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Changing roles of hospitals in a changing society
Changing roles of hospitals in a changing society
R. M.
Cunlljngtwrn, Jr.
Centunks, &ex the treasures of the temgdks at W p h i in ancient Greece h a d beem m o v e d by Nero and otheps, the Elnmperor JuEim sent a deputy to restore the riches It is reported that the oracle at Delphi respanded only with a waB. At that time there was 110 longer p a t belief in proph& 8s c e m partents of future events, and so contemporary hisbriam think the wail was a lament for departed gkwk Considering the way things have been going, however, it may readily have been a warning of horrors yet to come.
their arrival is picking up in our time. Just the other day, for example, a noted ecologist reported that we are overpopulating our planet, contaminating our food, and polluting our air at a rate which will run us out of space, nourishment and atmosphere in another 30 years if we can't turn things around.
The homrs have been coming ever since, and, if anything, the rate of
Unlike the ancient Greeks, we don't pay much attention to our oracles unless they tell us what we want to hear, and when, as in this case, an oracle suggests it is our corporate gods who are hurrying us along the path to doom, we respond with wrath or ridicule, or both, directed not toward the gods but toward the oracle.
Robert M. Cunningham, editor of M o d e m /forpito/ i s the featured speaker for the Writers' Workshop "You, too, can write," scheduled for the Eighteenth Annual Congress of the Association of Operating Room Nurses next month. This article was adapted from a presentation made to the South Carolina HosDital Association and members of the South Carolina General Assembly in 1970.
Our latter-day equivalents of the Greek chorus, now called Press and television, have learned how to cry "calamity" and praise the the same time. This is an art which annoys the gods more than it pleases them; members Of the chorus who
January 1971
41
even mention calamity are identified by the gods today as “effete snobs.” In spite of these and other hazards, the oracle business flourishes again in our time, especially at the end of one year and the beginning of another, as now, when oracles multiply like the fruit fly. In evidence particularly a t these times is a rule about oracles which might be stated like this: The more unaccustomed the oracle is to his role, the more optimistic the outlook is likely to be. Thus, once-a-year or once-a-decade oracles, w h o s e prophecies appear mostly in annual reports and house organs, commonly see everything coming up roses; while the once-a-day oracles of the press and television are more likely to see the rips and tears in the social fabric-a circumstance which causes pain among vice presidents. In medicine and medical affairs, as elsewhere, the oracles have been working overtime in recent months. The resulting range of prophecy runs all the way from the few who see starving in the fields and choking in the streets, to the many who see automated care, miracle nutrients and population controls practically eliminating illness and poverty and keeping everybody alive and well indefinitely. Within these extremes, however, there is a surprising degree of agreement among the medical oracles, especially for the coming decade. Thus everyone expects a flowering of computerized diagnosis, and computerized medical information systems, and electronic instrumentation, and multiphasic screening. Nearly everybody foresees some kind of comprehensive
42
health insurance; some kind of largescale prepaid group practice; some kind of regulation or control putting p a t i e n t m r at least aiming themwhere ‘they’ought to go for what they need; and some kind of physicians’ assistants all over the place. Now I don’t disagree especially with these oracles, but I’m not sure, in every case, that I understand how we’re going to get there from here, especially since I’m not sure we really know where we are. This is what concerns us all. Inevitably, this circumstance gives rise to confusion and contradiction. For example, every hospital today is expected to keep abreast of the emerging technology and offer its patients all the benefits of cobalt machines, blood volume analyzers, pump oxygenerators, monitors of all kinds, and computers. Yet every hospital is also expected to offer loving personal attention to the care and comfort and psychic well being of its patients and their families. This is the same kind of loving personal attention we like to think was so abundant back in the days when medicine and nursing were still “face-to-face,” or “hand-to-abdomen.” arts. Every hospital today is expected to expand and refurbish its physical plant; buy the latest equipment; raise salaries and wages of employees at all levels of skill to compete with industry for personnel in short supply; admit masses of patients without investigating their ability to pay for the services they are about to receive; and treat additional hordes in the emergency room without even finding out who they are, much less what they can pay.
AORN Journal
Yet every hospital today is also expected to keep charges down; balance revenue and expense; set aside huge sums for depreciation; pay for its own development program; keep separate sets of records for medicare, medicaid, blue cross, insurance, state, county, and city welfare and licensure departments, JCAH, PAS, and others. Then they are expected to join hands with other hospitals, clinics, physicians, nursing homes, health departments, and community groups in planning programs. These programs are supposed to encourage the total effectiveness of the health m i c e by developing and using less expensive alternatives for general hospital care. In other words, they are to empty as many as possible of the beds the hospital must keep occupied in order to earn the revenue i t has to have to perform all the things it is expected to do!
ends with what are always the limited resources at your disposal must necessarily result in some failures, if not total disaster. So the task remains one of selecting priorities. This is nothing new for hospital people. You have always had conflicting aims, such as the inevitable conflict between quality service and low cost. You have always had limited resources, and so you have always had to establish priorities. The new thing is simply that as technology, the hospital and the society change, the demands and expectations change too, and unless you keep constantly examining the pressures and adjusting the priorities accordingly, the rate of failure, or at least the exposure to failure, is likely to increase. I suggest that one of the problems of public position and public policy
you are facing today results from the fact that priorities haven’t always been managed as adroitly as they might have been.
