percent.

So, for example, in the Delta variant surge a few months back, it was very difficult to meet that increased demand as the patients came, as they were sick with Delta. And even a few months ago with Omicron, or a few weeks ago with Omicron, as more and more people came to the hospital, you were not able to increase the staffing the way that we needed to, because there are national nursing shortages and whatnot. And so it just kind of was a tough situation. It was stressful. I mean, patients maybe waited a little longer than they would have otherwise. And as I said before, hospitals had to decrease some of these services that they offer, purely because they just don’t have the staff that they need to support these things.

Kevin Pho: Now, what are some of your answers that would solve some of these issues? We hear, obviously, about the Great Resignation. I hear about nurses all the time going to travel companies, and these travel companies offer these nurses several times the pay that a hospital can offer them. Now, what are your solutions to get us out of this mess?

Vincent Roddy: So I mentioned this in the article, and what your viewers need to understand is that being a health care worker, this is actually really hard work. It’s not necessarily glamorous work. The people that are drawn to this profession do it because they truly want to help people, but when you’re in it, it’s hard work. I mean, you’re serving people all the time, and sometimes the patients are sick, sometimes the patients are a little irritable, and sometimes the patients don’t understand that they might have to wait because you’re dealing with another patient. So that is the reality of health care that I’m not sure people truly understand. And so what has happened is that nurses have historically been underpaid in this country for the value that they bring. I mean, people should be paid at a level that is commensurate with the value that they bring.

Now, what have we seen during the pandemic? We’ve seen that the essential health care workers, the physicians, the nurses, the techs, the respiratory therapists, the custodial staff in the hospital, or even our unit secretaries, these people are truly essential workers, because if they’re not there, the whole hospital system will literally shut down. You will come to the hospital, there won’t be enough nurses, there won’t be enough techs, and you’ll have to wait, and that could potentially put your health at risk. So historically, these people have been underpaid, our nursing staff, the ancillary support staff, all this type of stuff, and it’s really, really hard work.

So when the pandemic happened, a lot of these companies decreased their hours because maybe they weren’t in a COVID surge at that time. In the areas of the country that actually did have COVID surges, they needed staff, so it created a supply-demand mismatch. So now suddenly, hospitals in COVID hot spots that had more financial resources were willing to pay nurses three, four, five times the amount of money that they normally paid, purely to get them into their system so that they could actually see these patients. I mean, the reality is that it’s created a capacity crisis for the hospitals that can’t do that. So if you’re in a poor area, or working in a hospital that does not have as many financial resources, and they can’t afford to pay these nurses more money, then there’s just not going to be enough staff to service the patients.

And I talked about this in detail in the article with regard to what the solutions could be. I mean, really, the federal government needs to do more to shore up the worker shortages that exist right now as far as nurses go in this country. That situation is projected to get worse over the next 10 to 15 to 20 years, as more and more of our nurses are leaving the profession to become nurse practitioners. Many of them have been motivated, I guess, by financial concerns to do that. I mean, a regular bedside nurse is not going to be paid as much as a nurse practitioner. And then many of the regular nurses, or the clinical nurses that we need in the department and around the hospital, have left and taken the lucrative traveling jobs, as we said before. But all of this has been a result of just nurses being underpaid to begin with. I mean, had they been paid at a level that was commensurate with the value that they were bringing to the health care system to begin with, I don’t think that we’d have these problems.

And it’s disappointing to see that the federal government’s not doing more to address this. The federal government needs to do more to address the pay inequities that exist within health care as far as our support staff. Private industry could probably do more as well, maybe with federal assistance. I mentioned in the article that historically, in the United States, we’ve been recruiting nurses from the Philippines to meet our health care needs as far back as the 1960s. We should probably look at bringing more foreign-born, qualified nurses into this country, as our population is aging, as more and more nurses are leaving the profession, and as the demand for health care services is not going down in this country.

So in short, the whole purpose of the article was just saying that the goal of health care is to provide on-demand services for people in this country. The only way that you can do that is if you actually have the staff there to provide the needed capacity and resources to do that. Currently, in the United States, we do not have the staffing capacity and resources that we need. We’re not producing enough nurses. Nurses are leaving the profession to become nurse practitioners. If you ask many of them why, it’s purely because a clinical nurse might make $35 an hour, whereas a nurse practitioner is going to make closer to $70 to $80 an hour, maybe even more than that. Right now, travel nurses are making $100, $150 an hour. I don’t think that $150 an hour for travel nurses is necessarily sustainable, but I don’t think that $35 an hour is necessarily fair for them either, because I’ve seen them work during the course of my career, and they provide a tremendous value to our patients and to our health care system.

