What has Happened to Healthcare in this Country?

I’m asked this question that is the title of this post both  by patients and colleagues on a nearly daily basis. The answer is simple, Money. Before anyone jumps in with the old line “doctors make too much,” I want to point out that most physicians are making far less money today than they did a decade ago. This is true across the board for primary care and specialist physicians alike.  Don’t believe me? Just ask your doctor. And while you’re at it, ask him or her about their relative satisfaction with their life’s work.

But we’re spending more money on healthcare than ever, right? So where does all the money go? Certainly there are many more hands in the cookie jar than ever before. Pharmaceutical companies and device manufacturers are profiting from the sale of products that didn’t even exist a few years ago. Hospitals are buying the latest multi-million dollar scanners and surgical robots just to stay competitive. Healthcare has become a massive marketplace with everyone trying to get a bigger share.

No single segment of the healthcare system has become more about the money than America’s hospitals. The era of the small community hospital, run by the town’s doctors and supported by a religious group, is over. Mega-hospital systems have swallowed them up largely in an attempt to increase their contracting leverage with third party payers and squash their competition. Many of these healthcare giants hide behind their highly cherished, tax exempt “not-for-profit” status, but make no mistake, all these systems are businesses where the bottom-line is the bottom-line. An example of the healthcare shark-tank appeared as a news story in the Texas Tribune, April 11, 2011. Community Health Systems of Tennessee was attempting a hostile takeover of Tenet Healthcare Corporation, a smaller Dallas based hospital conglomerate. If you read this article (http://tinyurl.com/6gudnec) you won’t be able to distinguish between this business battle and those that occur in the telecommunications, manufacturing or banking industries, because there isn’t any difference

But the business of healthcare isn’t like selling cell phones or offering home mortgages. It is, by its very nature, a personal service offered by individual physicians, nurses and support staff to those in need. The hospital’s role should be to provide the necessary equipment and ensure the proper environment in support of the healing arts. Unfortunately, once the profit motive has been introduced, hospital systems aren’t satisfied with that limited role. The corporate moguls pulling the strings in countless boardrooms across the country are continuously looking for ways to expand their “business.” Over time they have established a set of clear priorities that further their objectives, despite the deleterious effect they have had on the actual delivery of care.

The Three P’s – Priorities for running a successful American hospital

#1 – Payment

Obviously, it is not possible for a hospital to remain open without receiving payment for the services provided. Most payments are received from third party payers and typically are at a negotiated rate based either on the admitting diagnosis (Medicare DRG) or a discounted fee based on a set percentage of billed charges, which generally have little or no relationship to actual costs. Typically if a hospital collects 50% of their “charges” they’re doing well. The key then is to place a high priority on capturing every possible charge, thus the need for computerized management of everything from how many Tylenol tablets are dispensed, to the number of minutes spent in the operating room. So what’s the problem with that you ask? Nothing, until the pursuit of payment becomes a higher priority than the delivery of care.

#2 – Process

Once upon a time, not so long ago, hospitalized patients complained that no one answered their call light when they needed help. Today there are typically several nurses at each station all the time, but the call lights still go unanswered because the nurses are too busy filling out forms. Things that used to take a few seconds now take several minutes because there is a system-mandated “process” for everything. The argument that these processes help ensure patient safety is, in a word, laughable. In an article published in the Richmond Times-Dispatch, CMS Director Donald Berwick sited the increasing problem of hospital errors and of course proposed even more regulations and processes. What is lost in these proclamations is the fact that every patient is a unique individual and every nurse and physician as well. Trying to micromanage every component of every point of care through process implementation has become a recipe for increased errors and decline in personal service.

#3 – Protocol

In recent years we have been bombarded with catch phrases like “Best Practice Guidelines” and “Quality Healthcare Management.” These are euphemisms for “you must do things according to a standardized protocol.” Frequently, such protocols are created by some academic committee and use statistics as a lever to move reluctant, albeit experienced participants. Hospitals are encouraged to implement such protocols because third party payers increasingly demand strict adherence as one more hurdle that hospitals must negotiate to receive payment. But, not all physicians are willing to go along with this cookbook style of medicine. One very effective way to force conformity is for the hospital to simply hire the physicians. Once on the payroll, physician protocol compliance ceases to be a problem. The net effect is every hospitalized patient gets pigeonholed into what one can only hope is an appropriate protocol. The most alarming aspect of protocol implementation is the absence of critical thinking on the part of healthcare professionals. Everyone is encouraged to “just do everything by the book.” Administrators quickly add that following the protocol is of course completely defensible in a court of law. Not that that ever enters the discussion.

What is interesting is the spin that is constantly being put on all this. Like any business, hospital systems recognize the need to maintain an image in the communities they serve. So, in the last decade we’ve witnessed a barrage of public advertising, promoting healthcare expertise and compassionate care by hospitals. But wait, does the “hospital” actually provide care? No, not really. It is the physicians and nurses that provide the actual care. This is why when patients have a positive experience they invariably attribute it to a specific nurse or physician, or in some cases a team of people who exhibited personal care and compassion. But when they have a bad experience it is common to hear patients talk about the poor care they received at a particular hospital. The lesson then is: Person-to-Person Care – Good; Impersonal, Institutional Care – Bad. This is clearly an over generalization, but the trend is definitely there and growing.

A major hospital system here in Texas recently launched an ad campaign with the tag line being “Making Healthcare Human Again.” The logical implication is that somewhere along the line healthcare became non-human, or perhaps more grammatically correct, inhumane. This is not a very pleasant thought for anyone entering through the doors of an institution where they have little control and are compelled to trust completely. But, until the public demands that the insurance industry, hospital conglomerates and the Federal government cease their efforts to practice medicine through hyper-regulated Payments, Processses and Protocols, the American healthcare system is likely to continue to deteriorate.