How are you going to accommodate all these conflicting pressures? How can you meet the expectations of physicians and patients, who want more and more of everything, and nothing but the best; and the expectations of employees, who want more money for less work; and the expectations of owners, or trustees, who want to balance the books without rocking the boat; and the expectations of third parties, notably today inchding the United States of America, who want an orderly, efficient, integrated, rational health service system in which needs and resources are always in perfect equilibrium?
The major new pressure, of course, results from the fact that all or nearly all our hospitals have become public facilities and are no longer in full control of what they do and how they do it. From a standing start a little less than four years ago, the federal government has become the single largest purchaser of hospital services in the United States, carrying all the authority the single largest purchaser has with the producer of any product or service.
Obviously, any attempt to accomplish even a minimum number of these conflicting and contradictory
You must understand, here, that what the single largest purchaser wants is some changes in the priori-
January 1971
43
ties. The problem isn’t made any simpler by the fact that the government’s priorities themselves h a v e b e e n changing, or a t least wobbling. Let’s look at some of the evidence:
not required; and, most importantly, the whole thrust of the massive reimbursement system would be aimed at keeping or getting people on their feet instead of treating them in bed.
A year-and-a-half ago, after two or three years during which committees and commissions and studies and reports had been taking the health services apart and putting them back together again over and over, the outlines of a national policy on health were beginning to take shape:
This became known as “emphasizing the less expensive alternatives to general hospital care.”
There were to be modifications and controls aimed at correcting deficiencies in the existing system-notably gaps which left substantial segments of the population without access to anything like adequate medical or hospital care. The links would be tightened, but the roles would be substantially unchanged. The modifications, or improvements, or controls, had also emerged pretty clearly and were obviously going to be written into laws or regulations of one kind or another: There would be up manpower input, for one thing. Communityewide and planning of facilities and services would be mandatory-that is, those who didn’t take part would be cut off at the knees. Cost reimbursement by third parties was on the way out; it was well established and uniformly recognized that cost reimbursement was a disincentive to efficiency. Instead, there would be negotiated reimbursement rates of some kind which would benef i t efficient and economic management of health services, and penalize inefficiency. Shared services and joint ventures aimed at achieving economics of scale would be encouraged, if
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It wasn’t by any means entirely clear just how this was to be accomplished, but there would be some kind of stepped-up utilization review certainly, and, of course, there has been also this big push for prepaid group practice. In fact, in the minds of some authorities, including some with substantial influence on the course of events, prepaid group practice appeared to have taken on elements of a sacred wisdom or mystique, somethink like the temples at Delphi. The answers were all supposed to be in there somewhere. It now seems likely that the blueprint for all this may have slid somewhere down the crack between administrations, or that all the programs and objectives and P r o ~ ~ l s simply disappeared into the Bureau of the Budget and some of them are just now beginning to emerge again. At any rate, the hell-bent-for-health policies of a year or two ago have obviously been turned aside. For example, the new administration proposed early last year to terminate Hill-Burton as we have known i t - a maneuver which was seen by the health professional establishment as roughly equivalent to repealing the New Testament. Since that time there has been brave conversation about a crisis in health care, but obviously it isn’t the kind of crisis evoking instant action.
AORN Joumzal
A five-year plan circulated some months ago in the Department of Health, Education and W e 1f a r e seemed to some observers to be mostly an exercise in demonstrating that more could be accomplished by spending less, a sort of fiscal Bauhaus. The coup de grace, of course, was a proposal to cut down drastically on the funds budgeted for medical research, including millions less for the Regional Medical Programs. Now obviously, a policy which is going to compromise with heart disease, cancer and stroke is incapable of doing anything. This is not to say that the present government, or any government, intends to let the health system or the hospital system alone. On the contrary, hospitals had a foretaste of what can happen when the 2% medicare lagniappe was taken away, and an aftertaste of the same flavor when the accelerated depreciation option was removed from the medicare cost computation. The one crisis in health care about which this government appears to be in dead earnest is the crisis in cost. The one slogan this government has picked up from the liberal element in the health establishment is the one about the need for change in the medical care delivery system. This kind of conversation has been around for years, but the surprise here is that there are many public officials in the Congress and in the federal departments and in the state legislatures and the statehouses who not only intend to change the deIivery system but think it can be done. Some of these officials were concerned when the chief problem in the
Januurg 19’71
health services was Seen as inadequate service for the poor. Now that the chief problem is seen as excessive cost of service for the middle class, they are positively hysterical. What they have in mind is not yet planned. Some, unquestionably, see hospitals as the principal villains and would put them under rigid price control. Others would go on a completely different route and hand hospitals over to profit-making corporations, innocently believing that a system that works for cookies and Cadillacs will work as well for fevers and fractures. These are the people who subscribe to the notion that hospitals are inefficient p e r se-a proposition that is just about as sensible as most other flat-footed declarations. The fact is, of course, that some hospitals obviously are inefficient, just as some businesses are, while others are as efficient as any enterprise managed by human beings can ever be. Moreover, as you know, but most people outside the hospital field don’t know, the measure of efficiency is enormously complicated when the purpose or goal of the enterprise is something which really can’t be measured-like “quality of care.” This is a circumstance not by any means fully understood even within the profession. Whatever the proposed remedy, however, talk about changing the delivery system refers chiefly to changing methods of organizing and financing health services. But the delivery system has to refer not only to the organizing and financing mechanism but also to the entire spectrum of resources with and within which some 250,000 doctors are brought face to face with patients.
