Books: "The Cost of Care" by Theresa Brown

 

The Cost of Care: How Four Nurses Put Patients First in a Profit-Driven System

By Theresa Brown

Algnoquin Books; hardcover, 256 pages; $30.00; available today, Tuesday, October 27th

Theresa Brown, RN, lectures nationally and internationally on issues related to nursing, health care, and the end of life. She is a frequent contributor to the New York Times, CNN.com, the American Journal of Nursing, the Journal of the American Medical Association, and the Pittsburgh Post-Gazette. Her first book was Critical Care, and she is also the author of The Shift, which was a New York Times bestseller.

In the incisive and deeply researched new book, The Cost of Care: How Four Nurses Put Patients First in a Profit-Driven System, Brown addresses the health care gap in this country with an intimate, on-the-ground investigation into human-centered medicine.

Amidst a lot of harrowing news about the crisis in American health care, with severe nurse shortages, escalating medical debt, hospital closures, and pervasive practitioner burnour, Brown gets to the most basic question of the situation - Where is healthcare actually working, and how can we scale those solutions?

The meaning of this book is shaped by Brown's experience going through breast cancer treatment, and working for twenty years in an oncology ward and working in hospice, which left exhausted by a system that prioritizes billable units over patient wellbeing. That led her to the realization that she needed to find hope in healthcare, hope that it could be truly focused on helping people.

"After my treatment finished, I returned to work as a home hospice nurse and foung myself either pushing against or implementing the very same indifferent care that I had disliked so much as a patient," Brown writes. "I worked at a for-profit hospice, and the obstacles to care could be formidable if those obstacles saved the company money. A dying patient needed a fentanyl analgesic patch, which is expensive, and so it took hours of crazy round-robin phone calls to the pharmacy, to my manager, and back again, to get that patient his pain medicine. Most of the nurses I worked with took time with patients and their families, but I knew one who rushed through visits at nursing homes, maximizing what the company earned by minimizing his time with patients. Another nurse hustled families through the hospice admission process without taking time to acknowledge their grief or slowing down to answer their questions. I know this because that nurse was 'training' me to do admissions by showing me that taking care of the company's bottom line mattered more than looking out for every patient."

"I got lost in my own frustration, which was scary, but one day I stumbled out of the maze of resignation, newly sure that the antidote to my burnout was hope. I wondered if I could recover the idealism and commitment that first drew me to nursing if I searched for hope - for places where the system was actually working, where patients were getting great care and nurses and other medical professionals could practice the way they felt patients deserved."

The four exceptional nurses she shadowed across the country operate across four critical stages of life, from Maternity & Birth Care to Primary and Community Care; Elder Care & Geriatrics; and Hospice & End-of-Life Care.

Here is a summary of the areas of health care Brown studied:

Maternity & Birth Care: In Pittsburgh, Pennsylvania, a nurse-led maternity program drastically reduces infant and maternal mortality risks through continuous, individualized support, offering a real counter-narrative to what is thought of out-of-hospital birth by a midwife, including by Brown herself. 

The Midwife Center in Pittsburgh is one of only three sites in the city where women can give birth, as a result of the consolidation of hospital systems and the closure of labor and delivery units. It is staffed by Certified Nurse-Midwives (CNMs) who started their careers as registered nurses, and its focus is on "normal physiologic birth" for pregnancies at low-risk, and their 10,000th new baby was born on March 19, 2026.

Primary and Community Care: Portland, Oregon, provided a deep look at preventive medicine, where nurses are given the time and autonomy needed to address social determinants of health before chronic conditions can escalate into costly hospital stays.

Brown started her trip there by shadowing a social worker and a physician whose specialty was geriatrics. She then visited Housecall Providers, or HCP, to see how they deliver primary care to patients in their homes or wherever they live because they couldn't or would not get care otherwise. They manage residents' physchiatric medications, and attend to other medical issues warranting attention, from high blood pressure to diabetes. 

The nurse practitioners (NPs) that work there are registered nurses with graduate degrees whose duties are comparable to physicians, in that they can diagnose, prescribe, and treat patients. In states like Oregon, they give NPs "full scope of practice," and they work independently. 

Elder Care & Geriatrics: In Denver, Colorado, Brown examines home care and assisted-living models that are designed around patient dignity, autonomy, and long-term comfort rather than corporate efficiency metrics. She wrote of this, "There is hope here. So much hope that it reminded me of all the good that health care can accomplish."

This is a story about ordinary people doing mundane things that can't be seen, but make as much of a difference as breakthrough drugs and complex surgery can in certain situations. At the CAPABLE program, which has 32 locations across the country, and is in service to American elders, who are often overtreated and, at the same time, under-helped by regular medicine. She relates a story about her maternal grandmother who had issues going downstairs to do laundry, and how the occupational therapists at CAPABLE would have handled it, partly by talking through the steps they could take to improve her situation and empower her to solve more problems.

Hospice & End-of-Life Care: This is an intimate examination of navigating end-of-life care in a compassionate way, prioritizing emotional and physical comfort instead of aggressive, expensive terminal interventions. Brown focuses on a palliative care nurse, Sanjana Patel, at Community Hospital, a mid-size hospital in a mid-size American city. She had a near-death experience at a very young age, which gave her a kind of comfort with this work, and a big part of the care is how people can choose the conditions for the end of their life. 

With The Cost of Care, Brown achieves her purpose, as these stories are heartwarming examples of people doing selfless, delicate work for others, and truly improving lives. 

"This book began with a personal mission and ended with me returning to the bedside as a clinical nurse," Brown explains. "My search worked for me! I would love to have the search for hope in healthcare work for our country,too!"