I work at a hospital that is part of Trinity Health Corporation, one of the largest Catholic health care systems, and

the 12th largest system in the United States. At my place of employment, no patient is ever turned away because of inability to pay. Saint Marys Hospital has a large amount of charitable cases that definitely impact the bottom line, but never the care for the patient. There have been years that have passes without pay increase for merit of cost of living due to the deficits and increasing amount of patients with an inability to pay, so from my perspective the staff have in that sense suffered, but the patient is always provided for and care for. I have witnessed many patients return to the hospital due to lack of resources or ability to pay for medications that do not have a generic formula, which in some cases is hundreds of dollars cheaper. Some patients need to choose between taking 2 different medications, only taking one when for their best outcome both would be preferable. With social work and our clinical pharmacist and case managers, we try to work with people when we know that this is going to be an issue upfront. Healthcare is expensive, I try to address some of these things with patients at discharge or prior. The most frustrating is when patients choose to do other things with their money, skip the medications and then end up back in the hospital time after time. According to The 21st Century Intelligent Pharmacy Project: The Importance of Medication Adherence, the cost of patients not taking their medications as prescribed is nearly 290 billion dollars annually. This amount of money is astronomical, much more education needs to be done on medication compliance not only for the patients health, but in the big picture it will cost them and the nation considerable less money. In researching information for this week I came across articles that discuss care providers denying care to those without insurance or ability to pay, referring a patient to a clinic, as well as forgoing medical tests and studies that cannot be paid for. I have been working at the same hospital for just over 10 years, and while this may happen other places, it does not happen where I am employed. The biggest time that insurance or ability to pay comes into play is upon discharge relating to patient placement for various types of post hospital care. The biggest change that I would make in healthcare would be to limit the spending on end of life care. According to the End-of-life care costs continue to climb upward more than one third of health care costs are accrued in the last year of life. After working in the ICU for more than 10 years I have discovered that most Americans in general are in denial about their own mortality. People with end stage illness from COPD, to ESRD, to terminal non operable cancer, to chronic heart failure and liver failure grasp at any and all straws offered to prolong what most medical professionals would deem the inevitable. This is a gross misuse of assets from money, to staff, to blood products, etc. I dont think that people should be denied potentially life-saving treatment, but there needs to be a prognosis of LIFE. According to CHEST journal, The technological advances that medicine has witnessed in the last few decades are no more apparent than in the ICU. Yet when used inappropriately, this technology may not save lives nor improve the quality of a life, but rather transform death into a prolonged, miserable, and undignified process. Life support technology is intended to provide temporary support for patients with potentially reversible organ failure and not a measure to conquer death. The second thing that I would change is staff awareness of cost. We all go to work and plan to do a good job in proving care for our patient, but I would venture a bet that most of us spend little time

considering our own use of assets in providing that care. This topic is touched upon in Chitty& Black (2011) where they discuss the first step to a nurse helping to manage health care costs is to become conscious or aware. Bedside nurses not only have the biggest impact on patient care and their outcomes, but on cost as well. Nurses care utilize non-disposable equipment, manage resources at the bedside by only taking and opening what you need at that given time, punch out on time and cut down on the overtime pay, when you transfer a patient to a different unit within the hospital make sure all of their things and medications go with them to reduce doubling or tripling of items such as basins, soap, incentive spirometers, ambu bags, etc. If nurses took care of hospital equipment like it was something they utilized at home I cannot even fathom how costs would be reduced. If we treated patient supplies as though they were items from our pantry we might be a little more mindful of waste. I think that it would behoove managers to list costs of items frequently used, get together teams to come up with creative ideas for cost cutting without impacting the quality of care, or to just help raise awareness of the cost of certain items. Nurses are the front line with a huge impact on the bottom line. Chitty, K.K., & Black B. P. (2011). Professional nursing: Concepts and challenges (6th ed.) Maryland Heights, MO: Saunders Harding, Anne. End-of-life care costs continue to climb upward. (2010). Retrieved from http://www.reuters.com/article/2010/10/14/us-care-costs-idUSTRE69C3KY20101014 The 21st Century Intelligent Pharmacy Project: The Importance of Medication Adherence. (2010). Retrieved from http://www.healthtransformation.net/galleries/wpHIT/White%20Paper%20on%20Medication%20Adherence.pdf Wood, K., Marik,P. (2004). ICU Care at the End of Life. American College of Chest Physicians. doi: 10.1378/chest.126.5.1403 CHEST November 2004 vol. 126 no. 5 1403-1406