In the summer of 2005, Charity Hospital, the country’s second largest, provided medical care to the poor and uninsured of New Orleans and had one of the nation’s busiest emergency rooms. Rebuilt for the sixth time in 1939, it had 2680 beds, and was a major teaching hospital for Louisiana State University. That August Hurricane Katrina struck the city and flooded the first floor of the structure. Aside for a few generators for breathing machines there was no power, no lights, and food was scarce. On more than one occasion the thermometer topped 100 degrees. Toilets didn’t flush. There was no water for hand washing and the port-a- potty at the end of the hall smelled. Observing from the forsaken building, a physician painfully watched each day as helicopters evacuated patients from the roof of the nearby Tulane Hospital, a facility that was 80% owned by the for-profit Hospital Corporation of America, “while our 250 patients were evacuated by twos or threes in boats”. It took nearly a week before the final 200 were rescued.19
Of the for-profit institutions, HCA, Hospital Corporation of America is the largest. The chain was started in Nashville in 1968 by a cardiologist named Thomas Frist. “The hospital he worked in was poorly run and equipped,” and he and a few colleagues decided to build another one. He met and partnered with Jack Massey, the man who developed the Kentucky Fried Chicken chain. They built Parkview hospital in Nashville and bought a second one. When Thomas junior talked to investors he encountered skepticism. They didn’t believe a doctor could be a good business man. The secret of his success, he once said, was the idea of bigness itself.
The company he founded has become quite large and has “164 hospitals and 106 freestanding surgery centers in 20 states and Great Britain”–and a “market cap” of over 9 billion dollars.
Another of the big four, Humana was established after a few Louisville realtors figured they could make money operating nursing homes. They chose the company name from a list of 500 submitted by a corporate identity consultant. After buying one, then a few hospitals they went public in 1968. By 1972 they were running 45 hospitals. In 1978 they took over a second hospital chain and more than doubled in size. Then in 2018 the company paid $4.1 billion for a 40 percent stake in 76 long-term acute care and rehabilitation hospitals operated by Kindred Healthcare.
Bob Appel founder of American Medical International worked for a medical diagnostics lab that served hospitals. When his employer had financial problems Appel purchased the lab and later started acquiring hospitals.
National Medical Enterprises, now Tenet was formed by three lawyers in 1967. One was quoted as saying “doctors don’t generally know how to run a business. A hospital is really just like a hotel. You just have to know the medical side.15”
Community health systems of Franklin Tennessee once owned 25 of the 50 hospitals that were the nation’s most expensive. In 2014 they controlled 200 hospitals and earned $18 billion in profits. Then they paid $7.5 billion for a for-profit chain “that had a slew of financial and legal problems”, and they started losing money. When their debt was close to $15 billion they sold 30 hospitals cheap and they are teetering.3
Currently about 1034 of the nation’s hospitals belong to one of several for-profit corporations. They have stockholders, earn money, and pay taxes. Their bottom line was boosted (and government revenues fell) in 2018 when the corporate tax rate dropped from 35% to 21%.
Our nation’s first, Philadelphia’s “Pennsylvania Hospital’, was founded in 1751 “to care for the sick-poor and insane who were wandering the streets.” The facility was the idea of a Quaker who was medically educated in Paris a century before physicians believed bacteria and viruses cause infectious diseases. He wanted to emulate Paris’ Hotel-Dieu, the continent’s second oldest. The Parisian facility was established by Saint Landry in 651 AD “to treat pilgrims and the poor.” By the early 21st century the facility had become central Paris’ “top casualty and emergency hospital.” It closed in 2013.12
In 1811 federal legislators established and funded a home and medical clinic for military veterans. Fifty years later, after half a million fighting men died of wounds and illness in our destructive civil war (1860-64),the government created a number of veterans homes. They “incidentally” also provided medical and hospital treatment. 50 years thereafter our nation entered the First World War (1917-18). 116,000 men lost their lives. Many more were wounded and disabled–and a number of facilities were built.
After they were officially launched in 1921, the Veterans Administration started building hospitals. By 1948 there were 125, and the VA currently says they operate1600 health care facilities.5 They once cared for all service men and women who had been on active duty, even briefly. After September 1980 the government began limiting the pool by requiring a “minimum length of service.” The VA and Indian health hospitals are directly and indirectly (through Medicare and Medicaid) federally funded.
