Posts Tagged ‘health care’
“Constant attention by a good nurse may be just as important as a major operation by a surgeon”*…
A recent (R)D unpacked a recent Gallup survey of public trust in different professions/ocupations; the undisputed champion, nursing…. to which, friend MK responded: “What’s worse than 24 out of 25 people not trusting members of Congress is one out of four not trusting nurses.”
Edward Ongweso Jr. has a possible explanation– one that has little to do with nurse and all-too-much to do with the deterioration of the system of which they’re a part…
Hello everyone, I’ll keep this bit short this time! Thanks for all the emails with stories about your own experiences in Vegas, with gambling addiction, and with CES in response to my last piece, I read them all and responded to most except the ones pitching me Guaranteed Parlays That Will Hit! Thanks also for subscribing, we’ve jumped a bit and are just shy of 4,400 subscribers. If you like what you’ve read and want to support me further, you can become a paid subscriber for $7 a month or $70 a year. What do you get in return? My undying love, some recommendation posts every now and then, and paywalled essays/rants just as long as this one! Now, let’s get to today’s essay.
I have long believed that one of the greatest threats we face is the proliferation of the on-demand labor platform. The so-called “gig economy” is one of the larger altars to greed and misery in our civilization where millions of people are sacrificed in order to grow Smaugian hoards that are then transmuted into this or that form of power.
My earliest introduction to this was through the work of labor ethnographer and legal scholar Veena Dubal via her law journal article “The Drive to Precarity,” which maps out how militant workers turned San Francisco’s precarious taxi sector into a stable line of work, how companies responded with a wave of deregulation and de-unionization that immiserated workers, and how Uber sealed the deal in returning ride-hail to its earlier insecure form: poor working conditions and starvation wages, with every possible cost (healthcare, fuel, maintenance, etc.) offloaded onto workers and consumers.
Key forms of on-demand labor—namely, ride-hail and food delivery—have proliferated over the past few years, but not because they are particularly profitable or innovative business ventures. Most of them either have no real path to profitability, report dubiously calculated profits, or are operating illegally in hopes of realizing or sustaining them after sufficient lobbying and monopolization and exploitation of consumers/workers. The lazy and incurious view has been that they will grow into profitability, but the transparent reality is that the firms at the vanguard of the gig economy have thrived because they take advantage of a few key phenomena: worker misclassification, algorithmic discrimination, anti-competitive capital-intensive strategies, impressive public relations, robust political lobbying, and shoddy journalism, to name a few…
[Ongweso unpacks the history of ride-hailing apps and of the tactics– some legitimate, some questionable, and some plainly illegal– the industry has used to prevail. Then he turns to nursing…]
… As[ Shawn Carolan, a partner at Menlo Ventures and early investor in Uber] observed, however, ride-hail and delivery are not the only places where the “business model” at the heart of on-demand labor can be applied.
Over the past few years, nursing has emerged as a juicy target for investors and firms eager to liberate entire industries of antiquated regulatory frameworks. Last month, the Roosevelt Institute published a great report on what the application of the on-demand model will mean for nurses and it paints a grim picture. While some hail the emergence of an “Uber for nursing” model as a salve for our nursing shortage, Katie J. Wells and Funda Ustek Spilda detail how these apps reliably degrade working conditions, wages, and care standards.
These apps encourage nurses to work for less pay, fail to provide certainty about scheduling and the amount or nature of work, take little to no accountability for worker safety, and can threaten patient well-being by placing nurses in unfamiliar clinical environments with no onboarding or facility training. On-demand nursing platforms are also using the Uber playbook to lobby state legislatures in an attempt to exempt themselves from existing labor regulations.
I’ll be going through the report section by section to highlight key points as I think the report is phenomenal, but I encourage you to read it in full (linked above).
