Vidette, et al,

Having never met martha i obviously have no idea what she would say -
though i have been concerned about HMOs, Managed care, and insurance
issues for three decades, i am clearly in the minority of human beings
and health care professionals in terms of my fundamental grasp of the
house of cards on which it is built.

but let me try to make a stab at this - minus the linguistic
faithfulness that true rogerians strive for but which stretch me to
the breaking point... :-)

The universe is connected - we can do nothing locally which does not
affect all of us, our planet, and ultimately the universe. In the much
loved "Butterfly Effect" analogy we politely pay tribute to the fact
that at some distant - perhaps eons long ago time, a butterfly in the
amazon zipped by a large toad's tongue, and the life course of that
butterfly's future flying led to a perturbation in the universe that
eventually led to Hurricane Katrina destroying New Orleans.

While true and somewhat inspiring, what this ignores is that millennia
of burning coal, two centuries of burning other fossil fuels, zipping
around the countryside with surfboards on the roofs of woodies, and
consumption run amok have had far more to do with Hurricane Katrina
than the butterfly. So, to the degree to which we fail to focus our
attention on the causal factors closer to our problems, the further
away we move from being able to take corrective action.

In many ways it does not matter what we do in our nursing schools, how
well we train future nurses, and how much time we fill them with the
ethical issues that are at the core of a nurse's response to his/her
patient(s). This is because the impact of our educational initiatives,
and do not misunderstand, I firmly believe that we need to continue to
educate nurses about ethics, but these efforts are butterflies
compared to their on the job training.

When our nursing grads go out into the world they enter a business
world whose primary ethic is profit maximization. The
people/corporations who own health care facilities operate in a global
market and unlike George Bush and John McCain, they understand this
environment.

If the return on investment in producing microprocessors in Chad is
25% and the return on investment in a nursing home in gainesville is
5% the astute and ethical CEO is going to move the assets for which
he/she is steward to Chad. That is what a global economy and ethical
stewardship demands. There is no ethic in our business sector that
business entities have a superseding obligation to Americans, to the
communities that will be devastated when the operations within them
are shut down, or to the patients whose lives and well being will be
devastated. In short, there is nothing whatsoever in the business
sector that says that corporations must divert some or all of their
resources to the well being of anyone or anything other than their
investors.

Even with the clear, focused, imperative of stockholder fidelity, what
we have seen, over and over since Adam Smith's 1776 treatise, is that
unless their feet are held to the fire we simply cannot assume that
ALL CEOs will act ethically - there will always be a small number of
retrograde human beings who seek their own, or their friend's personal
gains over the well being of their organizations, their countries, and
the world as a whole. ENRON wasn't the first monumental failure
inexorably linked to greed. AIG is just the latest.

Since the dawn of civilization there have always been and will always
be people who do and do not feel the sense of connectedness they share
with the rest of humanity, animals, plants, land, oceans, and
atmosphere. Some of these people act in concert with the highest
possible expression of interconnectedness - lending others a helping
hand, conserving their use of resources which in the most fundamental
sense, they do not own. Some, with the same insight - simply operate
on the basis that if the Titanic is sinking they want to go down with
all the gold, jewelry, and dollars they can grab from their fellow
passengers.

Segue - teaching nursing economics was an interesting experience.
Imagine a classroom filled with people who, fundamentally, cannot
begin to imagine that "private property" is a meaningless term. They
just do not get that all of the laws regarding private property did
not derive from the Big Bang - they were the end result of wars and
power struggles in which the victors codified their appropriation of
the resources that were common. No i am not, nor did I, suggest in
class that everything be freed up - but I did try to get people to
understand that there has never been such an entitlement to some at
the expense of others but it is merely the written codes that were
produced by those in power at a given moment. I was always quick to
point out that while I believed that the indigenous populations of
America had a legitimate beef with respect to europeans, they were no
more entitled than the europeans to the wealth of the land just
because they were there when the europeans arrived.


Sadly, even if 95% of all people do the right thing, the greediest and
most irresponsible 5% will have a far greater negative impact.


So, what happens when our well trained, ethical nurses, who if we are
good ethicists, believe that every patient should be treated
differently regardless of their ability to pay? They enter a business
environment that results from a system of "health care finance" that
essentially codifies the ethic that every single patient has a
different and unique (doesn't that sound swell?) right to diagnosis
and treatment based on the choice of health care plan they selected,
or which was imposed on them by virtue of their work status, location,
and available "quasi-insurance products".

Three patients - all of whom were patients in the same exact practice
a year before our scenario unfolds and who were, ostensibly in good
health:

One, a senior citizen, has Medicare, an old time indemnity type
Medicare supplement policy and is liquid. She discovers a lump in her
breast, goes to the same group practice as her peers the next day,
sees her internist/family practitioner, and is examined. The internist
immediately refers her to an oncologist, who she sees the next day, a
mammogram/MRI is ordered that day, she pays the $500 co-pay, the
results are available the next day, surgery, radiation and chemo are
prescribed and 10 weeks later she returns to life pretty much as
normal. Her Medicare, Medicare supplement and personal resources both
entitle her and enable her to receive this level of care.

