The plan behind Columbia's acquisitions was clear. Richard Rainwater, co-founder of Columbia/HCA, admitted, "The day has come when somebody has to do in the hospital business what McDonalds has done in the fast-food business and what Wal-Mart has done in the retailing business."55
"Do we have an obligation to provide health care for everybody?" former Columbia CEO and co-founder Richard Scott opined. "Where do we draw the line? Is any fast-food restaurant obligated to feed everyone who shows up?"56
Under federal law, the answer is hospitals do have an obligation to treat all comers who are seriously ill. Under the ethic of investor-owned hospitaling, the community does not count. When health care is a business, like fast food, communities can be starved.
Whistleblower Marc Gardner has discussed how the hospital giant he worked for turned the uninsured away — in apparent violation of the federal "take-all-comers" law. One homeless man with pneumonia, for instance, was discharged without having any tests and died an hour later on the hospital lawn. Another elderly homeless man was also released without testing. He went down the road to a Catholic hospital, where a brain hemorrhage was found.57 Such downsizing falls under the same type of justifications for cutbacks in the neonatal intensive care unit: "babies don't complain too much." After all, homeless men don't pay premiums.
While Columbia allegedly skimped on patients, it spent big bucks on advertising. Columbia spent nearly $200 million for advertising in 1995 and 1996 — the largest expenditure in hospital-industry history. In 1996, Columbia spent more than $1,567 per bed in advertising, or $106 million total.58
But it did not stop there. To corner the market, Columbia sought to kill off all competing community hospitals. One Columbia administrator Jon Trazona reportedly wrote to surgeons in Fort Pierce, Florida, "I pledge to you that Columbia/HCA will utilize all appropriate resources to insure the failure of any competing surgery center in our community [emphasis in original]."59
CEO Richard Scott himself allegedly told one hospital chief in handwritten comments on his evaluation of a rival hospital, "Don't let St. Mary's attract your patients." According to Marc Gardner, despite federal prohibitions on physician self-referrals, Columbia had physicians buy shares in the hospitals where they worked and paid doctors thousands in monthly fees to bring patients in the door.60 This cut-throat competition has a debilitating effect on communities and an inflationary impact on patient bills.
First, Columbia appears to have inflated prices and padded its Medicare billing. In one Columbia-owned hospital in Georgia, the average stay for a stroke victim cost $14,582, while a similar public hospital charged $6,735.61 The New York Times reported "Medicare had paid far more for Columbia patients receiving outpatient services than if care had been billed at the state average."62 So the taxpayers are cheated twice.
Second, the for-profit, not-for-patients ethos affects non-profit and community facilities, which must compete and play by the same rules.
For instance, Northridge Hospital Medical Center in Los Angeles was caught by the state of California refusing to give a woman in labor an epidural — a spinal block used in childbirth — because she would not pay cash up front to the anesthesiologist. The surgeon demanded payment from the husband in the delivery room before he would administer the pain killer. The woman was a Medicaid recipient.63 The hospital was not alone. Sally K. Richardson, the Medicaid program's national director, said Medicaid patients report they were asked to pay cash for an epidural at a dozen hospitals in Los Angeles, and Florida officials report similar problems.64 Los Angeles Times reporter Sharon Bernstein also uncovered that the County of Los Angeles, in a cost-cutting tactic, required poor women, even in high-risk cases, to undergo vaginal deliveries, rather than perform the more costly caesarian section. As a result, the County paid $24 million between 1992 and 1997 to settle forty-nine claims of mothers and children who died or were injured due to the policy.65
Public hospitals that have treated the indigent for years are pitted against franchises of the for-profit hospitals which, in the age of managed care, are even looking for Medicaid patients — while turning away the indigent who do not qualify for federal assistance.
Abraham Verghese tells how pressures from for-profit satellite hospitals have undermined care for the indigent and community hospitals, such as the one he works at, R.E. Thomason General in El Paso, Texas.
Suddenly, Medicaid patients, who for decades were not so subtly turned away by other providers and sent to Thomason, are now desired by all.
It hardly seems like a fair fight. Sierra and the four other for-profit hospitals in town have all been taken over by either Columbia/HCA Healthcare or Tenet Healthcare, two national for-profit chains. These companies have deep pockets and no public accountability.