The premise of the “Uber for nursing” apps is relatively simple: lets use algorithmic systems to managing the scheduling, staffing, and management at medical facilities. For understaffed workplaces looking to cut costs and corners, this is attractive. For nurses and nursing assistants who want more control over their work, this is attractive. But this is especially enticing for investors who drool anytime a firm compares itself to Uber. Take ShiftMed—one of the darlings of this sector and a subject of the Roosevelt Institute report—which has raised hundreds of millions (but declines to share its valuation): $47 million in a May 2024 venture round, $200 million in a February 2023 round, $45 million in October 2021, and an early $6 million boost in an August 2019 round. What concretely are firms like ShiftMed offering to draw financing like this?
After a nurse downloads an on-demand nursing app and submits the requisite documents, they can use the app to indicate their interest in a 6-, 8-, or 12-hour shift at a hospital, nursing home, assisted living facility, surgical center, dental office, or, in some states, correctional facilities. An algorithmic scheduling software program, which is the heart of these new companies, then approves the worker for a shift, notifies both the medical facility and the worker, allows the worker to clock in and out, and, finally, sends a paycheck.
The on-demand nursing industry promises hospitals and medical administrators a different set of controls, namely the capacity to seamlessly staff facilities, reduce manager workloads, and lower labor costs.
On paper, this sounds lovely—the digital disruption of an old rickety system full of middlemen, inefficiencies, misallocation, overcharging, yadda yadda ya. But what’s the reality on the ground? Wells and Spilda found:
… serious safety and health risks for workers and patients. The nurses and nursing assistants who use these apps must pay fees to bid on shifts, and they win those bids by offering to work for lower hourly rates than their fellow workers. Poor internet or cell service in rural areas can cause the apps to fail, resulting in missed paychecks for work performed. These apps also rate the nurses they hire based on facility feedback and internal algorithmic determinations. If a worker must cancel a shift due to sickness or personal conflict, their rating goes down, and they often lose out on future shifts or can be banned from the app altogether. In at least one case, a nursing assistant went into work at a hospital while sick with COVID-19 because she could not figure out how to cancel a shift without lowering her rating. At most hospitals and medical facilities, no orientations are required for gig nurses and nursing assistants. Workers do not know where supply closets are located, how to access patient portals with medical histories and current medication lists, and whom to contact in the chain of command. With gig nursing, there is often little to no continuity of care. Despite hospitals’ attempts to automate nursing, care work is inherently tricky to de-skill and predict. Shifts do not neatly end when the apps say they do as, of course, patients’ health-care needs do not end just because the clock says they should. Human frailty—the essential subject of nursing—defies algorithmic management.
As the report will detail, gig nursing has already proven itself to be an unmitigated disaster and we are still relatively early in its assault on our lethargic healthcare system…
[Ongweso offers more chilling detail…]
… Often the deployment of new technology is used as cover to rollback reforms and regulations that have made old levels of profiteering unrealizable or outright illegal. That tends to be a function of who is steering the design, development, and deployment of said technologies. It is one thing when managers and financiers are in the drivers seat, and it would be another thing entirely if care workers were in control. It is not clear to me why anyone other than nurses should be in control of what sort of technology is introduced into their workplaces, how this technology is designed, why it is deployed, and when it is used. To close out with Wells and Splinda:
“It is important to not lose sight of the enormous amount of skill, coordination, understanding of human vulnerability and frailty, and treatment of patients with utmost decency required to provide good quality care. Technology could provide solutions to automate and unburden the nurses and health-care workers from the everyday management tasks of their work; however, decision-making around such solutions should include the nurses themselves, from design to deployment.”
The gig economy’s metastasis and its threat to healthcare: “Uber’s Bastards,” from @edwardongwesojr.com. Eminently worth reading in full.
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As we contemplate care, we might send healing birthday greetings to Arthur Nicolaier; he was born on this date in 1862. A physician and bacteriologist, he isolated the tetanus bacterium and developed a successful cure for tetanus.