Second, a working single mother, who goes to the same exact practice
as an HMO member, waits six weeks for an appointment, is seen briefly
by an MD or NP who does a breast exam, notes that her HMO plan
requires approval for testing or referral and suggests that she come
back in 6 weeks/months, because maybe there is nothing wrong and why
go through all the grief. She endures the anxiety of the next
weeks/months, adding to the considerable stress she already has, and
when she finally gets that mammogram/MRI and Dx, after saving up for
her co-pay, she has a very similar conversation with the practice
manager who explains the limited options she has in her HMO plan
regarding treatment. If she doesn't pay thousands of dollars out of
pocket she gets the least effective and most painful treatment.
Months, if not years later, far too late to be of use, she finally
starts treatment. But it isn't treatment for a small lump which did
not metastasise, it is treatment for stage IV metastatic cancer with a
life expectancy measured in weeks or months.

Third patient used to go to the practice, but she lost her job working
for the manufacturing arm of the same company that just happens, as a
multinational conglomerate, to have a significant holding in the local
health care system. They moved the infant formula plant she used to
work in offshore, to China, and she had to go on welfare. She has a
Medicaid card but there isn't a single local provider that accepts
Medicaid. The closest provider in 100 miles away and she doesn't have
the resources to get there and certainly does not have the resources
for the Medicaid co-pays involved. She feels the same exact lump and
has nowhere to turn. She will never get 'diagnosed' and will die, a
few years later of untreated metastatic cancer. In truth, it is
probably kinder that she isn't diagnosed - because even if she was,
she wouldn't have been treated anyway so it would have just added to
her burden to be correctly diagnosed and not know that she wasn't
being properly treated.

Now, there are nurses working in this health care system and they do
understand what they were taught. But they have also been oriented as
employees in a profit motivated/seeking company. The orienters take
great pains to explain that patients come with different insurance
policies and that they must be careful to make sure that each unique
patient gets the services appropriate to the policies and resources
they have. The trainers carefully explain that the health plans the
patients have, were selected by the patients (which is true to some
extent) and that the facility did not make that choice for them (also
true) but that it would be unfair to the facility to treat everyone
the same when some people do not pay their way.

There is no clear right and wrong here. There is no clear basis for
ethical practice because the truth is that the patient who conserved
her resources, bought an indemnity plan, saved for a rainy day, had
more options than the person who overextended themselves, chose a
cheaper HMO policy, or wound up on Medicaid. This situation cannot be
fixed by the facility because it is a small cog in a much larger
system that is interconnected. If the facility consistently provides
higher benefits than deserved for the latter two patients the
corporation that owns it will conclude that that entity is financially
untenable and will withdraw its support, citing better opportunities
in different market sectors. They may shut down the hospital and
clinics and open an assisted living facility in a different state. The
local facility may limp along for a while but eventually it will
wither and die leaving the community without a significant health care
resource.

We are, at a transformative moment indeed. But just as the big bang
eliminated all the compounded errors of the last universe, the next
one will eliminate us as well. We are not going to be anywhere near as
fortunate in the future as we are now. There are 7 - 8 billion people
on the planet who are no less interconnected than the three examples
above. If they all drove the same distance everyday, in the same gas
guzzling vehicles that we drive, the whole planet dies. forget asthma
- there simply won't be any free oxygen left.

Could we conceivably avert the crisis that lies ahead - well, we can
buy years/decades but not centuries. We could, instead of building
dirty nuclear reactors and oil platforms, construct massive, floating
solar arrays and wind turbines in the ocean, use the cleaner energy
they produce to turn sea water into oxygen and hydrogen, pipe the
hydrogen onshore and use it to fuel our economy and release the oxygen
to clean up the atmosphere. Instead of polluting the environment we
would actually be cleaning it. What would it cost to do this? far less
than the oil drilling and nuclear reactors will cost us because those
alternatives never incorporate their true long term costs for the
destruction of the environment they entail.

When i suggest that John McCain and Sarah Palin are not up to the task
(and I can only hope obama is because he is the only choice we have in
November) it is because they are simply not globalists or holistic in
their thinking. They are the same sort of short-sighted, linear,
planners that have run us into the ground by imagining that only the
facts that are most imminent need to be addressed.

McCain and Palin would do, i have no doubt, to the current
dysfunctional system of health insurance, exactly what was done the
last 10 - 20 years in the financial sector. Deconstruct state
regulations that vary from the few states like Massachusetts and New
York which have active, tight, and functional insurance regulations
and allow companies to incorporate in states with no meaningful
insurance regulation or financial oversight and sell policies to
individuals and employers around the country, who have no idea of the
difference between a well run and incompetently run health insurance
company. These most inadequate companies will take all those pre-paid
premiums and pass them on to executives in the form of performance
bonus plans, and leave the companies inadequately reserved and unable
to meet their future costs. Years later, there will be no private
health insurance market left just as there is no private financial
sector left at the moment.

