Tuesday, July 30, 2013
The Demise of Hospital Charity
Among the many unremarked implications of Obamacare is its
contribution to the demise of the hospital as a charitable institution.
The modern hospital in its original form was created to
provide care for people who were economically unable to be sick decently at
home. In northern climes, there was
nothing humane about being ill in December in a third floor unheated walkup
when everyone else in the family had to go to work. Hospitals were developed as a remedy for
that. They were also a way to get the
bothersome mentally ill off the streets.
As the years went by, hospitals began to provide treatment
as well as care and so people of means had to use them too. They occupied private rooms (charity cases
were cared for in open wards) and were expected to pay for the services they
received. Then insurance came along,
creating a category of paying patients in between those occupying private rooms
and those housed in wards. They were
admitted to semi-private (two bed) rooms, for which the charges were lower.
As both the nature and the economics of what they did
changed, so did the charitable orientation of hospitals. From an initial dependence on donations, they
became increasingly dependent on revenues from paying patients. Charity patients, once the purpose for which
the hospital existed, came to be seen as a burden. In the large cities, publicly supported
hospitals were built to provide care to the poor.
With the exception of Catholic institutions, hospitals
gradually lost their sense of obligation to serve the poor – to the extent that
most states now have laws that prohibit them from denying care because of
inability to pay.
Obamacare promises to move that trend some distance towards
its final conclusion. By requiring
everyone to have insurance, it will greatly reduce the number of non-paying
patients. Legal proscription against
denying care to those who remain will no doubt continue, but for most hospitals
providing services to the indigent will become a minor burden and any remnant
of their identity as charitable institutions will pretty much disappear.
Sunday, July 28, 2013
A Note for Advocates of Single Payer
When thinking about government programs, it is always wise
to remember that government is controlled by politicians and therefore can be
counted on to respond to political considerations.
I was reminded of that by a July 21 Op-Ed piece in The
Boston Globe reciting the recent experience of columnist Robert Kuttner. It seems that Kuttner’s 99 year old mother
suffered a bad fall. She was taken to
the Mass General where she stayed for four days. Upon her discharge, Kuttner was surprised to
find that his mother’s stay had been classified as “for observation.” This meant that the services she received
were paid for as an outpatient service under Medicare Part B in which the
patient’s co-pay is much larger than it would have been had she been classified
as a regular inpatient, payable under Medicare Part A.
According to Kuttner, this stratagem has been devised by
Medicare as a cost reduction measure which results in paying the hospital less
and requiring the patient to pay more.
None of this should come as a surprise. Whatever political benefit attaches to new
programs is at its peak at the time of enactment. Thereafter, from a political point of view,
it becomes a drain on resources that could otherwise be used to generate
political benefit by financing other new programs. That helps to explain why the financing of
public programs tends to diminish over time.
Single payer advocates take note.
Tuesday, July 23, 2013
The Transition from Individuals to Institutions
A recent experience served as an example of the trend in
health care of relying on institutions rather than individuals.
Wife Marilyn has for some time known that she had a cataract
that would eventually require repair.
Recently, she decided that the time had come. She called for an appointment with her
Ophthalmologist, only to learn that he had suffered a major stroke and died.
An appointment was then made with another Ophthalmologist in
that same group. She saw him once in
clinic and yesterday underwent cataract surgery at his hands.
While sitting in the waiting room during the procedure, it
occurred to me that the only thing we knew about the surgeon performing surgery
on my wife’s eye was that he was a member of a large, well known and well
regarded group of ophthalmologists. I
couldn’t even remember his name. Without
thinking about it, we had placed our full confidence in the organization; i.e.,
the group, trusting that whoever it allowed to do surgery was competent.
I suspect that some version of the same was true of the
other dozen or so people in the waiting room.
The surgery was successful.
