Open Letter to a Hospital Administrator

Jane M. Orient, MD
Article Type: 
March/April 1998
Volume Number: 
Issue Number: 

Dear Sister St. Joan:

Thank you very much for taking the time to speak with me. As promised, I’ll put some thoughts to paper from 30,000 ft.

We know that we can’t predict the future. Certain things, that were inevitably supposed to happen, didn’t.

France was supposed to become a part of England. Whoever would have thought that an illiterate peasant girl would become the youngest person to hold the rank of general in the history of the world and would save France?

Obviously, Joan didn’t listen to the seers of the day, but to her voices.

At the staff meeting this month, I saw the “trek” statue for the first time, although I did hear the story a long time ago. I wonder what those Sisters would think now. They set out into the desert to found a hospital that stood alone. Well, not alone, of course, but not dependent on a network, or a corporation, or government funding, or out-of-town consultants. They followed their vision, not the Zeitgeist. They understood that one must seek the Kingdom first, then other things will be given besides.

Today, all the motion seems to be in one direction: mergers, consolidation, integration, capitation, third-party contracts, on and on. One is supposed to conform to all kinds of guidelines, and criteria, and pathways. But what about the mission and the Commandments?

The endpoint of current trends is perfectly obvious. The medical literature is full of Death. Abortion, living wills, advance directives, suicide, withdrawal of “artificial life support” (redefined to include food and water), and now euthanasia. The Oath of Hippocrates has been turned into something very different: the doctor is becoming the servant of the corporation-state, not of God and of His patients. We are in denial. We don’t want to see the consequences because they are too horrible. We live in the U.S.A. and “it can’t happen here.”

Catholic hospitals are enablers. They are going along and compromising. They are losing their financial independence and will inexorably compromise their ethics or else go bankrupt.

Unless...they take another trek. They could listen to the demoralized physicians and the angry patients.

More than 90% of physicians want nothing to do with managed care. They go along because they feel they are being forced. Patients go along because their employers are buying their insurance.

What can hospitals do? They could stop trying to offer group psychotherapy to help doctors and nurses adjust to the destruction of their professions. Instead, they could offer a better way.

The old St. Mary’s helped a lot of people. True, by today’s standards it might have been pouring oil and wine into wounds, but at least it was not fighting about who should be thrown in the ditch. It might not have gone out into the highways and byways to find everybody who wasn’t being “helped,” but it also wasn’t colluding in the robbery of Samaritans for the benefit of Levites.

Why not an experiment: break off a small, independent unit to try it the old way — which is also the right way, and in my opinion the new way. Maybe it would fail. But I think you’d get an outpouring of support beyond your wildest expectations.

Such an effort would have to be voluntary. No use of force, governmental or otherwise. We choose life, we choose to give, we choose to serve.

That means we’d have to turn down their money. The law does not require hospitals to take Medicare money; it just requires them to submit to onerous, counterproductive, and expensive demands in return for the “free” money if they do take it. The hospital is not forced to sign any managed care contracts; but if it does, it has to assume risk, and eventually will have to choose between bankruptcy and brutal rationing. I realize hospitals take Medicare money and managed care money and Medicaid money in the belief that the cash flow covers their fixed costs. My hypothesis is that the liabilities they assume are not worth it, from the financial viewpoint or any other, and that they are unjustly imposing a sickness tax through cost shifting. The only way you’d be able to figure it out is to try the experiment.

Here is an outline of the experiment. It may sound impossible, but please think about it, and if you think it is crazy, put it in the drawer and look at it again later. Or maybe at least try the questionnaire.

1. Withdraw from Medicare. No services at St. Joseph’s will be covered under Medicare. Remember, Medicare is funded solely through involuntary “contributions” by working people, through a highly regressive Medicare tax. It is a deceitful Ponzi scheme. It imposes very expensive requirements. Stop the DRGs, get out from under requirements of the “anti-dumping” law, get rid of the utilization reviewers. Don’t worry about the senior citizens. Other hospitals are killing each other for the Medicare business. Be very nice to senior citizens who come to you anyway and charge them fairly (see below). Or raise money from voluntary donors and provide charitable care.

2. Drop JCAHO accreditation. It is very expensive and unnecessary for operation as a hospital. Get a committee of volunteer citizens and physicians to do your own quality assurance.