So when I say the goal’s in peril, what I’m saying is that we don’t have the staff to run throughput for the patients. If you get sick in this country and you come to the hospital, you may have to wait longer than is ideal, purely because there’s just not enough staff there. And what we need from our politicians, our policymakers, and from health care corporations is to do more to shore up our health care workers. We need to support them the same way that we need to support the patients.

And in health care, it’s sometimes taboo to talk about the financials of it. I mean, the reality is this, and we’re talking about this in business school right now: There’s a quote, “No profit, no purpose.” Now, what does that mean? I mean, you need a margin in any business. You need a margin to keep the business open. You need a profit margin to pay the staff, to pay for your overhead expenses, and to recruit and retain people. And so in health care, somehow in this country, health care reform has been kind of pushed onto health care workers. And you know, this is a physician. Health care reform to the politicians is paying you less money for the work that you do, even though you’re providing an on-demand health care service that patients need and require. That’s not the answer.

They want to decrease health care spending as a percentage of GDP in this country. I think we’re at, like, 18 percent right now. They think it’s unsustainable; it’s going up. But true health care reform is not paying us less, or paying the nurses less, or paying the techs less for the needed services that we provide, particularly during a pandemic. True health care reform is paying the staff what they need to pay to provide the capacity, so the patients can continue to get the services that they need, while they need them, on demand, because we’re a first-world country. Additionally, it would be encouraging people to live healthy lifestyles: aerobic exercise, diet and exercise, and mental health services. If we invested in those things over the course of the next generation, 10, 15, 20 years, then you would see a decrease in health care spending as a percentage of GDP. But as physicians, we need to push back on people just essentially taking from us when we’re the people actually providing the needed service.

And so that is the real takeaway from the article. I mean, the goal is that we need to support nurses, we need to support techs, we need to support our custodial staff, and we need to support the unit secretaries. If they’re not at work, the whole throughput of the hospital becomes hamstrung. And I mean, I’m passionate about this, Kevin. I want us to do something about the capacity challenges and staff challenges that we face in this country. I’m currently in my last term of my MBA at Duke, and so this is a pretty big research focus for me, where I’m going to be spending the next maybe four to five months looking into this and hopefully coming up with actionable solutions, implementable solutions, for what we can do regarding our capacity challenges. But the goal is in peril. You heard it here first. We’re not seeing this on television from the politicians or even from the news broadcasters. People are sick. They want health care services, and we have to provide them. Only over the long term, with us living healthier lives, can we really get the type of health care reform that we need, with people living healthier lives and spending less on health. We need to pay our nurses, and we need to pay the staff to get the capacity we need.

Kevin Pho: We’re talking to Vincent Roddy. He is an emergency physician, and he wrote the KevinMD article “The goal of health care is in peril.” Vincent, what kind of long-term effects do you see from these nursing and tech shortages? I get the sense that the government may be waiting out the pandemic, and hopefully, as the pandemic dies out, these nurses can come back. But I’m interested in hearing your perspective. What do you see as some of the lasting impacts from this Great Resignation and the shortage of techs and nurses?

Vincent Roddy: People need to realize that nurses, physicians, techs, custodial staff, all these people truly are essential workers. Essential. They must be paid at a level that is commensurate with the value that they bring. If you don’t think that the health care system in this country brings tremendous value, just imagine what it would have been like had we not had it during the pandemic. It would have been even more of a calamity and just a terrible situation.

As far as the long-term lasting effects, I mean, a clinical nurse will never accept $35 an hour ever again. Why wouldn’t it? If there are contracts in Texas that are paying nurses $200 an hour, $150 an hour, $40,000, $50,000 a month, whatever it is, for however many shifts they would have to work, why would they ever go back to living paycheck to paycheck at $35 an hour, knowing that the whole health care system is essentially depending on their services? Now, you asked the question as far as what’s going to happen long term. I don’t think that those rates are sustainable in the long term, but I do think that there needs to be some type of new steady state that exists with the nursing profession, because you have to pay them enough. No profit, no purpose. You have to pay the staff enough to motivate them to come to work to do this hard work. Yes, it’s about patient care. Yes, it’s about empathy. Yes, it’s about putting the patient first. But at the same time, we live in a world where the cost of goods and services continues to rise, right? We live in a world where if you work hard, you should be able to provide basic necessities for your family: access to housing, education, food, clean water, clean air, that type of thing. Those things cost money, and that’s just the reality.