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This spectrum runs from the physicians’ own offices, which practically all of them have; their patients’ homes, which some of them still visit; the 8,000 hospitals, where most of them do at least some of their work and where most of the system’s resources are brought to focus; the 20,000 or so extended care facilities and nursing homes which carry the heavy end of the bed for patients the doctors don’t like to visit and the hospitals they just don’t like; to a reminder of what are still odds and ends, such as group practices and health centers. All this is included in the delivery system, and the whole thing can’t be changed, actually, short of replacing the medical profession with something else, and possibly giving the hospitals back to the church. These proposals may have a certain amount of appeal for some people but are probably not practical. The system can still be modified along the lines which have been emerging in recerd years, and it probably will be. One thing which could and may be changed is the way all the services are paid for. There is a new push going for some kind of comprehensive national health insurance plan which would cover everybody, possibly using and supporting the existing mechanisms such as Medicare, Medicaid, Blue Cross and private insurance. At the moment, the push is coming mostly from consumers groups-union and others-and a few providers and some public officials and deep thinkers. But if the money squeeze continues and the cost of the services continues to rise, (and both these things seems to be happening), it may not be long before
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the clamor for comprehensive national health insurance becomes deafening.
It is interesting and possibly significant, that many of those who don’t want any part of a national health insurance plan are not opposing it head-on in this new encounter, as they have always done before, with battle cries of “socialized medicine.” Instead, many of the opponents today are acknowledging that there are indeed large groups in the population without access to care; and larger groups with access but inadequate means; and still larger groups with adequate access and means but inadequate prepayment or insurance coverage; and that something must indeed be done. However, they add quickly, this is not the time. Anything like a national health insurance plan introduced now would swamp the system because the manpower shortage would make it impossible to meet the added demand. We must build up the manpower supply, they say, then think about broader health insurance coverage. I expect the argument has a sound base, and certainly it carries all the conviction of sweet reasonableness. It is also a complete justification for doing nothing at a22 about broader health insurance coverage until the manpower shortage is resolved. Since what we see as the manpower shortage isn’t going to be resolved, it is a justification for doing nothing. Another thing which could be changed, though possibly not as quickly or as substantially as it has appeared to some, is the number of physicians whose services are organized in groups and paid for in advance; compared to the number whose
AORN Journal
services are organized at random and paid for at their usual and customary fees.
It is significant that so many hospitals and hospital associations and Blue Cross plans and medical society foundations have been willing to lend their resources and their organizational skills to the extension of prepaid group practice, which is seen by so many as offering opportunities for some imtxovements in the total effectiveness of the health service. What may be needed now is the rapid extension of what are still largely local or regional or experimental efforts which would take a generation or more to bring about any substantial change. The initiation of enough new institution-based and free-standing groups to provide some real options for the whole population will take years to accomplish unless groups like the Association of Operating Room Nurses - physicians, nurses, supenrisors, hospital administrators, trustees and their professional associations, that is - become convinced that there is more to gain than to lose by pushing for the organization and support of such groups. Whatever it takes to convince you, you haven’t gotten there yet, and unti1 you do get there, talk about changing the delivery system is going to remain largely theoretical exercise. To the extent that professions are responsive to public attitudes and expectations, however, all these new developments obviously will have some bearing on priorities. The new voices tell us clearly that area-wide or regional planning of some kind is going to govern hospital capital programs,
January 1971
for example, and that the third or more of hospital revenue which comes from the Social Security Administration, if not the other third or more that comes from Blue Cross,too, is not going t o stay on a cost-base forever, and perhaps not much longer. There is going to be pressure to expand outpatient services, to tighten arrangements with extended care facilities and nursing homes, and to push utilization review. Another one of the new pressures resulting in some new priorities is the Pressure for COnSUmer representation in the planning and governance of the health services. This is the era of the consumer, or at least the era of the consumer representative. We have Ralph Nader going for us, or against us, depending on the point of view, in automobiles, and foods, and air and water pollution. We have a new department in the government and a new federal official going for us, or against us, depending on the point of view, in such matters as the pricing and packaging of everything from breakfast food to television sets. We have neighborhood representatives going for us, or against us, depending on the point of view, in housing, and urban renewal, and community planning; and we are going to have, and in some communities we already have, consumer or neighborhood representatives going for us, or going after us, in planning and running the health services, including hospitals. Professional opinion about consumer representation in the planning and governance of health services and hospitals varies all the way from a few who consider it a good thing to many who consider it unmitigated
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disaster; but, again, I’m not sure i t really matters what we think. We are going to learn to live with it-the way the universities are learning to live with the fact that their consumers, whom we call (sometimes with wild inaccuracy) students, are going to have some voice in the planning and governance of university services. As we all know, the universities got their consumer representation the hard way, by having it shoved down their throats, sometimes accompanied by the sound of smashing glass. I think most observers and analysts agree this was partly, at least, their own fault. The universities didn’t know what was going on in their own jurisdictions, for one thing: and they didn’t have any semblance of a plan for dealing with student dissent, in most cases, for another; and, most significantly, they had ignored rising evidence of student dissatisfaction with university services, and university life, for years.
I think there is rising evidence today that consumers are dissatisfied with the health services we have been providing. We may not have patients marching up and down the halls carrying signs, like students, but it might not be a bad idea for us to start now listening a little harder to what the consumers and their representatives have been trying to tell us. Basically, the message is the same one the students were trying to get across to the universities: the service isn’t always relevant to the need.