Before Medicare was passed in 1965 U.S. hospitals were largely segregated. Black physicians often couldn’t get privileges to practice at hospitals dominated by whites, and in some of our leading hospitals people of color were cared for in the basement wards of white hospitals.
Established In 1927 in the segregated south, the non-profit Houston Negro Hospital provided work for black physicians, and care for African Americans.
In St. Louis a hospital for the cities black indigents opened its doors in 1937. It was named for the Homer Phillips, a black lawyer from Sedalia, a small town in the middle of Missouri that was built on the main east west railroad line. Raised in an orphanage, then by an aunt, Phillips became a lawyer at Howard University, and moved to St. Louis. “Intensely interested in the Negro doctor”, he felt “more opportunities would be available for these men of medicine if there were a separate hospital.” In 1922 St. Louis passed an $87 million bond issue and Phillips made sure the legislation designated one million of the dollars as funds for building a black run hospital. Once the city had the money, it wasn’t easy to get them to turn it over. For more than a decade Phillips fought “interests that sought to prevent the hospital’s construction.39 It’s doors opened in 1937, and 2 years later Phillips needed to get additional funding. The facility was inadequate. “Patients were crowded into dark corridors and their lives were often in jeopardy because of fire hazards.” By 1961 the institution had trained the “largest number of black doctors and nurses in the world, and it was a leader in developing the practice of intravenous feeding and treatments for gunshot wounds, ulcers, and burns. It closed in 1979.1
The hospital that provided a significant part of my medical training, St Louis City Hospital, was integrated and lost much of its clientele to more upscale facilities when Medicare and Medicaid became the law of the land. The facility existed until 1985; then it closed. City and county hospitals elsewhere (Cook County in Chicago, Bellevue in New York, San Francisco City Hospital, and Charity in New Orleans (to name a few) remain very much alive and well.
Cook County hospital in Chicago, the caregiver for the poor in our second largest city (committed to providing “quality care with respect and dignity regardless of their ability to pay”) gets close to 40 percent of its operating revenue from state and city taxes. Of the remaining 60 percent, a third of the money comes from Medicaid, and 9 percent from Medicare. I don’t know how much the institution gets from private insurance companies.
New York City has 11 publically funded hospitals plus clinics and nursing homes. With an annual budget exceeding $5 billion they provide emergency services and hospitalize close to a quarter of a million people a year.6
University hospitals, which are presumed to be “the best” by many, are staffed by esteemed professors who are often astute physicians and who write papers and books. These educational institutions provide complex services that require a team approach and interventions like liver, heart, and kidney transplants. Many of the researchers who teach future physicians survive on research money supplied by the NIH or pharmaceutical companies.
By the 1950s all of our large cities and many small towns had a modern day facility. The government had constructed and ran military, Veterans administration, and public health service institutions. Multiple hospitals were operated by religious groups or by university medical schools.
According to one analysis, U.S. hospitals have been merging at a rapid pace for a decade, forming powerful organizations that influence nearly every health care decision consumers make. The mergers have essentially banished price competition and raised prices for hospital admissions. In one analysis of 25 metropolitan areas, between 2010 and 2013, prices rose 11 percent and 54 percent.17
Public and university hospitals derive their funds from private and governmental insurance, from taxpayers, and from donors. The law says that if charitable organizations want to avoid taxes they must be operated exclusively for “exempt purposes”. None of the earnings can go to shareholders or individuals. They can’t try to influence legislation as a “substantial part of their activities.”
(The list of organizations that could potentially acquire tax exempt status is quite long. It includes groups that are: “charitable, religious, educational, scientific, literary, testing for public safety, fostering national or international amateur sports competition, and preventing cruelty to children or animals.” Etc…) 4
Some universities and charitable hospitals make a lot of money, and their profits are not taxed. The Affordable Care Act did not challenge their IRS exempt status. It did, however, add a few hoops.
The institutions are now required to have a financial assistance policy that’s written in “plain language” on their web site. The “audience should be able to understand it the first time they read or hear it.”
