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Cross Roads: Some critics say Dominican's stated commitment to Christian values conflicts with its new ER policies.

Photo by Hillary Schalit

Dominican's UrgentCare unit introduces 'financial triage'

By Kelly Luker

IT IS LATE AT NIGHT WHEN TWO families arrive at the doors of Dominican Hospital's emergency room. Two mothers are cradling crying, feverish babies. One family is ushered quickly into a tastefully appointed waiting room, then whisked into the new UrgentCare emergency clinic, where the sick child is immediately seen by doctors. The mother without cash or private insurance takes a seat to the right in a plastic chair, where she waits three hours before harried staff members tend to her crying baby.

Dominican's administrators say their new, no-appointment-needed UrgentCare clinic serves a valuable purpose in the community. Besides offering prompt service for credit-card-carrying patients, hospital representatives say, it reduces the wait time for Medi-Cal patients and others who can't afford to pay cash.

But some outraged health workers charge that UrgentCare's existence in the emergency-room building drives home the growing belief that quality, expedient healthcare is a privilege, not a right.

Unveiled in early February, UrgentCare is similar to Doctors on Duty, a popular chain of emergency clinics. Known in the health industry as Doc-in-the-Boxes, these services provide emergency treatment for non-life-threatening illnesses or injuries--sprained ankles, allergic reactions or infections.

Clinics like UrgentCare provide a service for ill or injured folks who don't want to wait for a regular appointment or the often-slow hospital emergency room. And they are often less expensive than regular ER services.

But several former and current Dominican staffers say it gets a little sticky when an emergency clinic that accepts neither the indigent nor Medi-Cal is situated within the confines of the ER of a nonprofit hospital that professes dedication to the Christian values of charity and compassion.

"Look at the waiting room," writes one of Dominican's angry health workers, who asked not to be identified by name. "To one side the white and well-to-do, to the other side the people of color, the single mothers, the uninsured elderly.".

Public relations director Penny Jacobi and emergency room manager Linda Starn, RN, staunchly insist that their hospital's decision to open UrgentCare was motivated by a commitment to service. "We wanted to offer more care to the community for their non-urgent needs," Starn says.

In fact, she says, the new addition has decreased waiting times for the regular emergency room.

But some critics accuse the hospital of putting money before patients, citing greed as the motivating factor behind the decision. Other observers say it's simply an example of Dominican's efforts to stay competitive in the increasingly cutthroat climate of a business-driven $3 billion healthcare industry. They point to other changes in the medical community, where nurses and doctors are encouraged to think of patients as "customers" and each other as "associates."

The final straw, say nurses, was being told to participate in a mandatory in-service training on "financial triage."

Triage is a system developed during World War I to help doctors and nurses decide how to prioritize patients based on medical need. Now, with financial status thrown into the mix, emergency room nurses must make decisions based on a new set of standards. They must learn to take cash and run credit cards. They also must sort out those who can pay for services from those who cannot.

According to a document obtained by Metro Santa Cruz from Dominican titled "Philosophy of Financial Triage," prepared by Starn, patients will first be assessed to see if they are medically appropriate for UrgentCare. Then, continues the document, "If the patient is a potential for UrgentCare, the triage nurse will say: 'For your particular illness or injury, we offer a 45 percent discount if you wish to pay cash for your visit today.' "

Several nurses found this new "customer service" morally incompatible with the basic tenets of their jobs. In response, Starn allowed them to hand out written cards outlining financial requirements of the new UrgentCare.

"This is outrageous," says Kit Costello, president of the Dominican nurses' labor union, California Nurses Association. "It's medical red-lining based on class and financial status."

Costello also wonders how a business--any business--can afford to give 45 percent off services rendered.

"Where are they shifting the cost to?" she asks. "And how do you know what the 'normal' fee is? Is it posted?"

Starn says that UrgentCare can afford the discount because "we save on the cost of billing." And fees are not posted, says Starn, "because we felt it would be more confusing. But anybody who asks, we provide them with a fee schedule and we give them an estimate of what it will be that day."

Both Starn and Jacobi deny another allegation: that staff were urged to drop their titles and, like Wal-Mart employees, refer to each other as "associates." Beth Shafran, a local CNA representative, disagrees.

"Originally, on the name tags, [Dominican] wanted to put on 'associate,' and [CNA] fought to keep the 'RN's on," Shafran says. "Patient families have a right to know who is treating them."

Starn welcomes the new business approach to health care. "I'm getting used to using [the term] 'customers,' " she says. "We realize that if we don't treat them like customers, they won't be back."

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From the May 22-28, 1997 issue of Metro Santa Cruz

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