The current political maneuvering by the American Hospital Association and its member hospitals to extend the moratorium which the Congress imposed upon the proliferation of physician owned specialty hospitals seems to be missing the point as to whether the current general hospital model is viable in the long run. Can a general hospital be all things to all patients and still maintain quality of performance?
Can it continue to operate with an intricate, Byzantine structure of internal cross subsidization of services and compete with new lighter specialty hospitals and delivery facilities which will continue to develop regardless of whether physicians continue to participate in ownership through the whole hospital exception to the Stark law? Is the effort to protect general hospitals from competition from specialty hospitals not encumbered with a full range of "loosing" services similar to providing subsidies for buggy whip factories?
There are some truths in the future of health care that seem self evident:
- The cost of health care is going to rise faster than the general rate of inflation.
- Fewer people are going to be covered by traditional health insurance plans.
- Technology is going to become more complex, more mobile and more available to practitioners.
- The demand for improvements in quality in health care will continue.
- The trend of employers toward off loading the costs of health insurance for employees will continue.
The financial and political pressures of these "truths" will continue to spin the delivery of health care in America and the general hospital model is going to have to adapt to those changes. On average, specialty hospitals tend to produce a higher level of quality, efficiency and patient satisfaction than to large, impersonal general hospitals. Demands for specialty hospitals will continue as the boomers retire because the boomers like quality, efficiency and satisfaction. Specialty Hospitals will continue to proliferate because the demand will continue and the general hospitals will continue to pile up loads of chronic, cash draining low compensation patients, unless other models are developed.
Local, state and national governments are all complicit in the development of the current stagnant model of a general hospital where all the problems of health care finance are swept into an Alice in Wonderland world where up is down, east is west and an aspirin costs $10.00. True health care costs are difficult to get a handle on because the price never reflects costs. Medicare and Medicaid can pay less than the costs of a procedure or service to the hospitals because the hospitals are expected to play Robin Hood and overcharge private pay indemnity insurance financed largely by employers to subsidize the short fall.
Government expects hospitals to subsidize the costs of loosing services with the largesse of government payments in others. Hospitals are expected to serve as a safety net for the uninsured, which must also be subsidized through paying plans. Many uninsured patients only arrive at a hospital in extreme circumstances and as a last resort and the cost of their care is correspondingly acute. Government will on occasion withhold funding for illegal alien expecting mothers whose children will become citizens. The children will be eligible for care once born, but many will be in extreme circumstances because their mothers did not receive adequate pre-natal care. Nobody, least of all politicians seems to be monitoring these costs.
The health care system of the future will have to adapt to survive. It will have to permit competition and experimentation with new delivery forms. It will have to ultimately provide for universal coverage. It will have to push for the development of new and effective technology to expand the quality, range and efficiency of service. Patients, wherever possible, will have to be treated from their homes or low cost facilities. They will be monitored electronically for vital signs and other data at a central off site location with automatic alarms and computer input from smart machines that will diagnose and in some cases prescribe and administer medication to address sudden systemic changes in a patient's condition. (India perhaps?) Direct patient care will be provided for the most part by warm nurturing people with minimal medical education, but who are capable of collecting and forwarding data to a command center for input into diagnostic computers which will have its own Artificial Intelligence software to assimilate data and prescribe a course of action.
Physicians will intervene only in those rare cases where there is an objective impasse as to the meaning of data and a subjective evaluation that only a skilled physician can provide is the only rational alternative. 95% of all currently classified drugs will be available to patients over the counter if they can demonstrate to a pharmacist a need and use which is consistent with the properties of the drug. Mobile surgical centers will proliferate and you will be able to obtain a hip replacement in your driveway. Change, experimentation and growth to improve service and lower the cost are the only likely constants.
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