“The Money. They are making money.” Much as Captain Renaud explained his “shock” at the gambling in Rick’s Casino in Casablance: “I’m shocked, shocked to find that gambling is going on in here!,” so too we shouldn’t be “shocked” that hospitals make money.
They make money by performing the procedures and administering the treatments that will, in the best of all worlds, lengthen patients’ lives, or at least alleviate their pain. The ends — improving health — are noble; but the ultimate byproduct, money, so easily becomes the goal.
For hospitals, the New York Times recently highlighted the “Casablanca gambling” moment. The series began, like a mystery, with a question. In one North Carolina hospital, why did so many children undergoing surgery die?
The search for clues started with data. Surgery inherently carries risks: every surgeon enumerates them before proceeding. Some patients, moreover, enter riskier than others. Even in the “best” hospitals some patients will die. Were disproportionately more children dying at this hospital than in others? Were the patients at this hospital disproportionately sicker? Riskier?
The data-search was difficult because this hospital hadn’t routinely given up all the data to a central agency. Hospitals are “supposed to,” but not “forced to.” This one had lagged. So the data-search did not easily yield answers.
Yet the Times persevered and concluded that in truth, more children were dying there than in other hospitals.
Next came the search for reasons. There were the usual suspects. Medical incompetence? Nursing incompetence? Was inexperience the key? Were procedures unclear? Some hospitals use the kind of checklists that are common for pilots, as well as for anesthesiologists: the more routinized the procedures, the fewer the omissions and errors. This hospital did not.
For each case, analysts could isolate possible factors; but each case differed. Unfortunately for clarity, there was no one obvious single bogey, but a constellation of problems. The Times sought to find a pattern to explain the statistical disparity.
One conclusion was commonsensical: this hospital did too few procedures of that ilk.
Outside the world of hospitals, we seek out the most experienced plumbers, the most experienced carpenters, the most experienced architects. If we want a lawyer to draft a will, we find one who has drafted thousands; indeed, we want a specialist in wills.
Similarly, hospitals that do more of a specific procedure show better results than hospitals that do fewer, taking into account severity of patients. Surgeons as well as nurses that do more of the pediatric surgeries in question show better results. Again, this is a statistical finding: most patients will do fine. The problem lies with that sliver of patients who do not do fine.
If experience is key, the next-commonsensical question loomed: Why did this hospital do markedly fewer pediatric surgeries. The reason: other hospitals in the region did more. The number of pediatric surgeries in a region is not elastic: In a given year, a set number of children will need surgery. Eventually hospitals that do “too few” will yield to ones that do more. And as more patients learn via the grapevine that a competing hospital has better outcomes, patients will gravitate there.
This hospital had neighbors that did more surgeries. Patients could drive there within a day; parents of ill children would have driven a few hours if they had known the statistical odds of success.
Closing this hospital’s pediatric surgery unit would have made sense.
It didn’t easily happen.
The answer echoes Captain Renaud: money. This hospital was making money from the unit.
That revenue paid the salaries of staff, from surgeons to nurses to attendants. When hospital chains have sought to shutter hospitals to save money, because the community had too many beds for demand, the screams of protest have come from staff who would lose their jobs. Similarly, when hospitals should shutter a unit, or even shut down totally because of quality-of-care, the loudest objections come from those employees made redundant.
Healthcare is a mega-industry: like Captain Renaud, we are “shocked shocked.”
The warning for patients: we are primarily “revenue-producers.” Our well-being is a means to an end for some hospitals.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.
From The Progressive Populist, August 1, 2019
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