They (theoretically, at least) can no longer generate inflated bills, claim they spent an unrealistic amount of money caring for a sick person. Hospitals typically send out exaggerated bills knowing full well that Medicare or insurance companies will only pay a portion of them. They use the amplified numbers as a starting point for negotiations with insurers, and as a means of demonstrating how charitable they are. As part of the ACA non-profit hospitals should no longer be able to generate inflated tabs—charges that are higher than the amount insurance companies and Medicare really pay for the services. Additional charges–the portion of a hospital bill that Medicare and insurance companies don’t usually pay—can’t be pumped up.
Finally, when a recently treated person doesn’t pay their share of the costs, these institutions are supposed to “make reasonable efforts to determine whether the individual is eligible for financial assistance” before they sick their dogs on them– before they take legal action, sell a person’s debt or notify a credit agency.
In 2013, of the ten most profitable U.S. hospitals, seven were non-profit. They earned over $1.5 billion, and, of course, didn’t pay any taxes. They included a few big name institutions: Gundersen of La Crosse Wisconsin earned $300 million. Stanford’s teaching hospital had a profit of $225 million”, and the University of Pennsylvania’s hospital in Philadelphia made 184.5 million.” “The hospitals with the highest price markups earned the largest profits.” These institutions could have returned some of the tax derived revenues to the government. (Fat chance.) They could have increased the number of non-paying patients they cared for. Since the affordable care act went into effect, they’re often caring for fewer people who can’t pay. If we’re going to make health care affordable we should probably revisit the tax exempt status of some of these institutions.5
A few years back Senator Grassley considered “removing tax-exempt status from teaching hospitals and forcing them to do more for local low-income, urban communities.” The hospitals fought him and won.
Much of the care our hospitals provide takes place in one of the country’s 983 state and local government hospitals or in one of the 2845 community sponsored nonprofit institutions.
The people who live far from the cities are served by many smaller institutions that are the product of a community or creations of health care workers who had a dream. Some are financially struggling to exist. 7
In May 2020 the New York Times told how, as a result of the Coronavirus bailout, the non-profit Providence Health System received over $500 million in government funds. The company was sitting on nearly $12 billion in cash and was earning, in a good year, over $1 billion tax free from its investments in venture capital funds. Two other for-profit hospital groups, HCA and Tenet Healthcare, had billions of dollars in reserves and received $1.5 billion from the government. Ascension Health in St. Louis, a chain that had $15.5 billion in cash, was given $211 million. And the largest rural hospital system in eastern Kentucky got $3 million, enough for 2 weeks of payroll.
“Even before the coronoavirus, roughly 400 hospitals in rural America were at risk of closing,” and the 2000 rural hospitals that are in the black, on average, only have enough cash to keep their doors open for 30 days.” 36
In the last decade 113, mostly rural, facilities went out of business. 20 were in Texas, 12 in Tennessee and 7 each in Georgia and Oklahoma. Of the 283 rural hospitals that in 2015 were “vulnerable to closure”, those located in states that did NOT opt for Obamacare Medicaid expansion were especially hard hit. 16.5 percent of the hospitals in states that opted OUT were on the brink versus 8.5% in Medicaid and indigent patients than suburban hospitals.”
Providing quality health care to our urban population is much more than a hospital issue. 60 million Americans—13 million of which are children lived in rural areas. 5.3 million resided in completely rural counties, 24.6 million in the mostly rural counties and 30.1 million in mostly urban counties. Their numbers have been dropping. A non-profit: A Healthy Rural America is struggling with the problem.23
A third of the Health Care dollar, $1.1 trillion (2017) is spent on hospital care. The Affordable Care Act led to increased hospital revenues and kept a number of smaller hospitals alive. States that “expanded Medicaid” saw 7.4 percent more Medicaid discharges in 2014 versus 1.4 percent in non-expansion states.
| Total Number of All U.S. Hospitals.18 | 6,210 |
| Number of U.S. Community Hospitals | 5,262 |
| Number of Nongovernment Not-for-Profit Community Hospitals | 2,968 |
| Number of Investor-Owned (For-Profit) Community Hospitals | 1,322 |
| Number of State and Local Government Community Hospitals | 972 |
| Number of Federal Government Hospitals | 208 |
| Number of Nonfederal Psychiatric Hospitals | 620 |
| Other Hospitals | 120 |
In 1981, a deranged 26-year-old man shot the president of the United States. A bullet hit a rib, and Ronald Reagan was in pain. At the time, neither he nor his aides sensed how close he was to death. As the presidential limousine sped to George Washington University Hospital, Reagan coughed up blood. When he tried to walk from the car to the emergency room, his legs collapsed, but his aides kept him from falling and dragged him to a gurney. A senior surgeon arrived on the scene and realized the man had lost a lot of blood, and was still hemorrhaging. An operating room was empty and, as a gurney occupied by Reagan was wheeled in, O-negative blood was pumped into his veins. The urgent surgery and transfusions were so successful that few realized Reagan had used up one of his nine lives.
