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Workshop Talks by Htun Lin
News & Letters, July 2001
HMO leeches
Working at the Kaiser HMO, I sense a major cultural change.
Nobody seems to feel like they belong anymore as they walk
around with frustrated expressions on their faces. The heart of
the operation used to be the admissions office, driving the
practical activity of the hospital. We had the sense that our
reason for being here was to take in patients from emergency and
assign them to the hospital.
Efficiency used to mean how quickly we could get a patient from
emergency to a hospital bed staffed by qualified permanent
medical staff. After ten years of restructuring, efficiency has
taken on a whole new meaning. It now means how few nursing and
allied staff can they get away with providing each day.
Because head count flexibility is paramount, we see a revolving
door of temporary and casual staff provided by subcontractors
and labor agencies. The heart of the operation now is the
imperious staffing office. Everyone has to answer to them
including the nursing supervisor who now is reduced to no more
than an artful accountant and skillful juggler of
nurse-to-patient ratios.
Her concrete nursing abilities are no longer primary. Her main
job is to keep costs in line by restricting staffing levels
within budgetary constraints, predetermined by the bean counters
at headquarters. Taylorism has arrived in health care.
We know it is nothing personal against us health workers that
makes our employer do this. I don't even think they are lying
when they say their pharmaceutical and equipment costs went up
with the explosion of high-tech. I think they are telling the
truth when they say the large corporate subscribers of group
health plans have been pressuring them to cut costs. Not only
that, Kaiser feels compelled by cutthroat competition from the
for-profit HMOs to abide by "market" standards.
I see this as Kaiser merely responding to what Marx called a new
social average labor time. Labor time for a given product
averaged over the whole society determines value. That new
social average tells them to cut costs because all the employers
insist on cutting health care costs for their employees to
compensate for their own diminishing profit margins. The
pressure is to reduce the cost of labor by cutting the cost of
their health care and cutting the number of workers themselves.
Health care workers feel the pressure from both angles. So what
Marx called "socially necessary labor time" required
to deliver the product, in this case health care, is what drives
managers. This drives front line health care workers crazy. We
want to really care for our patients and that contradicts the
corporate goal of value production.
Our daily tasks are broken down into discrete manageable
mathematical units. Each task is assigned a value as is each
patient care requirement and each morbidity factor. All of this
used to be a tool for the nurses to determine the level of care
needed by the patient. Now it is used by staffing administrators
to mathematically manipulate these numbers to meet their
budgetary constraints.
The bottom line is to get away with the least amount of nursing
time, eliminating as much labor as possible. This is done
through the use of machines, accompanied by less skilled
personnel and also through the promotion of patient "self
care" and "home care" techniques. In other words,
anything that would "liberate" the nurse from bedside
care.
What is especially alienating is that the pressure never stops.
Workers implicitly recognize the inner workings of value
production and its extraction of surplus value from our labor to
satisfy the quest for profits. We have seen them spend a billion
dollars on high-tech to replace half our workforce and still
come back to us later crying "red ink" and "we
need more effort from you."
They call for us to be better "team players," cut
costs more, and work faster in order to take on more patients.
Because nursing has been so thoroughly abused by managed care's
staff reductions and speed-up, now they are unable to attract
new applicants into the profession.
We know we are more productive than ever. Our rate of on-the-job
injuries, especially bad backs and needle sticks, are proof of
this. Yet our employer, like a hapless giant hounding the goose
that lays his golden eggs to produce more, never seems to be
satisfied.
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