What does that mean? What i t means essentially is the same thing the public officials and public surrogates have been trying
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to tell us over this same period: For the most part, the strictures of the consumer representatives enjoin physicians, hospital administrators and other professionals to consider the whole problem, and not just their own disjunctive little segments of the problem. Medical care isn’t relevant, for example, when an elderly woman in marginal circumstances is treated and cured of pneumonia in a fine, modern hospital and then discharged to return to the same unheated flat where she contracted the pneumonia. Relevance isn’t especially considered, either, when a surgical patient with obvious psychopathic symptoms is admitted, diagnosed, o p erated on and discharged without any attention to the psychiatric symptoms. Nor is relevance notably accomplished when a patient is put to bed in a hospital for 72 hours at $70 a day just so he can put through a few tests and Blue Cross will pay the bill: or when neighborhood patients wait for hours in outpatient departments and then are told the doctor they should see isn’t here today; or when a stroke patient with obvious potential for rehabilitation and return to useful life is allowed to lie in a nursing home bed or sit in a wheel chair day after day as his potential diminishes and his dependency rises. The push for more preventive services, more planning, more controls, more outpatient services, more rehabilitation, social service and shared services and group practices and other modifications and innovations is a push for relevance and the somewhat disquieting circumstance is that we often seem to be making the same mistake the universities were making
AORN Journal
a year or so ago: we aren’t really listening. What is the evidence? One example of the professional response to the push for relevance was in evidence a short time ago when some physicians opposed the effort to organize neighborhood clinics for poor populations in an effort to make their medical care relevant-or a t least visible. Another federally-funded program aimed at improving the availability and relevance of medical care, the Regional Medical Programs for heart disease, cancer and stroke, also encountered indifference and opposition in s o m e professional groups.
gestions as to how we should a p proach it?” Well, he was told, you might report how the hospital has been working with other institutions in the community and the area to integrate planning so that all the needed services are being offered, or will be offered, without duplication and overlap. You might want to report how you moved out into the neighborhood to establish communication with the nearby population and plan services accordingly. You might want to report how you are working with nursing homes in the neighborhood to integrate your services with theirs. You might want to report on the success of your home care program; and you might want to report how you called in air pollution engineers to study the incinerator system so the hospital would be insured against contributing to a severe public health problem in the community.
Still another example was when the American Hospital Association, after two years of study, announced a new policy on the financial requirements of health care institutions and services in an effort to encourage the relevance of institutional facilities and services to community needs be rewarding its presence and penalizing its absence. Hospital administrators, trustees, MDs and their associations notably failed to throw their hats in the air and cheer. They weren’t about to let anybody else, not even other hospitals, invade their autonomy and tell them what was and what wasn’t relevant for their institutions.
That wasn’t exactly what they had in mind. In fact, it turned out, they weren’t doing any ‘of those things.
Still another response from within the profession-less visible but perhaps most typical of all-was exemplified not long ago when the director of public relations at a well known teaching hospital called me to talk about the hospital’s annual report, which he said was just being planned. “The theme is the hospital as a community institution,” he said proudly. “Have you got any sug-
What they were thinking of was more like how they had a Santa Claus visit the children’s ward at Christmas time with presents for all the children there; and how the nurses’ glee club always gave a concert every year at one of the big churches in the neighborhood and how the administrator and his assistants went to meetings of all the men’s and women’s clubs and made speeches about hospital costs;
January 1971
You might even want to report how your institution saw the need to give up some of its autonomy in the interest of community planning and relevance and supported the AHA’S new financial policy.
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and how the hospital published this bulletin every month telling all about what the doctors were doing, and what the services were, and why the charges had to be increased; and how the hospital related to the community by sending out these opinion polls asking the patients whether the coffee was hot, and how they like the food, and how was the temperature of the room, and, of course, urging them to report any criticisms or suggestions they might have. Things like that. Certainly there is nothing to be against Santa Claus, or glee clubs, or speeches by administrators, or hospital publications, or patient-opinion polls. Certainly these are all legitimate and useful activities, and they have something to do with relevance, I suppose, though certainly they are not a t the core of relevance. The core of relevance has to do with comprehending the whole problem, and all the problems, and then getting on about the business of organizing and ordering the manpower and facilities and resources appropriate for all the problems, even at the sacrifice of autonomy. Unfortunately, this involves doing a lot of things doctors and hospital administrators and trustees and their associates are often disinclined to do. They are inclined instead to rely on their own judgments of what is right. and proper for them to d-that is, how they can best distribute all the skills and resources at their disposal to what they see as the greatest advantage for the people they think should be serving. The only trouble, or the chief trouble, with this view of the health
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professional establishment as all-wise and all-beneficient is: 1) the rest of the population simply isn’t accepting it any more; and 2) at the best the wisdom and beneficence of the professional establishment are certified only for judgments and decisions involved in the immediate care of the acutely ill and injured. This, even, is only to a limited extent, because the technology today has moved f a r beyond the place where any individual, or even any single institution, can be counted on to summon all skills necessary to provide all services needed. The transition from professional to consumer decision-making in hospital and medical care is already well under way, closely following the transition from private to public financing. The transition from private to public financing closely follows the escalation of individual distress to community crisis. This is the familiar choreography of social action.
It has been the public outcry-first about the aged, then about the poor, and now, accordingly, about everybody else-which has brought public financing and then public decisionmaking into medical care in our time. Over the last several years I think i t has been plain to all of us that most of the response to public outcry has not been coming from the health professions, but from Washington, and this is something which makes us all nervous. We may not all agree with what might be called this extreme view, but I’m sure we can agree that the best way to respond to the outcry is to initiate some action of our own.