The first U.S. level one trauma center was established in Chicago in 1970. By 2003 most states had at least one facility where surgeons, neurosurgeons, orthopedists, appropriate anesthetists and operating rooms are available 24 hours a day. Some facilities have helicopter landing pads.34 Others use nearby airports and bring the severely injured to a hospital by ambulance. 50 million Americans are unable reach one of these centers in less than an hour.
E.R.s in the U.S. hospital clock 136 million visits a year. Forty million of them are for minor injuries, auto accidents, and gunshot wounds.35 Sixteen million of the people who are seen are admitted to the hospital. People with myocardial infarctions who arrive by ambulance are sent to the catheterization/stent department. Women in labor are wheel chaired to the hospital delivery areas. The people with a new neurologic problem: a leg or arm that won’t move, inability to speak, loss of vision– are briefly assessed and routed to the CAT scan room. An X-Ray without contrast only takes a few minutes, and doctors need to be sure the acute brain damage was not caused by a cerebral hemorrhage before can attempt to dissolve a clotted blood vessel.
A few years back (according to a colleague) the physician-in-chief of Northern California Kaiser was visiting one of our ERs and was disturbed by waiting rooms full of people. Some had minor injuries that needed a quick fix; others who were quite ill, had to wait a long time before they were triaged. He decided something needed to be done and he had clout.
He met with the chiefs of our hospitals and an agreement was struck. After a person entered the waiting room and registered, he or she would be taken to an exam room and evaluated by a doctor, nurse and tech within 15 minutes. Lacerations had to be sewn shut, minor fractures casted, and a person sent home within an hour. Sepsis, strokes, and bleeding were treated promptly. Tests and consultations were ordered for problems of unclear significance and severity. Efficient competent evaluation might not always be possible but that was the goal.
Then Dr Pearl retired and waiting room wait time worsened.
San Francisco General Hospital is a hybrid. It’s a trauma center and a teaching hospital. The doctors who care for patients come from the University of California Medical center. The facility also operates the city’s “Community Health Network.” 80% of its $600+ million operating budget is paid for by Medicaid, Medicare, and private insurance, and it gets the other 20% from the city’s general fund. As detailed in an earlier chapter, in response to criticism for their crazy high fees they recently lowered and capped the amount people pay when they are ill and injured and need care. It’s too soon to tell if their billing approach will be viewed as a beacon for the rest of the country or as a hippy, odd ball gesture.
A few decades back “the general” developed a unique approach to its visitors who slept outside in unsheltered locations. Many suffered and died prematurely from diseases caused by alcohol, smoking, exposure, and poor sanitation. Violence, mental disorders and suicides were common. San Francisco General “identified individuals who had visited their emergency room five times in 12 months. With the help of attorneys and with a staff of case managers, a primary care physician, nurse practitioner(s), and a psychiatrist, they got many of the people permanent shelter, a primary care doctor, and “benefits.” It was quite a legal feat in people who are disabled by mental illness. In time, 70-75% of the homeless were housed, and emergency department use decreased 50-75%. That was a few years back, the homeless problem in Northern California has gotten worse and the funding has changed.11
In the 1960s intensive care units were created. By the end of the 70s each nurse in one of the units cares for one or at most two patients. Machines monitor blood pressure, pulse, and blood oxygen levels. Respirators filled lungs. When appropriate food is dripped into stomachs through naso-gastric conduits. Multiple IV tubes infuse bodies with nutrients and a variety of chemicals and blood products.
