Kaiser Changes Worry Nurses

by Laura McCreery

Kaiser restructuring may put more than 500 nurses out of work	The nursing profession in Northern California is feeling a chill this winter season as it awaits the details of a massive restructuring planned by Kaiser Permanente that may put jobs on the line for some of the 2,200 employees, including more than 500 nurses, at its Oakland hospital. The giant health maintenance organization (HMO) announced three weeks ago that it plans to cut costs by farming out inpatient services from its Oakland Medical Center to three other East Bay hospitals -- Children's Hospital and Summit Medical Center in Oakland and Alta Bates Medical Center in Berkeley. If successful, the model may soon extend elsewhere in Kaiser's Northern California region, which serves 2.4 million members at 15 medical centers and 31 medical offices from Sacramento to San Jose. "The main motivator is an excess of hospital beds, not only in Kaiser, but in Northern California in general," says Kaiser spokeswoman Laura Rohde, citing vacancy rates of 30 to 50 percent in many area hospitals.
The whole population is older and sicker, yet their hospital stays are shorter	If the new plan becomes a reality, Kaiser members in the Oakland area still would visit the local Kaiser facility for outpatient services but could land in one of the other three hospitals -- where they would see Kaiser doctors -- if an overnight stay were required. The California Nurses Association (CNA), which provides union representation to RNs at Northern California hospitals, says Kaiser already has reduced nurse staffing in the region by more than 800 positions in the last two years. The Oakland facility now has 535 nurse positions, according to Kaiser's figures for last month. CNA says Kaiser's latest strategy to relocate inpatients is a bad move, not just because jobs will be lost, but for the potential effects on patient care. "It will affect patients very badly," says CNA spokesman Chuck Idelson. "We believe there will be far less access to care for Kaiser members." Kurt Laumann is an RN with 16 years of experience at Kaiser's Oakland facility. He says the patients he was seeing a few years back were fairly stable overall. In his current job as a telephone advice nurse, Laumann interacts with a wide variety of Kaiser's members. These days, he says, the whole population is older and sicker, yet their hospital stays are shorter. "There are more and more of these same-day surgeries," Laumann says, where patients are sent home just hours after surgery. "For the most part, it's no problem. But [Kaiser is] gambling that there will be no complications." "I took a call from a 70-year-old man who had just had orthoscopic surgery [and was sent home the same day]," Laumann says. "He lived alone in a house that had eight stairs just to get in, and he was bleeding. I had to call a doc and get authorization for an ambulance to bring him back." RNs also worry about their ability to provide their patients with adequate treatment in the fast-changing world of managed care. California law requires specific nurse-to-patient ratios for critical care units, but other hospital wards have no such standards.
There is a great deal of distortion when hospitals give census figures	Patient care and its relationship to nurse staffing is a prominent issue in the current national debate about managed care. A new study by the Institute of Medicine (IOM), the health policy arm of the National Research Council, found no overall evidence of inadequate nurse staffing nationwide, stating that enough RNs exist to meet the nation's needs and that nursing jobs will remain plentiful. But the report recommends that hospitals use more RNs with advanced training to lead teams of care providers rather than to provide most patient care themselves. That, according to some local nurses, is precisely the problem. Many RNs are convinced that their removal from the bedside of their patients is an invitation for disaster. Their concern is mounting as many hospitals jump on the bandwagon of "de-skilling" their staffs, or having more hands-on patient care tasks done by less specialized, non-licensed -- and cheaper -- health care workers. To complicate matters, CNA has a consumer fraud case pending against one of Kaiser's intended partners, Alta Bates Medical Center. The class-action lawsuit, filed in September 1994, charges Alta Bates with restructuring to cut nurse staffing by as much as half in two prominent units -- a family care center and a medical/surgical unit serving AIDS, cancer, and renal patients -- and then misrepresenting the level of patient care available. The case is in the deposition phase and will go to trial in November. In addition to issues of direct patient care, there is the matter of how many patient beds exist in each hospital and how many are available. Kaiser's census figures for Oakland indicate the hospital is operating at just over half its licensed capacity of 334 beds, with occupancy at an average of 54 percent for 1995. The East Bay hospitals that are negotiating to take Kaiser's Oakland inpatients have census figures to suggest each is only half to three-quarters full and might easily accommodate more patients. But census figures are averages and may not give an accurate picture of a hospital's ability or willingness to fill its empty beds. A hospital licensed for 300 beds may have the budget and staffing to fill only half that number, and budget decisions are business decisions. "There is a great deal of distortion when hospitals give census figures," CNA's Idelson says, citing the case of Children's Hospital in Oakland. "Right now there are plenty of beds sitting empty, but [Children's] turns kids away the entire winter, just when the most kids are sick."
Profits for 1994 were nothing to sneeze at	Despite their philosophical differences, all the players in the local health care game agree that changes in the next few years will be rapid and dramatic, in Northern California as elsewhere. They just don't agree on what to do about it. Kaiser and other managed care corporations are racing to cut costs and stay competitive enough to keep their current members and attract new ones. For Kaiser, the whole issue of cost is central. The 50-year-old private HMO is the nation's largest health care system as measured by net patient revenues. In California, Kaiser enjoyed a corner on the large HMO market for years, and its membership grew steadily throughout the 1980's. But recently other HMOs in the state have offered serious competition, resulting in a loss of members and corresponding drop in revenues for Kaiser. Still, profits for 1994 were nothing to sneeze at: $816 million in the region. Doctors who practice at Kaiser are employed not by the HMO, but by the affiliated Permanente Medical Group, Inc., a privately held for-profit concern owned by its member physicians. Nearly all physician pay is from salary, but year-end profit sharing and financial incentives for cost containment give individual doctors good reason to keep costs down and to discharge patients quickly. Incentives for doctors are not unusual. But Kaiser's Southern California Region last month ratified a contract with its nursing union, the United Nurses Associations, that includes financial incentives for RNs who facilitate early patient discharges. That initiative, the first of its kind for Kaiser nurses, drew harsh criticism from Idelson, the CNA spokesman. "It is the view of our organization that [financial incentives for RNs are] just simply disgraceful," Idelson says, adding that such incentives present a conflict of interest. "If Kaiser proposes something like that here, I can't imagine our members supporting it." While Kaiser navigates the fast-changing road map for health care, 1990s style, hospital employees in the Bay Area are calling for substantial changes as well. CNA is so concerned about patient care in light of many recent and planned health care changes that it is spearheading a drive to get the Patient Protection Act on the November ballot in California. Statewide efforts will begin this month to gather the 700,000 signatures needed to qualify the measure, starting with a kickoff event in the East Bay on February 24. The proposed Act addresses patient care and health policy in several areas, including: direct protection of patients required disclosure of quality indicators by health care providers to consumers formation of an independent, voluntarily funded health care consumer board based on the model of consumer utility boards whistleblower protection, and uniform safety standards One of the Act's provisions is that HMOs and other corporations reaping health care profits in the state would be assessed fees to fund implementation of the Act's various components. That provision would require the health care industry to share some of its profits in a way that is intended to benefit all the state's citizens. And that, says RN Laumann, would be fitting in the case of Kaiser. "They're not losing money at all," he says.

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