Tuesday, August 16, 2011

Time to talk for the common good

Over a decade ago, a common refrain was that there were too many tertiary care/academic medical centers in Boston.  Of course, that comment often came from the dominant hospital system and the most prestigious medical school in town, but not exclusively.  The conversation would then continue to the question of which one was surplus.  BIDMC was in financial trouble, so some assumed it would be the one to go.  Indeed, as I have related, the then-Attorney General was pressuring the organization to sell itself to a for-profit and drop its teaching and research mission.  Others assumed it should be Tufts-New England Medical Center, which also had had financial problems.  Still others assumed it should be St. Elizabeth's Hospital, the flagship of the Caritas Christi system.

By the way, the rationale for choosing "favorites" in this unfortunate race generally had no substantive basis.  All of those centers have experienced and dedicated and highly competent staff and excellent records of clinical care and academic programs.  Indeed, in another city without a tertiary hospital, any one of them would have been considered a highly desirable asset for the community.  But underlying prejudice, arrogance, contempt, and old grudges often formed the basis for many opinions on the matter.

Over the years, the ranking of candidates for extinction changed.  BIDMC has had a successful turn-around and many continuous years of profitable operations and has gained substantial market share, while expanding its research and education programs.  It is clearly out of the woods.  Likewise, strong administrative and medical leadership at Tufts Medical Center has stabilized that organization and created new clinical affiliations with referring physicians in the region.  But St. E's continues to show weakness.  Its clinical volumes are down, and residents reportedly need to go to other hospitals to get sufficient surgical experience to meet their training requirements.

But, none of this suggests that the initial premise was valid, that there are too many such facilities in Boston.  Each of these institutions brings something important to the region.  The question is not whether one should cease to exist.  The question is how to rationalize the mix of clinical care, teaching, and research across all of them to create increased value for the community.  Ultimately, that requires, too, a rationalization of the functions and services of the medical schools in the city, for the teaching activities of these tertiary centers are important components of their added value.

Would it be possible, among these highly competitive hospitals and medical schools, to share resources, to allocate clinical programs for the greater public good, and to engage in truly cooperative undergraduate and graduate medical education?  I don't know, but I am reasonably sure that, absent such a joint effort, the extinction of one of the members of this elite club is likely to occur.  Therefore, the conversation is worth having and should be at the top of the agenda of the university presidents and medical school deans, along with their hospital counterparts.


Barry Carol said...

One problem, I think, with regional resource sharing by AMC’s is the wide variance in the profitability of various services. Everyone wants to do as much of the well paid work as possible. While you would know better than I, I’m told that hospitals make most of their inpatient profits from surgical procedures and cancer treatment. They usually lose money on trauma care and don’t make much from OBGYN, mental health and low to moderate acuity medical (as opposed to surgical) cases.

I also suspect that the very presence of AMC’s increases healthcare costs as patients choose to access routine care at the high cost AMC because they perceive it as “better” care rather than at a much more cost-effective community hospital that can provide the routine care just as well. If there are more AMC’s in Boston than a rational marketplace can support financially, one or more of them probably should disappear or at least downsize and narrow their focus.

Anonymous said...

Paul, I have long admired you for seemingly tilting at windmills and then actually effecting change - but I fear you have met your match in the halls of Boston medical academia. Since not even the hospitals affiliated with Harvard appear to be willing to cooperate, how on earth could all the medical schools get together?
Once, on vacation in FL, I took a photograph of a giant (10 ft) pig with wings sitting in someone's front yard - I fear that when that pig flies, only then will the Boston academics cooperate.
And BTW, this is the view from outside Boston.

nonlocal MD

Howard said...

I agree with your comments about talking for the common good. I suspect that one of the things that has prevented such conversations occurring is the lawyers raising concerns about anti-trust concerns.
The Sherman Act enacted in 1890 has prevented any progress from being made in health care at a time when collaboration between hospitals and between hospitals and physicians is crucial to maintaining the delivery of quality health care at reasonable costs.

Paul Levy said...

The kind of thing I am discussing would be unlikely to violate the law; but, in any event, you can be protected by inviting someone from the AG's office to attend.