Nurses have always been “the glue that held hospitals27 together. Their numbers increased during the Second World War II.” At the end of the conflict RNs earned an average of $2,100 a year, somewhat less than most male workers. Their wages didn’t rise and their numbers started going down. There increasingly weren’t enough RN’s to do the job right and those who remained had to work longer and harder. To keep costs down hospitals froze their wages. These women were dedicated, right? They wouldn’t quit. By 1966 the average RN earned $5,200 a year.40
At the city hospital where I was a resident one nurse passed medications and tried to handle the needs of the ill on an entire ward. The women (and at the time they were all women) were energetic, amazing, and often exhausted. Their wages were so low that none of their nursing school graduates wanted to work at our hospital. When our few nurses went on strike in 1965 the papers thought their action was outrageous.
The idea that in America workers could strike if they were underpaid was challenged when the nation’s Air Traffic Controllers struck in 1981. President Reagan said they were federal employees and were breaking the law. He gave them 48 hours to return to work or be fired. His anti union stance changed attitudes. In a decade, major strikes plummeted from an average of 300 each year to fewer than 30. Despite an average annual inflation rate of 2.9% and a huge surge in productivity, the federal minimal wage, which was $3.35 in 1981, barely doubled in the 3 post-Reagan decades.
In the San Francisco Bay Area 2 types of union actions have continued to be effective. The interruption of BART commuter trains by striking workers always leads to jammed freeways and lengthy commutes. When the police struck a few decades back the chief went on T.V. and warned that criminals, murderers, and rapists would have a field day.
At Kaiser where I worked, nurses felt they were underpaid. They knew how to take care of sick or needy patients, but they soon learned that dealing with management was something else. Every 5 to 10 years or so their contract came up for renewal, they asked for a raise, management hung tough and the nurses decided they needed to strike.
That was fine with Kaiser. The insurance money kept coming in. People didn’t like to cross picket lines unless they were quite ill.
Before the strike started traveling nurses were hired, elective surgery was canceled, and the very ill were sent to other hospitals. I remember driving to work and seeing throngs of young and middle aged nurses carrying picket signs, and standing by the entrance of the parking structure. They were friends, colleagues. Many hated the thought of abandoning their patients and some believed strikes were unethical.
After three weeks of pacing in the heat of the day or under an umbrella nurses started coming back to work. Most had loans, rent, bills, and lived from one pay check to the next. When a majority of worses had returned to the job management offered a small raise and signed a long term contract.
Eventually the nurses hired a labor organizer named Rose Ann DeMoro and everything changed. In 1968 she declared a 2 day strike, and the hospital prepared. Critical patients were moved out, elective surgery was cancelled, and traveling nurses were hired. A few days prior to the date, the strike was cancelled, but it was rescheduled for a date 60 days hence.
Two months passed. As before, very ill patients were moved out, nurses brought in, and elective surgeries cancelled. This time the nurses struck for two days and no one lost much money. As the strike was ending the union announced it would soon strike again. Management understood what was going on and cried “uncle.” The nurses pay rose substantially and they later fought for and won the right to make improvements to the quality of care they provided.
Nationwide, one in five nurses belong to a collective bargaining unit. On average their wages are 20% higher than the pay of the nurses who are not in unions. In 2020 the average hourly wage of a registered nurse in half the states in our country was $28 to $34. The other half earned $35 to $48 an hour. In Hawaii and California the average hourly wage was $50 to $54.
Inside the large multispecialty hospital where I worked there is a large birthing wing. Large rooms accommodated doulas and invited family. Nurse midwives handled the uncomplicated vaginal deliveries. An anesthesiologist or nurse anesthetist was always on duty and performed epidurals. Needles are inserted into the lower back, into the space between the vertebrae and the membrane that surrounds the spinal canal and lidocaine, a numbing agent was infused. The drug blunted much of the pelvic pain of childbirth. An obstetrician was hanging around and was available for consultation and urgent C sections.
In the hospital’s basement 2 CAT scanners and 2 MRI machines created detailed body images far into the night. The pictures of the sliced body sections were immediately visible on every computer screen in the facility. A radiologist sat in a dark room, carefully checked the images, and looked for anything that didn’t belong. He or she dictated a report that was transcribed by trained worker in the facility, or increasingly by people in the Philippines, India, or some other country.
A multi bed outpatient recovery area was staffed by nurses. They prepared and observed patients before and after interventional radiologists performed biopsies or invasive procedures. The unit also served as the pre and post procedure area for people having an emergency heart catheterization. A cardiologist was always on call, no more than 15 minutes from the hospital, and available 24 hours a day, to catheterize and stent the coronary arteries of people who are probably having an acute myocardial infarction.
