Conventional yardsticks of success are
particularly misleading in the paid care sector of our economy, the
sector that provides health care, elder care, child care, education,
and social services. Government surveys don't officially recognize
this category, but with a bit of pushing and pulling, official numbers
can be used to construct a category called "professional care
services" (using the standard industrial classifications of
Hospitals, Health Services except Hospitals, Educational Services, and
Social Services). Employment in this category has increased steadily
over time, and it now accounts for one fifth of the total paid labor
force, about the same as employment in the combined sectors of
manufacturing, mechanical, and construction industries. Hospitals and
schools should now count as much in forming our image of wage
employment as factories and construction sites.
Professional care services are
disproportionately provided by women. In 1998, women accounted for
about 46% of the paid labor force over age 16, but 76% of those
employed in Hospitals, 79% in Other Health Services, 69% in
Educational Services, and 82% in Social Services. The ways in which
these care industries are structured--including incentives for cutting
costs and methods of setting pay and measuring performance--have
especially important implications for women workers. They also have
obvious implications for the welfare of those being cared for.
In the last thirty years, the overall
costs of care have gone up relative to the costs of other goods and
services, for a number of reasons in addition to those discussed in
the preceding chapter, such as the difficulty of automating this type
of work. Changing demographics have increased the relative size of our
elderly population. Technological changes in health have created
marvelous, but expensive, options for treating disease and prolonging
life. The increasing importance of education has intensified demands
for higher quality in primary and secondary schools and higher
enrollment rates in colleges and universities. As more and more
mothers have starting bringing home paychecks, families have begun
purchasing substitutes for the care they once provided.
When costs go up, pressures tend to
intensify. Managers, professionals, and policymakers in the care
industries have struggled to devise ways of keeping costs down, often
through major institutional restructuring. A good example is the
growth of Health Maintenance Organizations, which have largely
displaced conventional insurance as a means of financing health care.
The growing cost of providing public assistance to our elderly
population through Medicaid has changed the way in which nursing home
care is financed and regulated. Continued shortages in the
availability of high quality child care have contributed to demands
for more public subsidies Dissatisfaction with schools has led to
proposals that we dismantle our public education system and simply
provide parents with vouchers that enable them to spend a certain
amount of money purchasing educational services on the open market, an
issue that will be discussed in more detail in Chapter 6.
The pressure to cut care costs creates
new openings for private, profit-oriented providers that focus on the
financial bottom line. Public and nonprofit institutions must compete
with these providers, even though they are bound by different rules.
Private hospitals, for instance, don't need to provide emergency room
care for the indigent, or learning opportunities for interns and
resident physicians. Public hospitals do. Private schools can refuse
to admit any student whom they fear might bring down their average
test scores, or expel any student who is a troublemaker. Public
schools don't enjoy such privileges.
Even within the private sector,
competitive pressures are mounting. Globalization is reducing barriers
to trade and capital mobility. Companies can locate in countries where
they needn't provide health benefits for their workers and aren't
required to pay taxes to help finance schools and hospitals (more
about this in Chapter 9). The introduction of competitive discipline
can help reduce the escalation of costs in care services. But it can
also reduce the quality of services in ways that people may be slow to
recognize, and even slower to act upon. Much depends on how we
measure, monitor, and defend quality.
Hands-on Health
Much of the cultural history of nursing
revolves around ideals of empathetic care, and nursing organizations
have for year tried to fend off the growing impersonality of our
health care delivery system. They have not been successful, in part
because hand-holding has been considered a luxury--as though emotional
well-being is subjective--just a transitory state of mind. Evidence
suggests, however, that emotions have significant effects on physical
health. The most striking examples come from studies of the placebo
effect--the seemingly inexplicable fact that patients often benefit
just as much from a sugar pill or fake surgery as from bona fide
treatment. It seems that the expectation of being treated, the feeling
that you safe in someone else's hands, has measurably beneficial
effects.
Emotional support is a therapeutic
force. Journalist Margaret Talbot describes a study on postoperative
pain at Massachusetts General Hospital in which patients were randomly
divided into two groups. One group was visited the night before
surgery by a doctor (an anesthetist) who treated the patient
brusquely. The other group was visited the night before by the same
doctor, who made an effort to be warm and sympathetic and held the
patient's hands as he sat on their beds. Those in the second group not
only required less pain-killing medication after the surgery; but they
were also discharged significantly earlier from the hospital.
"The placebo effect can occur," as one doctor put it,
"when conditions are optimal for hope, faith, trust, and
love."
"Optimal conditions" do not
include situations where patients lack a personal (much less
long-term) relationship with their health care provider. Nor do they
include situations in which doctors are under financial pressure to
meet a quota of patients per hour or stay under a per-patiet limit of
diagnostic costs. Yet these situations are increasingly characteristic
of health care today. Most health care is provided either by insurance
companies, who face increasing pressure to cut costs, or by emergency
rooms (the only form of health care that most uninsured folks can
afford). In both cases, medical decisions are often supervised by
individuals who are not in personal contact with patients, and whose
job it is to limit spending.
