The state of hospitals today

According to oncologist Ezekiel Emanuel (Rham Emanuel’s brother), hospital numbers are shrinking. Dr. Emmanuel believes it’s a good thing. The shrinking has partly to do with the fact that some rather complex care can be provided elsewhere, including at home. Also, many services have been shifted to surgical centers, imaging facilities, and “doc in the box” clinics.

Hospital numbers may be shrinking, but those remaining have been consolidating into huge, multi-hospital systems (where I live, it’s Sutter). These mergers create local monopolies that raise prices to counter the decreased revenue from fewer occupied beds. (Hospital costs here are 12 times higher than in the Netherlands.) Dr. Emanuel believes that antitrust regulators should be more vigorous in opposing such mergers.

Another doctor, Sandeep Jauhar,  is opposed to hospitals being run by corporate executives rather than by medical personnel, as was the case a generation ago. Today less than 5 percent of America’s roughly 6,500 hospitals are run by chief executives with medical training. In fact, the number of non-medically trained hospital administrators has gone up 30-fold in the past 30 years, while the number of physicians has remained relatively constant. With business people at the helm, decisions are based on business—not clinical—imperatives. For example, doctors are being pressed to discharge patients quickly to maintain “throughput.” Doctors’ status is often based on the number of patients they admit. Some of the best hospitals in America are still run by physician chief executives, such as at the Cleveland Clinic and the Mayo Clinic. In 2011 a study found a “strong positive association between the ranked quality of a hospital and whether the CEO is a physician.”

A famed cardiologist, 96-year-old Bernard Lown, recently spent time in a hospital. His experience—which included those middle-of-the-night checks for temperature, blood pressure and the like—led him to remark that a hospital is more like a factory.  “It tests every ache and treats every laboratory abnormality, but it does little to heal its patients. Care is supplanted by managing.” Is this what they mean by “managed care?”

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