Gastroenterologists, who sometimes worked at bedside in the intensive care unit, had a dedicated in-patient procedure room, with equipment. If needed we would insert a scope and treat people whose upper GI bleeding was ongoing or those who had a bolus of food lodged in their esophagus.
There were medical, surgical, and pediatric intensive care units and a coronary care unit.
Hospital rooms had piped in oxygen and suction, a place where a partner or parent could spend the night and an annoying T.V. on the wall.
A special inpatient pharmacy provided a large range of medications, including specialized drugs and infusions, 24 hours a day.
Pathologists processed, stained, examined, and interpreted the significance of tissue that was removed from bodies. Samples were often sent “out” for molecular diagnostics (DNA/RNA analysis).
Phlebotomists drew blood and brought it to the lab where it was extensively tested. The labs also cultured and assessed stool, urine, blood, spinal fluid, sputum etc.
And there were clerks, social workers, discharge planners, janitors, patient transporters, painters, security people, guards, physical, occupational, and speech therapists, dieticians, telephone operators, IT personnel, people who provide food for the patient and staff, and engineers who regulate and repair the electrical, cooling-heating and other building systems.
In 2017 American hospitals were responsible for $1.1 trillion of the nation’s $3.5 trillion in health care expenditures, and an average day in the hospital was costing nearly $4 thousand.28
I was employed by a pre-paid group, and all the physicians and surgeons were salaried. The hospital had ten large operating spaces and the OR had a calendar that was controlled by a scheduler. Each area was manned between 8 AM and 3 PM by a hundred or so nurses, technicians, and others. In the late afternoon most of the rooms closed. The few that remained open handled the overflow. One was available around the clock for urgent cases. During the work day each of the designated areas was managed by a different surgical subspecialty, and had some unique equipment,
Gawande explained the importance of introducing the patient who will undergo surgery to everyone in the O.R., including the person who cleans the floor and the medical student. He thinks the presentation gives everyone permission to sound an alarm if they notice a problem. Before a case starts, all the people who might play a role gather around the patient and are introduced. Then a “time out” is called. The nurse or physician in charge would ask the patient their name and what they thought was about to happen, When indicated the involved breast or extremity was inked. (“In 1995 when a nurse told Florida Surgeon Rolando Sanchez he was cutting off the wrong leg, he kept going and she started to shake and cry. He felt he had gone too far. The leg he had started to remove couldn’t be repaired and there was no turning back.”) 29
A surgeon or team of surgeons usually performed all the cases in a morning or an afternoon block. If three hips were replaced that half-day, one surgical team usually did them all. After each operation, the room had to be cleaned and efficiently turned around. In bloody cases, like a hip replacement, soaked pads were not thrown on the floor. They were instead bagged, and the containers were tied and slipped into the hall outside the room. Following invasive surgery, when blood in the abdomen made it hard to be sure no foreign objects remained in the area, the sponges were counted before and after the operation. Post-operatively, people went to a recovery area where 20 to 30 nurses cared for them for variable periods of time. If a spinal anesthetic was used, the patient remained in the observational area until the numbness had worn off.
In fee-for-service facilities surgery accounts for a substantial part of hospital revenue. Akron General Hospital published what it charges on its website. The bill for using the operating room at their facility, which is part of the Cleveland Clinic, depends on “the complexity” of the procedure. Their billers created five intervention levels: For those on the lowest rungs the first hour costs $2718. Each additional half hour adds $1100 to the bill. For level 5 procedures—the most complex– the room cost is $4935 for the first hour and $2200 for each additional half hour.20
Free-standing facilities currently perform many of the “interventions” that were once done in hospitals: cataract surgery, colonoscopies, knee arthroscopies, cosmetic surgery, pain management, dental and ENT procedures. In 2019 there were 6100 ambulatory surgical centers in the U.S., and they performed more than half of that year’s 35 million operations and procedures.21
A 6 year old seemed cross eyed and saw an optometrist who realized the child had a 6th nerve palsy. The nerve that controls the lateral movement of his eye wasn’t working and that set off all kinds of alarms. He was immediately sent to an ophthalmologist. The physician detected evidence of brain swelling and ordered an emergency MRI. That night one of the two hospital pediatric neurosurgeons told the parents their son had a brainstem tumor. The child was admitted and started on high dose steroids to decrease the pressure inside the skull. A few days later two pediatric neurosurgeons at Oakland Kaiser Hospital made a small opening in the rear of the child’s neck and removed the back of a vertebra. They then sucked out the medulloblastoma cells (it is a friable malignant tumor) and rolled an MRI machine into the OR. It revealed a tiny trace of tumor had invaded his spinal canal. The vertebrae was replaced and fastened, and the wound was sewn shut.