Nicolaier discovered that the tetanus bacterium lived in soil. Because of its presence in earth, it is responsible for infection from dirty wounds, which was a particularly significant issue in the cases of wounded soldiers during WW I. The toxin secreted by this bacterium, Clostridium tetani, travels along nerves to the spinal chord, causing increasingly severe, often fatal spasms of the head and neck and jaw– from which came the common name of the affliction: “lockjaw.” Thanks to Nicolaier, from 1915 injured soldiers– and any other sufferer– received an anti-toxin.
In the mid-1920s a tetanus vacine was developed. It has subsequently been improved, and has successfully warded off infection in those areas where it is administered. In 2013, it caused about 59,000 deaths worldwide—down from 356,000 in 1990; in the United States, from 2000 through 2007, an average of 31 cases were reported per year. Nearly all of the cases in the United States occur in unimmunized individuals, or individuals who have allowed their inoculations to lapse.
“I analogize it to sex. You realize there were certain things you shouldn’t do, but the urge is there and you can’t resist.”*…
The estimable Cory Doctorow on the incursion of private equity into health care…
As someone who writes a lot of fiction about corporate crime, I naturally end up spending a lot of time being angry about corporate crime. It’s pretty goddamned enraging. But the fiction writer in me is especially upset at how cartoonishly evil the perps are – routinely doing things that I couldn’t ever get away with putting in a novel.
Beyond a doubt, the most cartoonishly evil characters are the private equity looters. And the most cartoonishly evil private equity looters are the ones who get involved in health care.
Writing for The American Prospect, Maureen Tcacik details a national scandal: the collapse of PE-backed hospital chain Steward Health, a company that bought and looted hospitals up and down the country, starving them of everything from heart valves to prescription paper, ripping off suppliers, doctors and nurses, and callously exposing patients to deadly risk…
[There follows an illuminating– and truly terrifying (backed up sewage in the wards; bats colonizing hospital floors; stiffed employees and vendors)– an unpacking of Steward’s deeds and a location of them in the larger landscape of private equity.]
… But despite Steward’s increasingly furious creditors and its decaying facilities, the company remains bullish on its ability to continue operations. Medical Properties Trust – the real estate investment trust that is nominally a separate company from Steward – recently hosted a conference call to reassure Wall Street investors that it would be a going concern. When a Bank of America analyst asked MPT’s CFO how this could possibly be, given the facility’s dire condition and Steward’s degraded state, the CFO blithely assured him that the company would get bailouts: “We own hospitals no one wants to see closed.”
That’s the thing about PE and health-care. The looters who buy out every health-care facility in a region understand that this makes them too big to fail: no matter how dangerous the companies they drain become, local governments will continue to prop them up. Look at dialysis, a market that’s been cornered by private equity rollups. Today, if you need this lifesaving therapy, there’s a good chance that every accessible facility is owned by a private equity fund that has fired all its qualified staff and ceased sterilizing its needles. Otherwise healthy people who visit these clinics sometimes die due to operator error. But they chug along, because no dialysis clinics is worse that “dialysis clinics where unqualified sadists sometimes kill you with dirty needles“
…
The PE sector spent more than a trillion dollars over the past decade buying up healthcare companies, and it has trillions more in “dry powder” allocated for further medical acquisitions. Why not? As the CFO of Medical Properties Trust told that Bank of America analyst last week, when you “own hospitals no one wants to see closed.” you literally can’t fail, no matter how many people you murder.
The PE sector is a reminder that the crimes people commit for money far outstrip the crimes they commit for ideology. Even the most ideological killers are horrified by the murders their profit-motivated colleagues commit.
Last year, Tkacic wrote about the history of IG Farben, the German company that built Monowitz, a private slave-labor camp up the road from Auschwitz to make the materiel it was gouging Hitler’s Wehrmacht on…
Farben bought the cheapest possible slaves from Auschwitz, preferentially sourcing women and children. These slaves were worked to death at a rate that put Auschwitz’s wholesale murder in the shade. Farben’s slaves died an average of just three months after starting work at Monowitz. The situation was so abominable, so unconscionable, that the SS officers who provided outsource guard-labor to Monowitz actually wrote to Berlin to complain about the cruelty.