3. Resign from all managed care contracts or any other third-party contracts. Bill all patients directly. (Take credit cards, cash, payment plans.) Talk to employer benefits managers about demanding insurance policies that reimburse the subscribers for covered expenses. If you do it right, your bills will be so much lower than everybody else’s that you’ll corner the market on self-paying patients and those with true indemnity insurance. And you’ll be able to offer better service because all your nurses will be caring for patients instead of doing paperwork.

4. Talk to insurance companies about writing “bad outcome” policies for patients, rather like flight insurance. Think of the legal costs that could be saved. If a patient bought $2 million coverage in case his spinal surgery didn’t come as well as could be expected, he could collect all the benefit without giving a cut to a lawyer, even if the bad result wasn’t proved to be the doctor’s or the hospital’s fault. The insurers could figure out how to accurately price risk: the premiums might be higher for certain surgeons, certain outcomes, certain procedures. Patients could choose their own level of compensation (but of course would have to pay a premium for a higher level). Of course, there could still be lawsuits, but many fewer and only for gross malfeasance, as patients became more involved in decision-making and assumed some responsibility. And if you didn’t have liability insurance, there would be many fewer lawsuits.

5. Set up some special programs especially suited to St. Joseph’s mission of celebrating life. How about a unit for certain patients that nobody else wants, like those with persistent vegetative state. It might be an opportunity to try innovative measures, simple ones like more sensory stimulation. Do it at the lowest cost possible, the old-style ward service. Maybe you could staff it largely with volunteers who receive a benefit, say training in basic nursing skills.

6. Charge patients for what they get and only for what they get. Even free choice of the most expensive drugs if they’re willing to pay or if someone else is willing to contribute. Ask and ye shall receive. Without cost-shifting and federal regulations, prices could be much lower.

7. Give tours of the neonatal ICU. Have a doctor or nurse available to answer questions. Show them the neat technology. Show them the nurses and mothers cuddling the tiny babies, even if they don’t have long to live.

Well, I had to turn off the computer because the plane was going to land. I could go on with other ideas, but maybe this is enough to see if you have any interest. I think you are on a slippery slope. Either you will make more and more compromises or you will be eaten up by more carnivorous plans that are higher on the “food chain.”

I did find this quote from Friedrich Hayek’s master work, The Road to Serfdom, which explains the food chain in more scholarly terms:

Just as the democratic statesman who sets out to plan economic life will soon be confronted with the alternative of either assuming dictatorial powers or abandoning his plans, so the totalitarian dictator would soon have to choose between disregard of ordinary morals and failure. It is for this reason that the unscrupulous and uninhibited are likely to be more successful in a society tending toward totalitarianism....

Recently, our public relations counsel happened to be on an airplane, seated next to a doctor from a teaching hospital. He told how Medicare came in and audited a small selection of claims and decided the hospital had been overpaid some $9 million. They trebled it and came up with $30 million. A few wanted the hospital to defend itself, but they decided to settle for $30 million rather than face a horde of auditors looking at every single claim, who could probably make a case that they owed much more. As Medicare sinks further and further toward its inevitable bankruptcy, more and more hospitals will be targeted. So you have to add to the current Medicare losses the incalculable unfunded liabilities that an aggressive, bounty-hunting prosecutor can cook up.

Get out now, and be a leader, instead of waiting to be devoured. Doing the right thing pays off in the long run. And selling your soul in a Faustian bargain always leads to a Day of Reckoning.

Why don’t you at least ask your doctors some open-ended questions, for example: 1. What effect does managed care have on your ability to care for patients? 2. Would you be willing to support a hospital that dealt only with patients and not with third-parties? 3. If you worked at St. Mary’s 40 years ago, what do you remember about relations with the hospital administration and how problems were handled? Well, I can think of many more if you are willing to undertake the survey but am pressed for time. So I’ll stop for now and continue if you have any interest in these ideas.

Dr. Orient practices internal medicine in Tucson, Arizona, and is the Executive Director of the AAPS. Her address is 1601 N. Tucson Blvd., Suite 9, Tucson, AZ 85716.

 Originally published in the Medical Sentinel 1998;3(2):60-61. Copyright © 1998 Association of American Physicians and Surgeons (AAPS).






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