How you get death panels

This tragic story of bureaucratic arrogance, resulting in the potentially avoidable death of an infant, recalls my experience with Certificate of Need regulations, back in the early days of that movement to save costs and centralize equipment and expertise.

As chief radiologist of the x-ray department of a small hospital (110 beds, fairly active E.R.), I was asked to lead the process of application for buying and operating a C.T. scanner which would be perhaps the sixth in Portland.  A rather large private x-ray clinic with some political clout was a mile down the street and had installed its own C.T. scanner a while before, as had the Adventist hospital a couple of miles farther down.  The state health care agency had been exercising its powers, and so we assembled our documentation and statements from clinicians and hospital staff and, dressed up, appeared before the board.

The board was composed of nineteen people, around a large oval table with the three of us at the other end from the chairwoman.  I presented our case with totals of admissions (and estimates of acuity), outpatient work, E.R. traffic, and the potential costs and risks of patient travel for needed exams, and I waited confidently.

Of the nineteen, not one was a physician.  There were three nurses, a pharmacist, a dentist, several schoolteachers, and unspecified state employees.  The discussions were scary.  Much chin-stroking and speculation, deliberating on costs and efficiency.  They seemed bemused and asked each other questions and asked us nothing.  Finally they voted, and our request was voted down by a majority of one.  There ensued a shocked total silence that lasted maybe 20 seconds but seemed longer, at which point I asked in a loud voice if we could request a reconsideration.  The chair quickly agreed, and the dentist and the pharmacist asked us a couple of questions and then decided they would change their vote, as did a few others.

In a totalitarian state, bureaucrats have a vested interest in a) exercising their power, b) extending and increasing their power, and c) advancing in glory.  They can use the pretext of economizing state expenditures because the state pays for everything.  They also have the option of favoring friends and family.  And they may put a thumb on the scale just because they can.

In Oregon, one might think the free market (hah!) would be a satisfactory means of modulating costs, as enterprises succeed or fail based on experience and expertise.  Some enterprises – I'm thinking of imaging services here –  might actually operate successfully at a loss if they support the other services in the hospital and the requirements of the admitting physicians.  The idea that a state agency can reliably decide on what to allow and what to forbid is absurd.  One could argue that it might be defensible if the default were to allow, with the option to disallow based on irrefutable proof of absence of need.  A podiatric clinic, for example, would not need a C.T. scanner but should certainly be allowed to maintain a blood draw station.  But even that seems like too much to assume, and I would prefer no regulatory control based on need.

This is a very minor example of the kind of unnecessary regulation that we may now, finally, hope to see reduced or eliminated.  Lives may be saved.

This tragic story of bureaucratic arrogance, resulting in the potentially avoidable death of an infant, recalls my experience with Certificate of Need regulations, back in the early days of that movement to save costs and centralize equipment and expertise.

As chief radiologist of the x-ray department of a small hospital (110 beds, fairly active E.R.), I was asked to lead the process of application for buying and operating a C.T. scanner which would be perhaps the sixth in Portland.  A rather large private x-ray clinic with some political clout was a mile down the street and had installed its own C.T. scanner a while before, as had the Adventist hospital a couple of miles farther down.  The state health care agency had been exercising its powers, and so we assembled our documentation and statements from clinicians and hospital staff and, dressed up, appeared before the board.

The board was composed of nineteen people, around a large oval table with the three of us at the other end from the chairwoman.  I presented our case with totals of admissions (and estimates of acuity), outpatient work, E.R. traffic, and the potential costs and risks of patient travel for needed exams, and I waited confidently.

Of the nineteen, not one was a physician.  There were three nurses, a pharmacist, a dentist, several schoolteachers, and unspecified state employees.  The discussions were scary.  Much chin-stroking and speculation, deliberating on costs and efficiency.  They seemed bemused and asked each other questions and asked us nothing.  Finally they voted, and our request was voted down by a majority of one.  There ensued a shocked total silence that lasted maybe 20 seconds but seemed longer, at which point I asked in a loud voice if we could request a reconsideration.  The chair quickly agreed, and the dentist and the pharmacist asked us a couple of questions and then decided they would change their vote, as did a few others.

In a totalitarian state, bureaucrats have a vested interest in a) exercising their power, b) extending and increasing their power, and c) advancing in glory.  They can use the pretext of economizing state expenditures because the state pays for everything.  They also have the option of favoring friends and family.  And they may put a thumb on the scale just because they can.

In Oregon, one might think the free market (hah!) would be a satisfactory means of modulating costs, as enterprises succeed or fail based on experience and expertise.  Some enterprises – I'm thinking of imaging services here –  might actually operate successfully at a loss if they support the other services in the hospital and the requirements of the admitting physicians.  The idea that a state agency can reliably decide on what to allow and what to forbid is absurd.  One could argue that it might be defensible if the default were to allow, with the option to disallow based on irrefutable proof of absence of need.  A podiatric clinic, for example, would not need a C.T. scanner but should certainly be allowed to maintain a blood draw station.  But even that seems like too much to assume, and I would prefer no regulatory control based on need.

This is a very minor example of the kind of unnecessary regulation that we may now, finally, hope to see reduced or eliminated.  Lives may be saved.