Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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Hospitals and their Future
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New topic 691 2020-09-08 21:49:55 TITLE Pennsylvania Hospital, Nation's First :
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Philadelpia Hospitals, Past and Future

It was sixty years before Philadelphia had a second hospital, so the way things were done at the Pennsylvania Hospital tended to set patterns. The central pattern was: charity for poor folks, during a period when prosperous people were treated in their homes. Since Franklin was the secretary of the Board of Managers, it is in his own handwriting that we see "Founded for the sick poor and, if there is room, for those who can pay." In 1900, two-thirds of all hospital beds in Philadelphia were still ward beds for the poor. In 1948 when I was a two-year unpaid intern there, a posted sign said the accident room charge was fifty cents, but in fact, it was only collected if the patient happened to have insurance. The student nurses ran the place unpaid, and the main exceptions were the two paid administrators, the Steward, and his secretary. Philadelphia was settled for religious freedom, enjoyed many new religions, and consequently had a long era of Methodist, Episcopal, Presbyterian, two Jewish hospitals and the hospitals belonging to three Catholic Orders.

With the advent of the Civil War, PGH (Philadelphia General) grew to seven thousand beds, all of them free, when it was discovered more soldiers were dying from diseases than from wounds. Surgeons and obstetricians built specialty hospitals for their patients, mostly small ones, like Babies Hospital, Preston Retreat, Contagious Disease (mostly polio), Casualty, and a host of tuberculosis and psychiatry hospitals, Eye Hospitals, HEENT Hospitals, Children's Hosptial, and a number of small paying hospitals. The Civil War and the invention of anesthesia created a need for small hospitals for people who could pay, like Skin and Cancer.often in the shadow of larger charity hospitals for those who couldn't' pay. The first question any audience asks with bewilderment is about the cause of so many current hospital mergers. Part of the answer is we once had too many hospitals, and the rest of the answer was that the Flexner Report created a surplus of government money, intended to support research, and similarly stimulated by the creation of Blue Cross in the 1920s. Flexner favored research money, and the Universities grabbed it. The insurance mechanism was the best available means to save money when you were well, in order to spend it later when you were sick, but insurance muffed the chance. They chose one-year term insurance, mostly because short-term business was paying the bill. When money was no object, money was wasted.

The quickest example of honey attracting flies was observed shortly after 1965, when Philadelphia teaching hospitals (there were 104 of them at the time) went to Mayor Rizzo, suggesting PGH should be closed, ostensibly in order to facilitate the flow of federal funds to private hospitals. Thus they would help teaching hospitals absorb the abundant flow of government charity while eliminating the $11 annual cost of PGH to the City. That transformation from mostly charitable to largely private hospital care took from 1977 to 2010, to the private amusement of those who had been present at the meeting. At the end of this transformation, their positions had reversed; the teaching hospitals now bemoaned the shocking disappearance of the city's medical charity through PGH, casting such people back onto the teaching hospitals. Vannevar Bush probably had a hand in this, as the pretext was that only teaching hospitals did research. Meanwhile, they lobbied strenuously to retain monopoly control of federal research money, at the expense of charity beds within the teaching hospitals. In other words, we had a reasonably satisfactory system of charity care until charity patients demanded equal facilities from public money. Lyndon Johnson gloried in his achievements, but the fact is they opened the door to the unsupportable expense. The nursing profession was utterly flummoxed to be given degrees in return for the disappearance of their profession. If the combatants had stopped long enough to ask, there simply was not enough money to do what politics was demanding. The nursing school was always the heart of the hospital; the doctors were too busy tending to patients. And charts which they mostly falsified to save wasted time. Adding to the confusion was the effect of shifting nurse training costs, from the hospitals (diploma) to university responsibility (bachelorette degrees) and the adverse effect on nurse quality was noticeable. Doctors no longer married nurses, for example, they married lawyers and similar pre-professionals. The greatest effect, aside from higher cost, was to remove the loudest objectors from the scene, at just about the wrong time. The universities were clamoring to transform the nursing profession into administrators, in order to satisfy a seemingly insatiable demand stirred up by muddling the medical record-keeping system with the task of creating huge records which no one has time to read. The public regards medical matters as too obscure to understand and so does not appreciate how much cost has been created by switching everything non-essential around. It seemed obvious to them that non-essentials were poorly done. But not being medically trained, they weren't able to tell what was non-essential. Improving legibility and interphysician communication was nice, but it wasn't the main business of a hospital. Physicians learned to practice good medicine in tents and scarcely saw any difference.

Lawyers have learned something, too. They learned that antitrust violation is not signaled by per se violations or even vertical integration. It is signaled by mergers. Senator Specter may have kept Robert Bork from the Supreme Court. But the Law is slowly catching up with mergers, and Bork's books are still in print.

The future of hospitals does not lie in buildings. Doctors' practices are easily moved to retirement villages where the old folks are. Patients are there a long time, and equipment is easily moved there to be with them. It would save a lot of money because diseases are disappearing. Something like five diseases now represents something like 80% of the cost, but all that money spent on hospital buildings has already been spent, so it will take too long to get there peacefully. For all I know, five new diseases will replace five old ones, but the trend is downward. Costs keep going up. Doesn't that tell you something? What's going to happen to all that real estate after we cure cancer?

Originally published: Monday, March 25, 2019; most-recently modified: Monday, July 20, 2020


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