What would McCain and Palin say when the government is forced to bail
out the health insurance industry in 2012 as they are running for
re-election?

"Nobody could have predicted this collapse..."

But, with all due deference and regard for my acausalist leaning
friends - THIS OUTCOME IS PREDICTABLE. This is what will happen if we
deconstruct insurance regulation and shift the system that works
poorly to one that works not at all.

We have state regulation because we already know that some insurance
companies operate fast and loose. Before the AIG bailout of Hank
Greenberg's old company AIG there was the largest insurance company
bankruptcy in American history at Reliance. Who owned Reliance? Saul
Steinberg - a schoolmate of junk bond pioneer Daniel Milken (SP?).
What is the connection? Greenberg and Steinberg were rivals - each
trying to grow a bigger company by taking ever increasing risks,
writing more and more outrageous insurance policies, expanding into
reinsurance, global insurance, and taking on more and more risk.
Reliance simply failed earlier. Steinberg replaced the solid, blue
chip assets on Reliance's books with junk bonds. AIG simply bought bad
mortgages and insured others who bad mortgages. What the hell is the
difference?

Footnote - I worked at Reliance, in the actuarial department, 10+
years before the final closure and it was abundantly obvious to me
that Reliance would fail long before it actually came to a halt. I
also interviewed at AIG in the 1980s and concluded that it too would
eventually fail based on the operating philosophy espoused by
employees during my interviews.

We cannot simply train people to behave how we would like them to
behave because we are woefully out of touch with the realities they
face at work. Trust me, I have a good handle on the fact that there
aren't but a handful of nursing faculty members in the world who
really understand the financial structure of current nursing practice.
If the faculty don't understand what is happening - how can they
possibly arm their students with the skills, mindsets, and strength to
resist the imperatives they will face at work?

and yes, i suppose i have some sort of ethical obligation to publish
and present - but believe me, i really understand how big a gap there
is between my grasp and the readiness and preparedness of those who
need to understand. For better or worse i am not your typical nurse -
most nurses didn't study mathematics, operations research, statistics
and engineering, didn't work in the insurance industry, have never
prepared a financial statement for anything larger than a family. i
did and it still took me decades to sort out the garbage and
understand what was happening. I have tried to explain it - but the
questions i get are so far off the mark that i 'despair'...

As I write this, our economy is tottering on the brink of collapse and
we are left with one presidential candidate who has admitted that he
doesn't understand economics at all. Half the country seems to think
that this admission doesn't automatically disqualify him for election
as president - you have no idea how scary that is for me...

bear
--- In Martha_E_Rogers@yahoogroups.com, "Vidette Todaro-Franceschi,
RN, PhD" <vtodaro@...> wrote:
>
> Bear,
>
> I for another, also believe that we cannot keep shoving the stuff,
and especially the "nasty stuff" under a rug. We need to have
dialogue and we need to be particularly vigilant whereever we are
working. It is essential to have discourse, and while we may not
particularly agree on the nitty gritty things, I think we are all in
agreement on the bigger picture. We are in trouble, and the chaos is
fundamentally breaking apart all aspects of life, globally. But
transformation is basic to life and there have been many abrupt
transformative changes throughout the history of humankind (and
universe (s), thinking about the big bang...and expansion, but also
black holes, and the mysterious stuff).
>
> I think we need to concern ourselves with the whole of it, and that
of necessity includes DNS/PhD issues--of preparing a workforce to
teach the new students who aspire to be a nurses. At the same time,
we need to address where and why we have failed:
>
> to work collectively to participate in transformative change to
enhance quality of life, health, and yes, death.
>
> to properly educate and emphasize the wholeness of the human being
in relation to environment and lest I be considered 'possilby' biased,
I will say, I most assuredly am. We are preparing nurses to provide
safe efficient care but we are not addressing quality of care. One
might say (and many of those I work with do), that if we educate our
students to provide safe, efficient care, they are providing quality
of care, but I don't agree. There is something missing that is a
manifestation of pattern reflective of the whole (of what is going on
in our world/universe). Yet, perhaps all of this chaos is needed at
this point in our evolution; what I am seeing in nursing education and
in practice has certainly shaken me up and I am participating ever
more knowingly in change these days....
>
> Note, I can picture the look on your face Bear, as I have completely
evaded the political end of it and instead rather more or less said,
that all this pain and suffering may well be for some reason
unbeknownst to us.... (I am trying to grin as I write this, but of
late it is hard to even grin -though I can write a grin <GG>
>
> I dare say Martha would have something perfectly outrageous and at
the same time truly enlightening to say about all this, though I
haven't a clue right now. Any of you Rogerians willing to take a
gander at it?
>
> Peace, Love, & Light,
>
> Vidette Todaro-Franceschi RN, PhD.
> Associate Professor & Specialization Coordinator
> Adult Health Advanced Practice Graduate Program
> Hunter-Bellevue School of Nursing
> Hunter College, City University of New York
> 425 E 25th St
> New York, NY 10010
> vtodaro@...
>
> *********************************
> www.energy-enigma.com
>