Health care is costly, and we need to
figure out ways to keep those costs down. But in the tug of war
between costs and care, it is care that seems to be losing. Unlike
traditional fee-for-service insurance programs, health maintenance
organizations (HMOs) charge their members a fixed amount of money in
advance. In return, they agree to meet the subscribers' medical needs.
Not all aspects of this incentive structure are bad. Unlike
fee-for-service insurers, HMOs have much to gain by encouraging
regular health check-ups, good nutrition, and exercise. By improving
the overall health of the subscribers, such measures can reduce the
incidence, and therefore the cost, of treating serious medical
problems.
Unfortunately, the HMO system also
creates some unhealthy incentives. Many HMOs provide only limited
treatment for mental illness, because it is more difficult to classify
than physical illness. Many HMOs discourage their doctors from
offering expensive diagnostic procedures or hospitalization. As of
July 1999, less than half of all states had laws allowing patients to
appeal such decisions. Most of the touted cost savings that HMOs offer
derive from lower hospitalization rates than other kinds of programs.
Another tactic for saving money is to exclude unhealthy people from
membership. It was hoped that, as many elderly people receiving
Medicare moved into HMOs, their health care costs would decline. But
HMOs realized that the elderly were driving up their costs; in the
last few years, many have eliminated coverage for seniors on Medicare.
The greater the competitive pressure, the more irresistible the
temptations to offload costs.
A study published in the Journal of
the American Medical Association found that several measures of
the quality of care are significantly lower in for-profit than
non-profit HMOs.
The authors offer a poignant example of
the limitations of standardized measures of quality. A national
committee monitors HMOs, collecting data on the percentage of women
patients who receive regular mammograms. Hence, administrators have an
incentive to encourage doctors to increase mammography rates.
Unfortunately, they have no incentive to encourage physicians to take
as much time as they need to perform clinical breast examinations,
patient education, or other activities that the committee does not
monitor.
"Let's face it," says one
health care economist, "people went into the for-profit managed
care business to make bucks." A law suit filed against six large
managed care companies in June 2000 charged them with failing to
disclose to members that rewards were offered to doctors and other
employees who denied payments for care and limited hospital
admissions.
Hospitals have dramatically reduced the
length of stays by sending patients home more quickly than ever
before, shifting care costs to family members and friends. New
portable technologies make it easier to do things like administer
intravenous medication at home, which is great. But many family
members are now assuming these responsibilities without pay--about 26
million people in 1997, each working an average of 18 hours a week.
Measures of cost-effectiveness do not take into account these hidden
costs. Nor have the health effects been closely scrutinized. Forced
cutbacks in hospital stays created so much bad publicity that Congress
passed legislation in 1996 prohibiting so-called
"drive-through" deliveries, and requiring insurance
companies to reimburse at least two days of hospital care for a normal
childbirth. Even Congressional Republicans voted recently in favor of
a Patient Bill of Rights albeit in an effort to forestall stronger
regulation by Democrats.
These well-publicized issues, however,
are less troubling than is the less visible deterioration in the
emotional dimensions of care. As a recent New York Times
article put it, critics say "hit and run" nursing has
replaced Florence Nightingale." Bedside nurses have been replaced
by unlicensed "care technicians." A survey of over 7,500
nurses released in 1996 reported that 73% felt they had less time than
previously to comfort and educate patients. A research report that
analyzed over 18 million patient discharge records from hospitals
between 1994 and 1997 found a 9% increase in the average number of
patients for which each full-time registered nurse was
responsible--from one to every 56.9 to one for every 62.3.
Cutbacks in reimbursements to nurses
and to aides who help provide care in patients' homes have reduced the
emotional quality of care there, as well. Reflecting on her interviews
with workers, Deborah Stone concluded "The more I talked with
people, the more I saw how financial tightening and the ratcheting up
of managerial scrutiny are changing the moral world of care giving,
along with the quantity and quality of care."
Elder and Child Care
Anxiety about quality also runs high in
market-provided elder and child care, the rapidly growing industries
that care for the two dependent ends of our age distribution. Nearly
all nursing homes are privately run, though most are subsidized with
public dollars. Few ordinary elders can afford to pay the roughly
$40,000 a year price tag on their own. More than two-thirds of all
nursing home residents are indigent and rely on Medicaid to pay their
expenses.
They have no choice about where or how
they will be cared for; nor are they well-protected by the government.
Complaints about abusive treatment are often ignored. According to Consumer
Reports, about 40% of nursing homes repeatedly fail to pass the
most basic health and safety inspections. In 1999, the government's
General Accounting Office echoed these concerns.
Nursing home profits depend largely on
the difference between revenues paid by the government and the costs
of providing care. When subsidies remain low--or fail to increase
along with prices--the pressure to cut costs is powerful. Wages for
workers in elder care are extremely low, and turnover rates are high.
Working conditions are difficult. Chronic understaffing contributes to
stress and burnout. Injury rates are high. Reform advocates argue that
the federal government needs to set staffing ratios, making no aide
responsible for more than five residents at a time. To date, only 18
states have adopted minimum ratios.