So long term, there needs to be some type of evolution within the nursing profession where a new steady state is found, because right now, I believe there are 30,000 travel nursing positions in the United States, 30,000 open positions. Also, the baby boomer generation is nearing retirement. Many of them are already retiring, already planning to retire, or have already left the profession. This is at the same time that our population is aging, so the demand for services, home health care services, nursing services, whatever, is only going to continue to increase over the next 15 to 20 years. Also, if you look at the statistics right now, they’re not making enough nurses in this country to meet that demand, so that supply-demand mismatch is always going to be there.

We need to do something to, one, recruit more nurses into the profession, and a financial incentive could be a part of that, no profit, no purpose, and to retain the nurses that we have. Again, a financial incentive could be a part of that. So many of our best nurses over the course of my career have left to become nurse practitioners. Why? Because a clinical nurse makes $34 an hour, and a nurse practitioner might make $75 to $100 an hour. Why, why would they stay as a clinical nurse, when they’re excellent at what they do and they know that they could go to school to be a nurse practitioner for a year or two and get this higher-paying job? So that’s also contributing to the exodus, in addition to just the mental health struggles of being a health care professional. We put the patients first consistently. Who’s really looking out for us?

And I’m not complaining. You’ll never hear me complain as a physician. I chose to do this job. I’ve wanted to be a physician since I was a child. I feel very privileged to be in this position, to be able to serve, particularly during a time of need. However, some people might need a little more support, mentally, emotionally. As a medical director, I understand that some people need that pat on the back, that attaboy, to keep them going, and I’m just not seeing enough of that for them. And I get it; in a world where the cost of goods and services is increasing, you just have to pay these people sometimes. That’s the answer. Let’s pay them and get them to come to work and do what is needed.

So again: Pay them more to recruit more nurses into the profession. Pay them more to retain the nurses that we have, the high-quality nurses that we have. Look into importing foreign nurses that are qualified, obviously, into this country, and maybe give them H-1B visas. And again, we’re looking into this heavily. I mean, we need to provide the solutions. I’m sorry, I don’t want to just be a physician who sees this problem and sits around and does nothing about it. Physicians should be the leaders of the health care system, because we have the real equity in the health care system.

Kevin, you and I went to medical school. We took years of our life to go to med school. We took years of our life to do residency. I did my residency in New York City. I distinctly remember being in the CCU overnight when the Giants won the Super Bowl. I mean, there’s no better place in the world to be than in New York City if the Giants are in the Super Bowl. Was I out in a bar celebrating with the whole city when they won? No, I was at work. I mean, you and I have the equity. We have the credibility, I should say. Not to mention, you’ve probably helped, I don’t know, 50,000 patients in your life, so we have all the patient testimonials too. I mean, physicians really should be the leaders of the health care system. This is part of the motivation to go to business school: to ultimately understand these things that we’re not taught in medical school, and, because we care about the patients, to put in actionable solutions to give them the services they need.

Kevin Pho: And my final question, Vincent: What are some of your take-home messages that you want to leave with the KevinMD audience?

Vincent Roddy: I mean, pretty much that you’re going to hear a lot about this moving forward. I didn’t touch on this specifically in the article, but don’t be seduced by the idea of health care reform. I mean, health care reform, as they discuss it in aggregate, is really just paying physicians and nurses and techs less money than they currently pay us now, in order to bring down the health care spend as a percentage of GDP. I should remind your viewers that I believe it’s only 10 percent of the health care dollar that actually gets spent on physicians in actual medical services. I mean, the rest of it is administrative, pharmaceutical, device manufacturer, all of these other things. Real health care reform would involve us living healthier lives, so that we don’t need the services as much and we’re not spending as much, because we don’t need the services.

In the meantime, the goal is in peril, my friends. We need staff. The staff has to be paid well in order to do the work. The nurses, the physicians, the techs, the custodians, the unit secretaries, these are essential workers to the functioning of not only this cut of our economy, and not only the health, but just to the country in general. This is a national security issue, and I would like to see the federal government do more to shore up our staffing issues so that we can have the capacity to serve you when you come. And despite our challenges, we’re going to be here for you. But because I care about this country, because I care about the patients, and because I care about our workers, I want things to be the best that they can be, not just good enough. Good enough just doesn’t, and that’s how we’ve been operating in this country, and we need to do more so that you can have the services that a first-world country should afford its citizens.

Kevin Pho: Thank you so much for sharing your time and insight, and thanks again for being on the show.

Vincent Roddy: Thanks so much for having me, Kevin. Hopefully I can come back at some point.

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