AORN Journal
R. M.
Cunlljngtwrn, Jr.
Centunks, &ex the treasures of the temgdks at W p h i in ancient Greece h a d beem m o v e d by Nero and otheps, the Elnmperor JuEim sent a deputy to restore the riches It is reported that the oracle at Delphi respanded only with a waB. At that time there was 110 longer p a t belief in proph& 8s c e m partents of future events, and so contemporary hisbriam think the wail was a lament for departed gkwk Considering the way things have been going, however, it may readily have been a warning of horrors yet to come.
their arrival is picking up in our time. Just the other day, for example, a noted ecologist reported that we are overpopulating our planet, contaminating our food, and polluting our air at a rate which will run us out of space, nourishment and atmosphere in another 30 years if we can't turn things around.
The homrs have been coming ever since, and, if anything, the rate of
Unlike the ancient Greeks, we don't pay much attention to our oracles unless they tell us what we want to hear, and when, as in this case, an oracle suggests it is our corporate gods who are hurrying us along the path to doom, we respond with wrath or ridicule, or both, directed not toward the gods but toward the oracle.
Robert M. Cunningham, editor of M o d e m /forpito/ i s the featured speaker for the Writers' Workshop "You, too, can write," scheduled for the Eighteenth Annual Congress of the Association of Operating Room Nurses next month. This article was adapted from a presentation made to the South Carolina HosDital Association and members of the South Carolina General Assembly in 1970.
Our latter-day equivalents of the Greek chorus, now called Press and television, have learned how to cry "calamity" and praise the the same time. This is an art which annoys the gods more than it pleases them; members Of the chorus who
January 1971
41
even mention calamity are identified by the gods today as “effete snobs.” In spite of these and other hazards, the oracle business flourishes again in our time, especially at the end of one year and the beginning of another, as now, when oracles multiply like the fruit fly. In evidence particularly a t these times is a rule about oracles which might be stated like this: The more unaccustomed the oracle is to his role, the more optimistic the outlook is likely to be. Thus, once-a-year or once-a-decade oracles, w h o s e prophecies appear mostly in annual reports and house organs, commonly see everything coming up roses; while the once-a-day oracles of the press and television are more likely to see the rips and tears in the social fabric-a circumstance which causes pain among vice presidents. In medicine and medical affairs, as elsewhere, the oracles have been working overtime in recent months. The resulting range of prophecy runs all the way from the few who see starving in the fields and choking in the streets, to the many who see automated care, miracle nutrients and population controls practically eliminating illness and poverty and keeping everybody alive and well indefinitely. Within these extremes, however, there is a surprising degree of agreement among the medical oracles, especially for the coming decade. Thus everyone expects a flowering of computerized diagnosis, and computerized medical information systems, and electronic instrumentation, and multiphasic screening. Nearly everybody foresees some kind of comprehensive
42
health insurance; some kind of largescale prepaid group practice; some kind of regulation or control putting p a t i e n t m r at least aiming themwhere ‘they’ought to go for what they need; and some kind of physicians’ assistants all over the place. Now I don’t disagree especially with these oracles, but I’m not sure, in every case, that I understand how we’re going to get there from here, especially since I’m not sure we really know where we are. This is what concerns us all. Inevitably, this circumstance gives rise to confusion and contradiction. For example, every hospital today is expected to keep abreast of the emerging technology and offer its patients all the benefits of cobalt machines, blood volume analyzers, pump oxygenerators, monitors of all kinds, and computers. Yet every hospital is also expected to offer loving personal attention to the care and comfort and psychic well being of its patients and their families. This is the same kind of loving personal attention we like to think was so abundant back in the days when medicine and nursing were still “face-to-face,” or “hand-to-abdomen.” arts. Every hospital today is expected to expand and refurbish its physical plant; buy the latest equipment; raise salaries and wages of employees at all levels of skill to compete with industry for personnel in short supply; admit masses of patients without investigating their ability to pay for the services they are about to receive; and treat additional hordes in the emergency room without even finding out who they are, much less what they can pay.
AORN Journal
Yet every hospital today is also expected to keep charges down; balance revenue and expense; set aside huge sums for depreciation; pay for its own development program; keep separate sets of records for medicare, medicaid, blue cross, insurance, state, county, and city welfare and licensure departments, JCAH, PAS, and others. Then they are expected to join hands with other hospitals, clinics, physicians, nursing homes, health departments, and community groups in planning programs. These programs are supposed to encourage the total effectiveness of the health m i c e by developing and using less expensive alternatives for general hospital care. In other words, they are to empty as many as possible of the beds the hospital must keep occupied in order to earn the revenue i t has to have to perform all the things it is expected to do!
ends with what are always the limited resources at your disposal must necessarily result in some failures, if not total disaster. So the task remains one of selecting priorities. This is nothing new for hospital people. You have always had conflicting aims, such as the inevitable conflict between quality service and low cost. You have always had limited resources, and so you have always had to establish priorities. The new thing is simply that as technology, the hospital and the society change, the demands and expectations change too, and unless you keep constantly examining the pressures and adjusting the priorities accordingly, the rate of failure, or at least the exposure to failure, is likely to increase. I suggest that one of the problems of public position and public policy
you are facing today results from the fact that priorities haven’t always been managed as adroitly as they might have been.
