Rocky asks below, "Do you ever find that the decisions you make may be great for the hospital but not the best option for patients? This comes up repeatedly in the pharmaceutical industry, where often the products being developed are directed toward the business market and not the greater burden of illness. Hospitals generally generate surpluses from providing cardiac and cancer care but lose money providing mental health and pediatric care. Are you ever forced to put a higher priority on the well being of the hospital than on providing the best health care services for the well being of patients, and how do you grapple with that?"
I might word the question slightly differently, but essentially the answer is a sad and simple "Yes." The current reimbursement environment is such that we cannot afford to expand or maintain certain services that we know are of value to society. For example, we have one inpatient psychiatric floor and could probably have two or three, in terms of need. We used to have a transitional care unit, which was closed because of poor reimbursement. I would love to have a long term acute care facility and a hospice facility, but I cannot because they would lose money, under the rules that apply if they are part of a hospital. We are not the only ones facing this, and so you see similar trends throughout Boston and the country. Even in the surgical field, one of our neighboring hospitals shut down their ophthalmic program because there were "higher value" surgical services that would otherwise use that space. And while we have a superb obstetrics department, with 5000 births per year, I have had to limit expansion because of the relative profitability compared to other types of care.
The current reimbursement environment is a relic of the past. With regard to mental health, I believe it embodies long-standing societal prejudices against people with mental illness. Other aspects of the system reflect other societal decisions. As a hospital executive, I have to balance the need for the hospital to stay solvent with our desire to be as helpful as possible to people with different types of medical problems. While we do all kinds of cross-subsidizing within the hospital, some services, inevitably, are not affordable.