Perhaps recognizing the difficulties
facing families who are "comparison shopping" among nursing
homes, the Medicare Office offers a service on the World Wide Web
entitled Nursing Home Compare ( At this site you can obtain a list of
nursing homes in your local area, as well as obtain some standardized
measures of their performance. An elderly neighbor of mine moved to a
local nursing home a couple of years ago and I decided to check it
out. I learned that her nursing home had only 3 deficiencies out of a
range of health deficiencies in the state of 0-39. The average number
of health deficiencies in nursing homes in the United States is 5.
Extending my quest to ascertain exactly
what a deficiency was, I learned that the nursing home in question,
among other things, failed to 1) hire only people who have no legal
history of abusing, neglecting, or mistreating residents; or 2) report
and investigate any acts or reports of abuse, neglect, or mistreatment
of residents. I also learned that only 5% of the residents of the home
had bed sores (compared to a 15% average for the country as a whole)
and only 28% had behavioral symptoms such as wandering, aggressive
verbal or physical behavior, or inappropriate social actions, compared
to 37% for the nation as a whole.
Better these measures than no measures
at all. Still, apart from being downright depressing, they are rather
limited, saying nothing about more profound dimensions of care. I
can't help but wonder about the emotional and social environment
there. Researcher Susan Eaton describes the things companies
"can't bill for, but that make all the difference if you're
living in a nursing home: time to listen to somebody's story, time to
hold their hand, time to comfort somebody who is feeling troubled. And
you can't exactly put that on your bill; imagine finding ‘holding
hands' on the bill. You have to have a ‘treatment,' you have to have
some formal procedure."
The picture in child care is less
bleak. Most kids have parents to advocate for them, and most child
care workers genuinely enjoy working with kids. Still, child care,
like elder care, is difficult to monitor for quality. My favorite
illustration of the problem is the teddy bear with the hidden video
camera, a device invented to help parents maintain surveillance over
stay-at-home nannies. Only slightly more affordable are Web sites
linked to video-cams in child care centers, so that anxious parents
are only one click a way from a view of what their toddlers are
actually doing. As of December of 1999, some 150 child care centers
across the country offered this feature. Most parents obviously cannot
afford cybersupervision, but even those who do seldom have the time to
carefully scrutinize what they see.
Some home providers and child care
centers offer high quality care. Others do not. The workers who
actually provide hands-on care earn less than parking lot attendants.
Lack of regulation allows the child
care industry to draw from a reserve army of relatively unskilled
labor--predominantly women, disproportionately women of color. Only
nineteen states have preservice training requirements for teachers.
Few states have any training qualifications for family child care
providers. In general, hairdressers are required to meet much stricter
standards. Fewer than half of all child care workers receive fully
covered health insurance for themselves; coverage for their dependents
is even more rare. Turnover rates are well over 30% per year in most
big cities. It is hard for a young child to bond with a care giver in
a revolving door.
Plenty of evidence suggests that
high-quality center care can improve developmental outcomes for young
children. But a recent comprehensive survey argues that the physical
and emotional environments in many child care centers remain
inadequate in many states because of poor regulation. Voluntary
accreditation by the National Association for the Education of Young
Children tends to improve quality: a California study, for instance,
rated 61% of accredited centers as good in 1997, compared to only 26%
of those seeking accreditation the previous year. Nationwide, however,
only 5,000 out of the nation's 97,000 child care centers were
accredited in that year.
Quality is even more unpredictable
among home care providers. In the rush to expand child care slots to
accommodate the exigencies of welfare reform, some states have
provided child care vouchers that can be used virtually anywhere and
are set at extremely low levels. Such policies discourage the
development of high quality care, which costs more than public
subsidies will cover.
Child care is a complicated business,
with a mix of for-profit, family-based, and non-profit providers. We
don't know much about how different institutional forms affect quality
of care. What looks attractive to the parent is not necessarily what
is best for the child--shiny new toys matter less than the skills and
commitment of the workers providing care. Studies show that for-profit
child care centers do not in general emphasize "curb-side
appeal" at the expense of more difficult to monitor aspects of
quality. However, for-profit child care centers that are part of
national chains do appear to stoop to this strategy.
It is probably impossible to arrive at
an exact measure of care quality. But it is not hard to think of ways
to lessen the economic pressures that can undermine quality. Improving
the training, wages, and working conditions of workers in care
industries would be likely to reduce their turnover and encourage
greater personal connection between caregivers and those for whom they
care. Indeed, given greater opportunities to develop professional
standards and some protections against employer retaliation against
"whistle blowers," workers themselves could become leading
watchdogs for care quality.
Competitive pressures can have perverse
effects. This is why public provision of care services is sometimes
preferable to private provision and why public regulation of care
services is almost always necessary. But the difficulties of measuring
success are not limited to the care sector. Nor can they be solved
simply by reorganizing our care industries. We need to reevaluate--and
substantially revise--the ways we measure and reward success in our
economy as a whole.