How are you going to accommodate all these conflicting pressures? How can you meet the expectations of physicians and patients, who want more and more of everything, and nothing but the best; and the expectations of employees, who want more money for less work; and the expectations of owners, or trustees, who want to balance the books without rocking the boat; and the expectations of third parties, notably today inchding the United States of America, who want an orderly, efficient, integrated, rational health service system in which needs and resources are always in perfect equilibrium?
The major new pressure, of course, results from the fact that all or nearly all our hospitals have become public facilities and are no longer in full control of what they do and how they do it. From a standing start a little less than four years ago, the federal government has become the single largest purchaser of hospital services in the United States, carrying all the authority the single largest purchaser has with the producer of any product or service.
Obviously, any attempt to accomplish even a minimum number of these conflicting and contradictory
You must understand, here, that what the single largest purchaser wants is some changes in the priori-
January 1971
43
ties. The problem isn’t made any simpler by the fact that the government’s priorities themselves h a v e b e e n changing, or a t least wobbling. Let’s look at some of the evidence:
not required; and, most importantly, the whole thrust of the massive reimbursement system would be aimed at keeping or getting people on their feet instead of treating them in bed.
A year-and-a-half ago, after two or three years during which committees and commissions and studies and reports had been taking the health services apart and putting them back together again over and over, the outlines of a national policy on health were beginning to take shape:
This became known as “emphasizing the less expensive alternatives to general hospital care.”
There were to be modifications and controls aimed at correcting deficiencies in the existing system-notably gaps which left substantial segments of the population without access to anything like adequate medical or hospital care. The links would be tightened, but the roles would be substantially unchanged. The modifications, or improvements, or controls, had also emerged pretty clearly and were obviously going to be written into laws or regulations of one kind or another: There would be up manpower input, for one thing. Communityewide and planning of facilities and services would be mandatory-that is, those who didn’t take part would be cut off at the knees. Cost reimbursement by third parties was on the way out; it was well established and uniformly recognized that cost reimbursement was a disincentive to efficiency. Instead, there would be negotiated reimbursement rates of some kind which would benef i t efficient and economic management of health services, and penalize inefficiency. Shared services and joint ventures aimed at achieving economics of scale would be encouraged, if
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It wasn’t by any means entirely clear just how this was to be accomplished, but there would be some kind of stepped-up utilization review certainly, and, of course, there has been also this big push for prepaid group practice. In fact, in the minds of some authorities, including some with substantial influence on the course of events, prepaid group practice appeared to have taken on elements of a sacred wisdom or mystique, somethink like the temples at Delphi. The answers were all supposed to be in there somewhere. It now seems likely that the blueprint for all this may have slid somewhere down the crack between administrations, or that all the programs and objectives and P r o ~ ~ l s simply disappeared into the Bureau of the Budget and some of them are just now beginning to emerge again. At any rate, the hell-bent-for-health policies of a year or two ago have obviously been turned aside. For example, the new administration proposed early last year to terminate Hill-Burton as we have known i t - a maneuver which was seen by the health professional establishment as roughly equivalent to repealing the New Testament. Since that time there has been brave conversation about a crisis in health care, but obviously it isn’t the kind of crisis evoking instant action.
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A five-year plan circulated some months ago in the Department of Health, Education and W e 1f a r e seemed to some observers to be mostly an exercise in demonstrating that more could be accomplished by spending less, a sort of fiscal Bauhaus. The coup de grace, of course, was a proposal to cut down drastically on the funds budgeted for medical research, including millions less for the Regional Medical Programs. Now obviously, a policy which is going to compromise with heart disease, cancer and stroke is incapable of doing anything. This is not to say that the present government, or any government, intends to let the health system or the hospital system alone. On the contrary, hospitals had a foretaste of what can happen when the 2% medicare lagniappe was taken away, and an aftertaste of the same flavor when the accelerated depreciation option was removed from the medicare cost computation. The one crisis in health care about which this government appears to be in dead earnest is the crisis in cost. The one slogan this government has picked up from the liberal element in the health establishment is the one about the need for change in the medical care delivery system. This kind of conversation has been around for years, but the surprise here is that there are many public officials in the Congress and in the federal departments and in the state legislatures and the statehouses who not only intend to change the deIivery system but think it can be done. Some of these officials were concerned when the chief problem in the
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health services was Seen as inadequate service for the poor. Now that the chief problem is seen as excessive cost of service for the middle class, they are positively hysterical. What they have in mind is not yet planned. Some, unquestionably, see hospitals as the principal villains and would put them under rigid price control. Others would go on a completely different route and hand hospitals over to profit-making corporations, innocently believing that a system that works for cookies and Cadillacs will work as well for fevers and fractures. These are the people who subscribe to the notion that hospitals are inefficient p e r se-a proposition that is just about as sensible as most other flat-footed declarations. The fact is, of course, that some hospitals obviously are inefficient, just as some businesses are, while others are as efficient as any enterprise managed by human beings can ever be. Moreover, as you know, but most people outside the hospital field don’t know, the measure of efficiency is enormously complicated when the purpose or goal of the enterprise is something which really can’t be measured-like “quality of care.” This is a circumstance not by any means fully understood even within the profession. Whatever the proposed remedy, however, talk about changing the delivery system refers chiefly to changing methods of organizing and financing health services. But the delivery system has to refer not only to the organizing and financing mechanism but also to the entire spectrum of resources with and within which some 250,000 doctors are brought face to face with patients.
