Hospitals: Managed or Mismanaged?

The coronavirus pandemic has exposed many issues that American society will need to address if we are to avoid, as Karl Marx stated, repeating history "…first as tragedy, then as farce." Unfortunately, in this regard, people don’t seem to have a good track record.

The practice of medicine has undergone substantial changes over the past two centuries. Originally jacks of all trades, physicians began to restrict their practice by creating medical and surgical specialties.  From practicing as individuals, they morphed into single and then multi-specialty physician groups.  More recently they’ve become employees of hospitals.  Similarly, hospitals, once independent entities, merged to become multi-hospital systems, commonly expanding beyond the hospital confines, and even offering medical insurance, thereby becoming medical conglomerates.

The role of a physician, with the assistance of other medical personnel, is to care for the sick, injured, and dying, guided by constraints offered by the Hippocratic Oath, alternative medical school oaths, state medical boards, medical societies, hospital by-laws, malpractice carriers, and finally, their own morals.

But what guides a hospital?  Hospitals have a mission statement.  It’s usually a boilerplate statement consisting of three parts: their Mission (to provide quality cost-effective medical care, educate professionals, and perform clinical research), their Vision (advance the community’s health, transform lives, etc.) and their Core Values (advance inclusiveness, respect, etc.)  Collectively this is a statement inspiring positive feelings though it’s actually generalities short on specifics, or in other words, it exists for the purpose of deception.

So what are hospitals up to?  Well first, they’re actually big business, usually hiding behind a not-for-profit status.  With that status they reap the benefit of tax-free fundraising and donations creating an endowment that supports a foundation, but that’s a topic for another day. Second, and most important for our health, the money doesn’t go where it should.

As I see it, most hospitals should primarily fulfill three roles.

The first role should be to provide an emergency room.  This is where people who are acutely sick or injured are evaluated with an eye toward possible hospital admission.  It’s for situations where a physician’s office, or urgent care facility, is not appropriate.  An example is when someone has chest pain.  Are they having a heart attack, is it a blood clot, pneumonia, or just a spasm of the esophagus?  The first three if missed can kill you; the fourth will get you sent home.  The ER’s purpose is therefore to evaluate actual or potential emergencies, not do what can be performed outside of the hospital, or to issue missed-work excuses, or feed the homeless.

The second role involves the operating room.  Surgeries that are complex (either due to specialized equipment or staffing requirements), the surgical risk of the patient, the necessity of hospitalization for postoperative recovery, among other factors, should determine the safest location for any particular surgery.  The ambulatory surgery center therefore becomes the preferable location for less complicated and lower risk procedures.

The final role for a hospital relates to its hospital beds.  Hospitalization is indicated when a specific illness or the presence of multiple co-morbidities requires intensive care and observation, such as that delivered by nurses, respiratory therapists, etc.  It should be used primarily when care greater than what you’d get at home or in a skilled nursing facility is required.

Hospitals play the leading role in medical training and are involved in clinical research, both of which are critical for the continued supply of medical personnel and advancements in medical knowledge, however it does not require our current hospital model for that to exist. Adequate funding at the federal and state level can ensure that medical training and research proceed, though like any government spending it requires oversight.

Conversely, what are improper hospital activities?  Among these are: purchasing physician practices and employing physicians for purposes of hospital enrichment, merging with other hospitals to create medical monopolies (as such, violating 100 years of federal law), use of ‘clipboard nurses’ to provide physician supervision rather than care, using physician taskmasters to ensure that physician medical notes include enough stuffing and repetitive information to capture the highest level of billable coding for each patient ‘encounter’, or providing outpatient medical services to the community (either within or without the confines of the hospital), leading to a loss of focus on the core hospital functions.

In summary, hospitals have engaged in a building and monopolistic buying spree, taking the focus off of what the hospital’s three core functions should be: providing an ER, ORs, and hospital beds.

So what happens when hospitals deviate from a sensible mission to what we have today?  You’re seeing it with the appearance of the coronavirus. Shortages of ventilators, masks, gloves, etc., all of which would be in abundance had the mission of hospitals been to affectively address times such as these.  Being the storehouse for community emergencies, capable of handling complex surgeries, and caring for those too sick to be at home or at less sophisticated facilities, would not be a problem if the focus was not on the sheer size of the hospital but rather on actual and potential need. Certainly if hospitals could persuade attorneys general to ignore anti-trust law they could persuade politicians to adequately fund hospitals. 

Of course we didn’t get here by magic.  There is blame to be shared among many.

Physicians are the majority members on hospital staff medical committees.  Through their actions they’ve played the role of enforcers for hospital management, subduing any physician with an independent mind.  When flu vaccination of each staff physician becomes a priority over allowing an unscreened public to wander the halls of a hospital caring for sick and immunocompromised patients, you realize that not all physicians are acting in patient’s best interests.

The blame should also be borne by hospital boards, who acquiesce to CEO demands for the relentless expansion of hospital services, all for the CEO to justify greater pay and a larger golden parachute.  Board members benefit by the power they obtain through their collective action and networking opportunities.

Blame should also be assigned to the federal and state governments in allowing hospitals to violate 100 years of anti-trust law, allowing the co-mingling of funds when for-profit arms are within not-for-profit entities, and for not setting a minimum amount of charity care to warrant a not-for-profit status. Federal and state insurance programs reimburse hospitals in ways that at times inadequate for the work that’s done, thereby requiring hospitals to expand services within and beyond their walls, and again diverting attention from what should be their core mission.

The bottom line is that hospitals should limit their activities to what communities actually need, which I believe revolves around and should be restricted to the ER, OR, and hospitalized patients. Going beyond this mission diverts their focus and negatively affects medical care.  Outpatient care should be redirected to physicians since they are best suited to determine the needs of their communities.  Services needed while patients are hospitalized should consist of a medical partnership between the hospital and physicians, not exist in order to use physicians for the hospital’s financial gain.

The coronavirus outbreak has demonstrated that hospitals were ill prepared for what was actually foreseeable, since there’s a yearly influenza pandemic to contend with, along with daily medical and surgical situations.  Once we get over this outbreak, it’s time to revisit the role that hospitals have taken upon themselves and determine as a society if their oversized reach is best for us rather than for them. 

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