Post operatively the child had obstructive hydrocephalus—fluid was not flowing from one chamber of the brain to the next one. It was possible he would need a shunt that transferred fluid from his brain to the space in the abdomen called the peritoneum. As a first step, under anesthesia a small hole was drilled in his skull and a thin sterile videoscope was passed through the brain into the fluid filled chamber in its middle. The scope was maneuvered through the narrow passages that connected the ventricles, the fluid filled brain chambers. Cobweb like tissue was blocking the flow of fluids and it was pushed aside. Fluid started circulating normally and a shunt wasn’t needed.
After the child recovered from the surgery his insurer paid ¼ to ½ million dollars for proton beam radiation to destroy the small segment of tumor that remained. It couldn’t be surgically removed without causing major neurologic damage. Protons give off most of their energy (in a quick burst) to a precisely focused part of the body. This type of therapy decreases the amount of radiation to healthy tissues around the treated area.
The child was sent to the “Seattle Proton Therapy Center a facility where 10-foot-thick, lead-lined concrete walls isolate a particle accelerator that harnesses and fires protons generated from hydrogen gas. It was one in a national wave of costly facilities funded a decade or so back by private investors and lenders. The Seattle facility treats 500 people a year. “In 2018, after a net loss of $81 million over the prior two years, its original backers were handed a $135 million loss as part of a negotiated Chapter 11 bankruptcy.14” But they were still in business. At one time there were 27 proton centers in the U.S. They were expensive to build and maintain and their services are not covered by all insurance providers, so those that are still working are struggling financially.
Elsewhere on the planet, there are remote government funded community hospitals, in low and very low income countries—like Malawi and Bangladesh. As described by the Harvard M.D. who spent time in Nepal, they are commonly located in far off corners of their nation and are the only options available to the poorest of the poor. With 50 to 100 beds they serve 100,000 to a million people, and their doctors can usually perform a few orthopedic and general surgical procedures and C sections. They have some X- ray capability, but commonly lack certain basics: In Nepal 15% didn’t have piped in water; 20% lacked electricity; 55% didn’t have gloves, and 30% were unable to provide oxygen to those who need it22.
REFERENCES:
Marketplace Medicine—the rise of the for-profit hospital chains by Dave Lindorff a Bantam Book, 1992
Privatization and Public Hospitals by Charles Brecher and Sheila Spezio 20th century fund press, 1995
Black Physicians in the Jim Crow South by Thomas Ward, University of Arkansas Press 2003
Homer Phillips https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2642069/pdf/jnma00694-0003.pdf
https://en.wikipedia.org/wiki/Homer_G._Phillips_Hospital
Unexpected Necessities — Inside Charity Hospital, Ruth Berggren, M.D. N Engl J Med 2005; 353:1550-1553 October 13, 2005 https://www.nejm.org/doi/full/10.1056/NEJMp058239
Anna Deavere Smith, Let me Down Easy. Health Care In New Orleans Before And After Hurricane Katrina,
https://www.npr.org/sections/health-shots/2015/06/09/412964
https://www.healthleadersmedia.com/finance/top-5-differences-between-nfps-and-profit-hospitals
http://www.miamidade.gov/auditor/library/Cook_County_Health%26Hospitals_System.pdf
The community hospital survival guide: Strategies to keep the doors open by Ayla Ellison June 15th, 2015
Anesthesia: Biographical sketch of Dr. William T. G. Morton. U.S. National Library of Medicine. Concord, N.H. 1896.
https://archive.org/details/101495446.nlm.nih.gov/page/n7/mode/2up
Wier LM, Hao Y, Owens P, Washington R. Overview of Children in the Emergency Department, 2010. HCUP Statistical Brief #157. Agency for Healthcare Research and Quality, Rockville, MD. May 2013. Kindermann D, Mutter R, Pines JM. Emergency Department Transfers to Acute Care Facilities, 2009.HCUP Statistical Brief #155. Agency for Healthcare Research and Quality. May 2013.
