As many readers will know, I just spent the last eight months working full time for OR EVS at Hunterdon Medical Center in Flemington, New Jersey. About a week ago, I started a new job as a junior analyst in hospital revenue cycle management (RCM) with Aergo Solutions in Iselin, New Jersey. People have asked how I like my new job. Get back to me on that when I know what the hell I’m doing, since for now, I obviously don’t.

For now, I can only comment on the transition between the one job and the other. And the only comment I can muster is that I’m having trouble putting things in words. The difference between working for OR EVS and working for hospital RCM is so stark and abrupt that I’m inclined to think that you really have to experience it first-hand to know what it’s like. One day you’re working with fracture tables; the next day, you’re working with pivot tables. The two things have about as much in common as the two jobs themselves.

The only things that OR EVS and hospital RCM have in common are hospitals and health care. But try to imagine the difference between cleaning blood, urine, and propfol off the floor–and manipulating hospital revenue data all day. I once described OR EVS to a friend in nursing as “an 8.5 hour high-rep workout in a cold-ass gym.” I described her job, LTACH nursing, as a “12 hour marathon through a slow-moving hellscape.” How to describe hospital RCM? Well, it’s like….8.5 hours of being chained to a desk in front of Excel spreadsheets alongside other people in cubicles chained to desks in front of Excel spreadsheets. No workout analogies are going to fly here. RCM is about as sedentary as sedentary gets.

I still kinda remember what I used to do at my job with OR EVS. We’d walk into the OR, and the charge nurse would call, asking for a turn-around or terminal cleaning of a particular OR suite. Either way, we’d go in, haul the trash, wipe the surfaces, mop the floor, set up the bed, put the equipment in place, and then get out of the way, making sure to close the door behind us–the signal to the nursing staff to bring in and open the surgical instruments. Then we’d repeat that pattern for 8-9 hours. It all seemed straightforward enough.

What’d I do today at Aergo? Well, my boss gave me nine data sets corresponding to nine regional hospital systems, and asked me to arrange the data in pivot tables, displaying balances and account-counts for all patient financial categories, sorted by date of service.  It seems straightforward enough–said no one ever, except in hospital RCM.

Some of the “services” alluded to by those spreadsheets were, no doubt, surgical in nature. And OR EVS at all of those institutions undoubtedly did what OR EVS always does to set up a surgical suite: haul the trash, wipe the surfaces, mop the floor, etc. OR nurses, I’m sure, ran around as per usual like very calm chickens with their heads cut off. Anethesiologists put their patients under, then randomly threw things around the OR. Surgeons eventually made their appearance, made some incisions, and did some poking, prodding, pulling, and stitching up. Patients no doubt went under, got operated on, came out, felt sick, felt pain. Blood flowed onto the floor, and spattered on the walls, the ceilings, the lights. Patients shit the bed. Hospital-based infections–COVID, MRSA, VRE, C. Diff–filled the air and the hidden crevices of the room. Canisters filled up with mucus and saliva.

Sorry to be so graphic, but there’s no other way to hold onto the reality of the OR from the world of RCM–a weirdly sanitized space from which all unsightly sights and unspeakable smells have been scrubbed clean. There’s no blood, shit, urine, flesh, propofol, sharps, fracture tables, patients or nurses in the RCM world. There are no alarms, codes, or code carts, either. No one yells. No one sweats. No one gets their scrubs dirty. No one wears scrubs. “Scrubbed clean” is in fact the term RCM people use for a bill that’s been edited to maximize the chances of a high-yield pay-out from a third-party payer.

As far as a Junior Analyst is concerned, health care is just numbers on spreadsheets, column after column, row upon row, spreadsheet upon spreadsheet, account after account. Human beings themselves recede into a kind of data-saturated unreality. At this point, I’m not sure what I find more frightening–being in the proximity of a Code Blue in the OR or ICU, or being so far out of proximity of one that the only code that matters is Code Green.

Now that I’m chained to a desk in a cubicle (itself housed, as the photos nearby indicate, in an office suite…in a giant cubicle), I find it hard to believe that I had the sheer physical stamina to spend 8.5 hours hauling trash, wiping surfaces, and mopping floors in an OR. But when I was in OR EVS, I actually started to have trouble imagining what it was like to sit in front of a computer all day, despite the fact that until then, that’s mostly how I’d earned my living.

In Utilitarianism, J.S. Mill writes:

On a question which is the best worth having of two pleasures, or which of two modes of existence is the most grateful to the feelings, apart from its moral attributes and from its consequences, the judgment of those who are qualified by knowledge of both, or, if they differ, that of the majority among them, must be admitted as final. 

I’m not sure that Mill’s claim applies to the laboriousness of drastically different kinds of work (not that he necessarily meant it to). Of two sorts of work, which is the more laborious? Well, if the two contenders are EVS and RCM, the odd thing is that it’s hard to remember what the one was like while doing the other. Each sort of work takes its toll in a different way: the physical labors of the one crowd out the mental tensions of the other. Evidently, mothers aren’t the only ones prone to amnesia about labor.

There’s something disorienting about the fact that revenue management is what drives health care, despite standing at such an Olympian distance from the realities that make health care what it is. That seems an obvious fact at this point, practically a cliche–just watch John Q to have it driven home for you–but its true, visceral significance is likely lost until you experience it up close, in the first-person. As I sit in my air-conditioned cubicle at Aergo, poring over spreadsheets, I strain to remember what it was like to have an OR nurse tell me to turn OR 6 over “as fast as possible” for an emergency OB/GYN case: the patient was just outside the suite on a stretcher, bleeding out and waiting for surgery. I know it happened. I was there. I was the one who hauled ass to turn the room over. But from my cubicle on the eighth floor of the BASF building in Iselin, I can only dimly remember what it was like to be there, as though I saw it all in a movie–or as though it happened to someone else. It’s an odd feeling to experience amnesia over life’s most intense moments, especially when that amnesia has been induced by a contrary sort of experience. I wonder, with trepidation, what it means.

I’m still scheduled to do per diem work in the OR at HMC on weekends–one weekend a month for the indefinite future. I sure as hell hope I remember how. It won’t do much good to confuse a Jackson table with a pivot table, or to make an OR bed with an Excel spreadsheet. But my deeper hope is to keep the reality of both EVS and RCM fully real to me as I alternate–in a 9:1 ratio–between the one and the other. Is it possible to do justice to the grandeur and misery of front-line health care while doing justice to the imperatives of revenue maximization? Or does the one reality crowd out the other, and if so, which one? As I said, get back to me. We’ll see.

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The views I express here are entirely my own, and are not intended to represent the views or positions of my employers, Aergo Solutions and Hunterdon Healthcare.