Thomason, on the other hand, is the only public hospital for a population of about 600,000. Like many other county hospitals across the country, it is overburdened with care of the poor. The 300 or so hospital beds at Thomason represent only 14% of the total hospital beds in the city. Yet by county mandate the hospital is required to provide medical care not only to Medicaid patients but to the 240,000 or so El Paso residents who have no medical insurance or Medicaid cards. These residents are medically indigent because they do not meet the income requirement to qualify for Medicaid or because they are illegal aliens or because there is simply not enough Medicaid financing for all who qualify.
Thomason managed to care for them, despite the unwieldy bureaucracy that oversees the hospital and in the face of the increasing resentment by homeowners over the rising property taxes that go to support it.
The price tag for indigent care is about $40 million annually. The property tax generates about $30 million. The difference is made up by Medicaid and Medicare patients, who constitute 40% of Thomason patients and who indirectly underwrite the care of the indigent by allowing the hospital to have certain services and specialists in place — like neurosurgeons — that would otherwise be unavailable.
It used to be that Thomason's childbirth unit, the hospital's only consistent moneymaker (most pregnant women are eligible for Medicaid), was so busy that the hallways routinely served as holding areas. But the number of deliveries is dwindling as pregnant women are courted away by the for-profit chains whose elaborate labor and delivery suites look like Scandinavian design showrooms.
If Thomason loses its Medicaid base but continues to serve the indigent, it cannot possibly survive. Predictably, the city commissioners have seriously discussed closing the hospital or selling it.
Of course, it is hard to begrudge Medicaid patients, once the pariah of the for-profits, their new-found popularity. But those without Medicaid will suffer. Their voices are not well heard, and those who speak for them are an old guard of community activists and do-gooders whose plaints sound numbingly familiar.
If Thomason is forced to close and if Medicaid dollars are cast across El Paso, the indigent will likely be passed down from one hospital to another.66
The for-profit hospital industry does not dispute that it is closing beds, but says there are simply too many hospital beds.
Of course, this is a self-fulfilling prophecy. When bureaucrats refuse patients who need admittance, hospital beds go unused — but this does not mean that patients are not in need of hospitalization, simply that they are not allowed in or to stay over night.
The industry relies on hospital census data to show that there is so-called overbedding and excess capacity. But the "census" data is rigged and does not reflect the real number of patients actually in beds, just those staying past midnight.
Nurses now refer to the "twenty-three hour" hospital day. Census counts used by hospitals are invariably taken at midnight. They reflect patients who have actually been admitted to the hospital for an overnight stay. They do not account for the large numbers of patients who may spend all day in those beds but are not formally admitted as "inpatients."
"Outpatients," who undergo chemotherapy or an angiogram, spend hours in a hospital bed, but are not included in the census, which reflects an empty bed for the day. The California Nurses Association reviewed staffing census charts for an Oakland hospital and compared census counts made during the day shift with the official census count at midnight. Over a nineteen-day period, there was an 11% difference, 378 patients who were in the bed during the day but not included in the official census count. That's an average of twenty patients per day or 7,262 patients for an entire year.67
By artificially lowering the patient census count, hospitals also lower the number of nurses who must be on staff to meet regulated "acuity" standards — the number of nurses required for a specific number of patients with an acute condition. Other accounting manipulations in the census include deducting the number of patients in hospital observation units, a "short stay" unit. The patients in their bed at midnight were actually subtracted from the census count.
The industry also has an interest in manipulating census numbers because they artificially demonstrate that hospitals can be closed — reducing overhead costs. But that's little comfort to the trauma patient who has to be transported the extra forty miles to the next town because his community hospital closed. While profits to corporations like Columbia for the dismantling of hospital beds are substantial, the cost of rebuilding those hospital beds, when needed by a community, would be astronomical.
During the winter of 1998, for instance, an influenza epidemic exposed the "empty bed" myth. In California, the hospital industry had progressively downsized its hospital beds, boldly claiming an overbedding crisis. Unfortunately, when patients were stricken with a flu outbreak in the fall of 1998, there was suddenly a tremendous shortfall of hospital beds — with patients forced to wait in emergency rooms, hallways and parking lots. Prompted by the spectacle, the California Emergency Medical Services Authority issued a report in October 1998 that found there was not enough capacity in the state's emergency rooms and hospitals to deal with catastrophes.
During an earthquake or other natural emergency, hospitals are needed. As the hospital downsizing continues, though, community infrastructure will evaporate just when communities need them. The issue of required capacity is simple: do we close firehouses because there is not a fire every week, or do we keep them open so when fire hits, communities can respond appropriately? In the age of corporate medicine, the same civil values that keep a fire station open do not apply to hospitals. |