Inspired by the results, two California foundations started similar programs at six California public hospitals. One of them, Highland Hospital, the facility with the busiest emergency room in the county, targeted individuals who visited the ER ten or more times a year. A legal and health care team managed to get virtually all who were certifiably unable to work onto SSI. The $800 a month they received from the federal government was enough for a shared room and some food. Once the indigents had “benefits,” Medicaid, the federal government, paid for their medical care, and the state and county saved $2 million. But the start-up programs have largely ended, the funding has been used up, and in 2014, Obamacare kicked in and funding changed.
https://www.uphs.upenn.edu/paharc/features/creation.html
The Troubled Health Dollar by Steven Fredman. Virtualbookworm publisher. 2013.
Rami Grunbaum, Seattle Times, December 4, 2018. Proton center’s restructuring approved by bankruptcy judge;
http://www.fiercehealthfinance.com/story/several-u-s-hospitals-rake-huge-profits/2010-08-31
https://www.healthcarefinancenews.com/blog/five-reasons-hospitals-become-profitable
Reed Abelson, NY Times, Nov. 14, 2018 When Hospitals Merge to Save Money, Patients Often Pay More
Fast Facts U.S. hospitals 201700 https://www.aha.org/statistics/fast-facts-us-hospitals
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.25.w393
Cleveland Clinic Patient Price Information List https://my.clevelandclinic.org/-/scassets/files/org/locations/price-lists/akron-general-patient-price-list.ashx
21. Health Industry Distributors Association. 2018 Ambulatory Surgery Center Market Report. Available online at https://www.hida.org/distribution/research/market-reports/2018-Ambulatory-Surgery-Center-Market-Report.aspx . Accessed July 16, 2019
The neglected hospital . Interview: N Engl J Med 2020; 382:397-400 Dr. Ruma Rajbhandari. https://www.nejm.org/doi/full/10.1056/NEJMp1911298
In the 2 decades –between 1990 and 2010, the percent of rural dwellers went from:
- 21 to 15 percent in the north east
- 28 to 24 percent in the Midwest
- 14 to 10 percent in the west and
- 31 to 24 percent in the south.
Children in rural areas had lower rates of poverty (18.9 percent compared with 22.3 percent)—Healthy Rural America puts the percent of children who live in poverty at 25%. In 2015 more country dwellers were uninsured (7.3 percent compared with 6.3 percent). According to Healthy Rural America, the rural population tends to be older, sicker, and poorer, and they are more likely to be uninsured and unemployed.
There’s a need to build a sustainable and diverse health care workforce. Rural dwellers have less access to health care workers and “critical access hospitals” It’s challenging to get patients and enough care givers to the right place at the right time. Transportation can be challenging; there’s a lack of access to high speed internet. And, as with all of medicine, people argue about how we are going to pay for care. . Phil Pollakof plp@sbcglobal.net
https://www.congress.gov/110/plaws/publ23/PLAW-110publ23.pdf
https://www.amtrauma.org/page/LegUpTraumaReauth
file:///C:/Users/User/Documents/joc30383.pdf
https://www.govtrack.us/congress/bills/101/hr1602
Ether Day by Julie Fenster. copyright 2001. https://archive.org/details/etherdaystranget00fens/page/112/mode/2up
The Youngest Science, by Lewis Thomas. Viking Press 1983
https://www.vox.com/2019/1/22/18183534/zuckerberg-san-francisco-general-hospital-er-prices
An emergency field hospital, in Central Park –corona virus New Yorker, Rivka Galchen, April 20, 2020
The Cost Conundrum, by Atul Gawande. New Yorker June 21,2009
Planet Money the economics of hospital beds. podcast
helipads http://stophelipad.org/faqs.shtml
New York Times: May 26, 2020. How wealthiest hospitals reaped billions in bailout.
https://nurse.org/articles/highest-paying-states-for-registered-nurses/
nurses pay https://work.chron.com/salaries-changed-nurses-23316.html
One-Third of Hospitals in Developing World Lack Running Water
In low- and middle-income countries 50 % of remote health care facilities lacked piped water, 33 % lacked improved toilets and 39% lacked handwashing soap.
https://www.sciencedirect.com/science/article/pii/S1438463917303760/