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This spectrum runs from the physicians’ own offices, which practically all of them have; their patients’ homes, which some of them still visit; the 8,000 hospitals, where most of them do at least some of their work and where most of the system’s resources are brought to focus; the 20,000 or so extended care facilities and nursing homes which carry the heavy end of the bed for patients the doctors don’t like to visit and the hospitals they just don’t like; to a reminder of what are still odds and ends, such as group practices and health centers. All this is included in the delivery system, and the whole thing can’t be changed, actually, short of replacing the medical profession with something else, and possibly giving the hospitals back to the church. These proposals may have a certain amount of appeal for some people but are probably not practical. The system can still be modified along the lines which have been emerging in recerd years, and it probably will be. One thing which could and may be changed is the way all the services are paid for. There is a new push going for some kind of comprehensive national health insurance plan which would cover everybody, possibly using and supporting the existing mechanisms such as Medicare, Medicaid, Blue Cross and private insurance. At the moment, the push is coming mostly from consumers groups-union and others-and a few providers and some public officials and deep thinkers. But if the money squeeze continues and the cost of the services continues to rise, (and both these things seems to be happening), it may not be long before
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the clamor for comprehensive national health insurance becomes deafening.
It is interesting and possibly significant, that many of those who don’t want any part of a national health insurance plan are not opposing it head-on in this new encounter, as they have always done before, with battle cries of “socialized medicine.” Instead, many of the opponents today are acknowledging that there are indeed large groups in the population without access to care; and larger groups with access but inadequate means; and still larger groups with adequate access and means but inadequate prepayment or insurance coverage; and that something must indeed be done. However, they add quickly, this is not the time. Anything like a national health insurance plan introduced now would swamp the system because the manpower shortage would make it impossible to meet the added demand. We must build up the manpower supply, they say, then think about broader health insurance coverage. I expect the argument has a sound base, and certainly it carries all the conviction of sweet reasonableness. It is also a complete justification for doing nothing at a22 about broader health insurance coverage until the manpower shortage is resolved. Since what we see as the manpower shortage isn’t going to be resolved, it is a justification for doing nothing. Another thing which could be changed, though possibly not as quickly or as substantially as it has appeared to some, is the number of physicians whose services are organized in groups and paid for in advance; compared to the number whose
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services are organized at random and paid for at their usual and customary fees.
It is significant that so many hospitals and hospital associations and Blue Cross plans and medical society foundations have been willing to lend their resources and their organizational skills to the extension of prepaid group practice, which is seen by so many as offering opportunities for some imtxovements in the total effectiveness of the health service. What may be needed now is the rapid extension of what are still largely local or regional or experimental efforts which would take a generation or more to bring about any substantial change. The initiation of enough new institution-based and free-standing groups to provide some real options for the whole population will take years to accomplish unless groups like the Association of Operating Room Nurses - physicians, nurses, supenrisors, hospital administrators, trustees and their professional associations, that is - become convinced that there is more to gain than to lose by pushing for the organization and support of such groups. Whatever it takes to convince you, you haven’t gotten there yet, and unti1 you do get there, talk about changing the delivery system is going to remain largely theoretical exercise. To the extent that professions are responsive to public attitudes and expectations, however, all these new developments obviously will have some bearing on priorities. The new voices tell us clearly that area-wide or regional planning of some kind is going to govern hospital capital programs,
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for example, and that the third or more of hospital revenue which comes from the Social Security Administration, if not the other third or more that comes from Blue Cross,too, is not going t o stay on a cost-base forever, and perhaps not much longer. There is going to be pressure to expand outpatient services, to tighten arrangements with extended care facilities and nursing homes, and to push utilization review. Another one of the new pressures resulting in some new priorities is the Pressure for COnSUmer representation in the planning and governance of the health services. This is the era of the consumer, or at least the era of the consumer representative. We have Ralph Nader going for us, or against us, depending on the point of view, in automobiles, and foods, and air and water pollution. We have a new department in the government and a new federal official going for us, or against us, depending on the point of view, in such matters as the pricing and packaging of everything from breakfast food to television sets. We have neighborhood representatives going for us, or against us, depending on the point of view, in housing, and urban renewal, and community planning; and we are going to have, and in some communities we already have, consumer or neighborhood representatives going for us, or going after us, in planning and running the health services, including hospitals. Professional opinion about consumer representation in the planning and governance of health services and hospitals varies all the way from a few who consider it a good thing to many who consider it unmitigated
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disaster; but, again, I’m not sure i t really matters what we think. We are going to learn to live with it-the way the universities are learning to live with the fact that their consumers, whom we call (sometimes with wild inaccuracy) students, are going to have some voice in the planning and governance of university services. As we all know, the universities got their consumer representation the hard way, by having it shoved down their throats, sometimes accompanied by the sound of smashing glass. I think most observers and analysts agree this was partly, at least, their own fault. The universities didn’t know what was going on in their own jurisdictions, for one thing: and they didn’t have any semblance of a plan for dealing with student dissent, in most cases, for another; and, most significantly, they had ignored rising evidence of student dissatisfaction with university services, and university life, for years.
I think there is rising evidence today that consumers are dissatisfied with the health services we have been providing. We may not have patients marching up and down the halls carrying signs, like students, but it might not be a bad idea for us to start now listening a little harder to what the consumers and their representatives have been trying to tell us. Basically, the message is the same one the students were trying to get across to the universities: the service isn’t always relevant to the need.