The Nuremberg trials are famous for the Nazi officers who insisted that they were “just following order” but were nonetheless executed for their crimes. 24 Farben executives were also tried at Nuremberg, where they offered a very different defense: “We had a fiduciary duty to our shareholders to maximize our profits.” 19 of the 24 were acquitted on that basis.
PE is committed to an ideology that is far worse than any form of racial animus or other bias. As a sector, it is committed to profit above all other values. As a result, its brutality knows no bounds, no decency, no compassion. Even the worst crimes we commit for hate are nothing compared to the crimes we commit for greed…
“When private equity destroys your hospital,” from @doctorow. Eminently worth reading in full– and following his newsletter (from whence this comes).
* David Rubenstein, co-founder and co-chairman of the private equity giant The Carlyle Group, at a Harvard Business School Conference
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As we rethink returns, we might recall that it was on this date in 1944 that Louis Buchalter (AKA Lepke Buchalter, AKA Louis Lepke) was executed in the electric Chair at Sing Sing. One of the premier labor racketeers in New York City in the 1930s, he is better remembered as the creator (in 1929) and overseer (thereafter) of an efficient system for performing mob hits; while Buchalter never named it, it became known in the press as “Murder, Inc.“
The Cosa Nostra mobsters wanted to insulate themselves from any connection to these murders. Buchalter’s partner, mobster Albert Anastasia, would relay a contract request from the Cosa Nostra to Buchalter. In turn, Buchalter would assign the job to Jewish and Italian street gang members from Brooklyn.
None of these contract killers had any connections with the major crime families. If they were caught, they could not implicate their Cosa Nostra employers in the crimes. Buchalter used the same killers for his own murder contracts. The Murder, Inc., killers were soon completing jobs all over the country for their mobster bosses…
source
Murder, Inc. was believed to be responsible for as many as 1,000 contract killings before it was exposed in 1941, and Buchalter was finally charged and convicted of murder that same year.
“The welfare and the future of our societies depend on our capacity to remain mobilized so as to improve the health of every mother and child”*…
Preparing for a world post Roe v Wade…
The red states poised to ban or severely limit abortion already tend to have limited access to health care, poor health outcomes and fewer safety net programs in place for mothers and children.
If the U.S. Supreme Court overturns Roe v. Wade, as it’s expected to, the ensuing increase in births will likely leave families in tough circumstances and strain systems that are already hanging by a thread.
“What we’re facing as a country is hundreds of thousands of births, probably disproportionately located in the states that have been most limited in what they do for pregnant women, infants and children. So this is the great paradox that we are dealing with,” said Sara Rosenbaum, a health law and policy professor at George Washington University. “We have not ever designed these programs for a world without Roe,” she added. “You need a child welfare system, the likes of which we’ve never seen.”…
A growing shortage of obstetricians, higher maternal mortality rates and worse health care outcomes generally, increased pressure on U.S. foster and adoption systems— it all bodes ill…
We know from focus on health outcomes that kids born into poverty, kids born into unstable social circumstances, tend to have higher incidence of early onset chronic diseases,” Shannon said. “We also know that when those children are raised in unstable circumstances and have to be cared for in foster care, the outcomes there are really sobering.
Richard Shannon, chief quality officer for Duke Health
“Red states aren’t prepared for a post-Roe baby boom,” from Caitlin Owens (@caitlinnowens) in @axios.
* Jean Ping
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As we contemplate care, we might sending healing birthday greetings to Thomas Huckle Weller; he was born on this date in 1915. A virologist, he developed a technique for cultivating poliomyelitis viruses in a test tube, using a combination of human embryonic skin and muscle tissue– which enabled the study of the virus “in the test tube,” a procedure that led to the development of polio vaccines. He was awarded the Nobel Prize in Physiology or Medicine in 1954.
“Well, I was born in a small town”*…
… which is, new federal designations now dictate, definitely not an urban area…
Hundreds of urban areas in the U.S. are becoming rural, but it’s not because people are leaving.
