Pink Slips for Green Doctors
This little story of discarded pink slips, even after fifty years have elapsed, is on the short list of things I am proud of. I probably remember it so well because it was the forerunner of several other seemingly unrelated matters.
In 1956, I was the Chief Resident Physician of the Pennsylvania Hospital. That position doesn't exist any more, but most hospitals at the time had a Chief Resident, who was in charge of the house officers, the interns and residents. The Chief Resident was usually a doctor who had just finished his formal specialty training, and was thinking about starting a private practice. He was the father figure to the doctors still in their post-graduate training years, all of them overworked and tense, concentrating on avoiding dangerous mistakes while learning to assume new and difficult responsibilities. He was old enough to carry the weight of authority, but young enough so the residents could talk to him frankly, and still call him by his first name. The Chief Resident had his office and secretary near the accident or receiving ward, next to the resident's lounge, which contained mailboxes and coat hangers. The lounge was pretty shabby, as bachelor lounges tend to be, but it was all doctors, all the time, coming and going. If you wanted to know what was going on, this was the place to learn it.
Tom Paton, the credit manager, had his office further down the hall. In spite of his occupation, he was a jovial, convivial fellow, a former rugby player and soccer referee who fit right in with the lounge crowd. One day, I noticed he was throwing away a large stack of pink slips. He seemed surprisingly eager to tell me all about it. These slips represent the life blood of the hospital, sez he, without the flow of cash we would have to close the doors of the institution. Well yes, Tom, but taking care of the sick folk is sort of important, too. After a little explaining, I had to agree that he was talking about an interesting subject.
One of the everlasting problems in any hospital is to have the bill ready at the time the patient goes home. Nowadays, hospitals all have databases and many gigabytes of computing power, but the patient's bill is never ready when the patient is discharged, and may take weeks to be sent to them. Hospitals put on a good face, don't you worry about the bill, madam, we trust you and we'll send it to you when you are feeling better. And all that, but the truth is they haven't a clue what your bill is.
All of that drove Tom Paton nearly crazy. The time to collect a bill is when the tears are still hot. Every day you delay the bill costs you a provable fraction of it, and so on. So, the system was devised that the tabulating machines of the hospital would routinely work all night to produce a bill for everybody, every day. If they went home today, they were handed a bill. If they didn't go home, the bills were thrown away. For accounting purposes, a carbon copy of each bill was kept on pink paper. It was an amazingly simple idea, far less expensive than the random-access real-time whatchmacallits that nowadays do a far less effective job, and are out of commission much of the time. Let the record show that in 1956, every single patient at Nation's First Hospital got his bill as he was leaving, any time night or day. IBM charged us eleven hundred dollars a month to rent the machines, which also did the payroll and inventory systems.
An idea occurred to me. If you are only going to throw them away, could I please have the pink-slip copies of the bills of the patients who did not go home? Those patients are still in the hospital, and these slips show how much cost each patient is in process of running up. So a system was established that my secretary got these pink slips every day, and put them in the mailbox of the doctor taking care of the patients. It was a simple thing to do, but the reaction it got was explosive.
At first, the interns thought I was warning them, or criticizing them, but they soon got over that. We were all appalled at the costs which were being generated, and particularly appalled when a patient stayed a little longer than necessary. In those days before Medicare, any unpaid costs had to be made up by contributions and private endowment. The house officers and the student nurses who did most of the work, received no salary. The sense of guilt that arose from looking at those bills was very strong, and it was obvious that every one of them went back to the wards to try to speed things up. Since they all left their training to practice in various communities for fifty years, I like to believe that the multiplier effect was significant.
In those days, we had a two-year rotating internship. Every month before rotating to a new service, each intern would summarize the remaining patients on his ward for the benefit of his successor. In doing so, they were able to reflect in retrospect how each case could have been speeded up a little, and therefore wouldn't still be here to require a summary. There is an invisible counter-pressure at work. From a doctor's point of view, most of the heavy work of each admission to the hospital is concentrated in the first couple of days. You get things into motion, and then sort of watch it roll out. But if your ward is full, you can't get any new admissions, so your day suddenly gets a lot easier. Just let one of them go home, and bingo you have a new one. This little human frailty affects every one of them to some degree, and each one thinks he may have discovered this hidden incentive to slow discharges, except on the last day of the month. It was my job as Chief Resident to keep the system from sludging up. As much as for any other reason, an increased turnover meant more cases per intern, and therefore more training and experience. That's what most of them thought I was up to, when I started handing out the pink bill copies. It really wasn't purposeful at all, it was just sort of an accidental discovery of something useful.
From that, I developed an interest in efficient use of hospitals, a subject we called utilization review. Through the County Medical Society I formed a club of other doctors at other hospitals who had the same interest. When Senator Bennett of Utah got a law enacted, this organization turned into the Philadelphia Professional Standards Review Organization, which became part of the Pennsylvania PSRO, and eventually a national one whose name has changed several times. We had some interesting battles at the AMA House of Delegates, which dissolved into insignificance when the national business organizations took matters into their own hands and used their control of employer health insurance to push HMOs, Health Maintenance Organizations, onto the hapless public. Public outrage about HMOs put egg permanently on the face of national business, but the matter is now worse, not better.
What I got out of all this was an enduring interest in computers, which has served me well for half a century. And a sense of outrage bordering on apoplexy whenever some well-meaning activist declares that the doctors are responsible for pushing up hospital prices to enrich themselves in some way.