What does that mean? What i t means essentially is the same thing the public officials and public surrogates have been trying
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to tell us over this same period: For the most part, the strictures of the consumer representatives enjoin physicians, hospital administrators and other professionals to consider the whole problem, and not just their own disjunctive little segments of the problem. Medical care isn’t relevant, for example, when an elderly woman in marginal circumstances is treated and cured of pneumonia in a fine, modern hospital and then discharged to return to the same unheated flat where she contracted the pneumonia. Relevance isn’t especially considered, either, when a surgical patient with obvious psychopathic symptoms is admitted, diagnosed, o p erated on and discharged without any attention to the psychiatric symptoms. Nor is relevance notably accomplished when a patient is put to bed in a hospital for 72 hours at $70 a day just so he can put through a few tests and Blue Cross will pay the bill: or when neighborhood patients wait for hours in outpatient departments and then are told the doctor they should see isn’t here today; or when a stroke patient with obvious potential for rehabilitation and return to useful life is allowed to lie in a nursing home bed or sit in a wheel chair day after day as his potential diminishes and his dependency rises. The push for more preventive services, more planning, more controls, more outpatient services, more rehabilitation, social service and shared services and group practices and other modifications and innovations is a push for relevance and the somewhat disquieting circumstance is that we often seem to be making the same mistake the universities were making
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a year or so ago: we aren’t really listening. What is the evidence? One example of the professional response to the push for relevance was in evidence a short time ago when some physicians opposed the effort to organize neighborhood clinics for poor populations in an effort to make their medical care relevant-or a t least visible. Another federally-funded program aimed at improving the availability and relevance of medical care, the Regional Medical Programs for heart disease, cancer and stroke, also encountered indifference and opposition in s o m e professional groups.
gestions as to how we should a p proach it?” Well, he was told, you might report how the hospital has been working with other institutions in the community and the area to integrate planning so that all the needed services are being offered, or will be offered, without duplication and overlap. You might want to report how you moved out into the neighborhood to establish communication with the nearby population and plan services accordingly. You might want to report how you are working with nursing homes in the neighborhood to integrate your services with theirs. You might want to report on the success of your home care program; and you might want to report how you called in air pollution engineers to study the incinerator system so the hospital would be insured against contributing to a severe public health problem in the community.
Still another example was when the American Hospital Association, after two years of study, announced a new policy on the financial requirements of health care institutions and services in an effort to encourage the relevance of institutional facilities and services to community needs be rewarding its presence and penalizing its absence. Hospital administrators, trustees, MDs and their associations notably failed to throw their hats in the air and cheer. They weren’t about to let anybody else, not even other hospitals, invade their autonomy and tell them what was and what wasn’t relevant for their institutions.
That wasn’t exactly what they had in mind. In fact, it turned out, they weren’t doing any ‘of those things.
Still another response from within the profession-less visible but perhaps most typical of all-was exemplified not long ago when the director of public relations at a well known teaching hospital called me to talk about the hospital’s annual report, which he said was just being planned. “The theme is the hospital as a community institution,” he said proudly. “Have you got any sug-
What they were thinking of was more like how they had a Santa Claus visit the children’s ward at Christmas time with presents for all the children there; and how the nurses’ glee club always gave a concert every year at one of the big churches in the neighborhood and how the administrator and his assistants went to meetings of all the men’s and women’s clubs and made speeches about hospital costs;
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You might even want to report how your institution saw the need to give up some of its autonomy in the interest of community planning and relevance and supported the AHA’S new financial policy.
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and how the hospital published this bulletin every month telling all about what the doctors were doing, and what the services were, and why the charges had to be increased; and how the hospital related to the community by sending out these opinion polls asking the patients whether the coffee was hot, and how they like the food, and how was the temperature of the room, and, of course, urging them to report any criticisms or suggestions they might have. Things like that. Certainly there is nothing to be against Santa Claus, or glee clubs, or speeches by administrators, or hospital publications, or patient-opinion polls. Certainly these are all legitimate and useful activities, and they have something to do with relevance, I suppose, though certainly they are not a t the core of relevance. The core of relevance has to do with comprehending the whole problem, and all the problems, and then getting on about the business of organizing and ordering the manpower and facilities and resources appropriate for all the problems, even at the sacrifice of autonomy. Unfortunately, this involves doing a lot of things doctors and hospital administrators and trustees and their associates are often disinclined to do. They are inclined instead to rely on their own judgments of what is right. and proper for them to d-that is, how they can best distribute all the skills and resources at their disposal to what they see as the greatest advantage for the people they think should be serving. The only trouble, or the chief trouble, with this view of the health
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professional establishment as all-wise and all-beneficient is: 1) the rest of the population simply isn’t accepting it any more; and 2) at the best the wisdom and beneficence of the professional establishment are certified only for judgments and decisions involved in the immediate care of the acutely ill and injured. This, even, is only to a limited extent, because the technology today has moved f a r beyond the place where any individual, or even any single institution, can be counted on to summon all skills necessary to provide all services needed. The transition from professional to consumer decision-making in hospital and medical care is already well under way, closely following the transition from private to public financing. The transition from private to public financing closely follows the escalation of individual distress to community crisis. This is the familiar choreography of social action.
It has been the public outcry-first about the aged, then about the poor, and now, accordingly, about everybody else-which has brought public financing and then public decisionmaking into medical care in our time. Over the last several years I think i t has been plain to all of us that most of the response to public outcry has not been coming from the health professions, but from Washington, and this is something which makes us all nervous. We may not all agree with what might be called this extreme view, but I’m sure we can agree that the best way to respond to the outcry is to initiate some action of our own.
AORN Journal