It’s just that the U.S. Census Bureau is changing the definition of an urban area. Under the new criteria, more than 1,300 small cities, towns and villages designated urban a decade ago would be considered rural.
That matters because urban and rural areas qualify for different types of federal funding. Some communities worry the change could affect health clinics in rural areas as well as transportation and education funding from federal programs…
Groups like the American Hospital Association say the changes, which are the biggest being made to the definitions in decades, could cause problems for people who need medical care in rural areas…
Different federal programs use different definitions of urban and rural, and some communities qualify for rural funding for some programs and not others. But any changes “will have significant implications for many groups and communities,” said Kenneth Johnson, a senior demographer at the University of New Hampshire who studies rural issues.
“Another likely concern for many rural communities is that if many existing urban areas are redefined as rural, competition for the limited rural funds will increase,” Johnson said…
The difference a designation can make: “100s of US urban areas will become rural with new criteria,” from @AP.
[image above: source]
* John Mellencamp, “Small Town”
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As we contemplate categories and their consequences, we might recall that it was on this date in 1965, at Magoo’s Pizza in (the then small town of) Menlo Park, CA, that Phil Lesh attended a performance of a band then known as The Warlocks. High on acid, he enjoyed it so much that he danced by himself in front of the bandstand. The Warlock’s leader, Jerry Garcia, cornered him and announced, “Hey, man-you’re going to be the bass player in this band”… and so the fundamental line-up of what became The Grateful Dead was set.
“By temporarily disrupting the order of the brain, a new order forms. And that order may have incredible value at either the level of mental health and psychology or the level of creativity.”*…
But, Zoe Cormier warns, if the means of that constructive disruption are industrialized and turned into aggressively-marketed products, we could be in for trouble…
Welcome to the strange new world of “psychedelic capitalism,” where dozens of start-ups have already raised millions (and in some cases billions) of dollars to commercialize psilocybin (the psychedelic ingredient in magic mushrooms), DMT (found in the Amazonian brew ayahuasca), mescaline (peyote’s active component), and LSD—despite the fact that all of these “classic psychedelics” are still ranked as Schedule I drugs under the federal Controlled Substances Act. Manufacturing any of these drugs without a license can still land you a long prison sentence. But marketing one, even though they all remain illegal and none have passed all the clinical trials required for approval? That can make you a millionaire…
The days when mind-bending psychedelics were seen as appealing only to drug dealers, nut jobs, and hippies are over. Today, serious-minded people interested in randomized controlled trials and stock valuations are leading the charge.
The “psychedelic renaissance” we’ve awaited for half a century—the promised era when acid, shrooms, and peyote would be brought back into legitimate research and legal access—is finally here. But will it turn out to be worth the wait? Or the hype?
Because it’s not like we ever stopped enjoying them: In the West, hippies, scientists, “healers,” and others have used psychedelics continuously for seven decades. And before we got our hands on them, Indigenous cultures used psychedelics for thousands of years as ritual sacraments. Now dozens of start-ups want to standardize, commercialize, alter, patent, and market these ancient compounds—and they stand to make a fortune doing so.
Will old-school profit-centered tactics bring down decades of dogged work by activists, scientists, and reformers to have these drugs reassessed for their virtues? Will we experience another nasty, research-smothering backlash?…
The profiteers have arrived; get ready for Psychedelics Inc.: “The Brave New World of Legalized Psychedelics Is Already Here,” from @zoecormier @thenation.
* Michael Pollan, in conversation with Tim Ferriss on Ferriss’ blog
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As we tune in, we might spare a thought for Ellen Swallow Richards; she died on this date in 1911. The first female student admitted to MIT, she became its first female faculty member. A chemist, she did pioneering work in sanitary engineering, but is best remembered for her experimental research in domestic science, which laid the foundation for the new science of home economics, of which she is considered founder. She was one of the first ecofeminists, believing that women’s work within the home was not just vital to the economy, but also a critical aspect of our relationship to the earth.
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