The importance of community in an age of high tech, specialized medicine
Image taken from Flickr user Andrew Stawarz
by David Morris
By arrangement with On the Commons
As the rightly acclaimed TV series Downton Abbey unspools its final episode some fans have criticized the producers decision to devote so much time to a debate about the future of Downton’s Cottage Hospital. The show makes the issue mostly personal with delightfully snippy exchanges between Violet, Dowager Countess of Grantham who speaks for a way of life that is passing, and her relative Isobel, a nurse and daughter of physicians, who is the voice of modernity. But underneath the repartee lies a serious and persistent issue: what should be the relationship of the community to health care in the emerging age of high tech, highly capitalized and highly specialized medical systems?
As Mary Kay Clunies-Ross, Senior Vice President of the Washington State Hospital Association, who has taken a keen interest in the show told me, “They’re asking the right questions. Who will be in charge? Will someone tell me what to do? Will we be able to continue to provide free care?”
The US and British health systems, while dramatically different, have had to grapple with these same questions. And in their exploration they’ve discovered that a case can be made for big and for small, but the weight of evidence suggests that the optimum medical configuration is when high tech and specialization are in service to responsible and accountable community hospitals.
In 1859, in real life, Albert Napper opened the first cottage hospital in Cranley, England. As Doctor Irvine Loudon at Oxford University
By 1925, the year in which the final season of the TV series is set, these sort of voluntary hospitals constituted about
40 percentof all hospitals in the UK.
In a very early episode in the series a farmer John Drake was admitted to the hospital with a terminal case of Dropsy. Isobel suggested to a Doctor Clarkson they use a very new technique. He reluctantly agreed and Drake promptly revived. By 1925, the year in which the final season of the TV series is set, these sort of voluntary hospitals constituted about 40 percent of all hospitals in the UK. They were largely supported by contributions and staffed with volunteers. There were government hospitals as well: The infirmaries that grew out of the much-despised workhouses of the 19th century. But to many people these remained unwelcome venue.
In 1913 the Liberal/Labour party coalition passed a law that gave a cash benefit to workers ages sixteen through seventy, who earned below the poverty level and the right to receive medical treatment at no cost. (These benefits did not extend to their spouses or children.)
Early in the series Isobel asks Robert, Earl of Grantham, how the Downton Cottage Hospital was financed. He notes that his father had given the land and building and established an endowment and then he adds, “Mr. Lloyd George’s new insurance measures will help.” Violet is aghast. “Please don’t speak that man’s name, we are about to eat,” she archly announces.
By 1925, despite the infusion of government money, cottage hospitals were still suffering losses. Demand was up while charitable contributions were stagnating, in part the result of the decline of the landed aristocracy. Meanwhile the price of medical equipment was climbing.
Most hospitals filled the financial hole by introducing subscription medicine, a form of local self-insurance. Many of these systems were based in the workplace. Some hospitals doubled down on their efforts to gain contributions. The Granthams of Downton Abbey have responded by opening their castle to paying visitors as a benefit for the hospital.
Some cottage hospitals merged with bigger regional hospitals. That is the focus of the ongoing debate in Downton Abbey. Will their cottage hospital merge with the larger Royal Yorkshire Hospital?
Some communities converted their voluntary hospital into a municipal hospital. That is what happened in real life when the city council of Bradford, located about thirty miles south of Downton’s village of Ripon took over the running of hospital services in 1920.
Socialized Medicine and Community Hospitals
A Gallup poll in July 1944
That the NHS began operation on the American day of Independence would probably have struck Violet as a cruel joke. For to her it was a declaration of slavery, a sentiment that would make her comfortable with current Tea Party philosophy. Indeed, in 1961 Ronald Reagan opposed Medicare with a
The NHS made it possible for cottage hospitals to survive. But it didn’t make their survival inevitable. British health policymakers were unsure about community hospitals. At almost every turn they undervalued their benefits and overvalued the benefits of centralization. In the 1990s the NHS announced a wave of hospital closures. Communities fought back with equal resolve, writing petitions, packing public meetings, marches. Some were successful. Others were not. In Odiham a four-year battle against the closure of its community hospital
The town of Rye, East Sussex, after discovering that its pleadings fell on deaf ears in Whitehall, took matters into its own hands, bought the local hospital and land, improved it and managed it. That protest had the benefit of being led by a local resident named Sir Paul McCartney, who gave a million pounds to the community’s initiative. “My mother was a nurse,” McCartney
British support for community hospitals has waxed and waned and waxed. In 2006 a headline in The Independent newspaper
But even while criticizing large, impersonal institutions for robbing people of “dignity and compassion” the current Conservative Party government has cut another 20 percent from the NHS budget. Dr. Mark Porter, the Chair of the British Medical Association’s hospital consultants committee
Community Hospitals in the United States
The United States hospital system began much as it had in the United Kingdom—as a charitable, often church-related institution governed locally and staffed by volunteers.
A bill for national health insurance made significant headway in Congress about the same time the British Parliament enacted their first worker-based health insurance benefit, which had been pioneered in Germany. The plan ultimately failed when WWI made all things German distasteful and the 1920s Red Scare undermined any further efforts. In 1946 Republicans took control of Congress, in part by charging that Truman’s proposal for a single egalitarian medical system that included all classes (and races) was socialism. After Truman’s surprise victory in 1948, he doubled down on national health insurance. The American Medical Association
At the same time the British were rolling out the world’s first free universal health system based on citizenship, not premiums or payroll taxes, Truman’s plan died in a Congressional Committee. No political party in America ever again embraced a universal, national health insurance system.
Since 2010 more than fifty rural hospitals have closed and over 280 across thirty-nine states are vulnerable to closure.
After World War II Congress appropriated billions of dollars to build hundreds of mostly rural community hospitals. Many of these are now threatened. Since 2010 more than fifty rural hospitals have closed and over 280 across thirty-nine states are vulnerable to closure.
In big cities community hospitals built a century before are closing. Detroit boasted dozens of hospitals in the 1960s. It now has four. Since 1988, Milwaukee County has lost its public hospital and five city hospitals. Since 1990 New York has lost more than twenty hospitals even as its population has grown.
From 1999 to 2008,
Adding insult to concentration, most closures are occurring in poorer communities and in communities of color even while new fully equipped hospitals continue to open in wealthier suburbs.
Federal rules are complicit in undermining the financial stability of community hospitals. The original Affordable Care Act (Obamacare) required states to expand Medicaid. The law also reduced federal payments that hospitals previously used to cover their costs of providing care to the indigent because the federal government believed many of those poor patients would now be under Medicaid. Tragically, the Supreme Court declared that provision of the health care law unconstitutional and almost half the states have refused to expand Medicaid. The result is that in 2016 their hospitals will begin to lose federal revenues, putting a significant strain on hospitals, especially in rural areas. In states that have expanded Medicaid, 8.5 percent of rural hospitals are vulnerable to closure, nearly double the rate in states that refused to expand Medicaid, where 16.5 percent of rural hospitals are vulnerable to closure,
Hospital administrators complain about too low reimbursement rates from federal health care programs. As one administrator told USA Today, “Commercial insurers reimburse the hospital $1.33 for every dollar spent on a patient, on average, while Medicare pays about eighty-three cents for every dollar spent, and Medicaid pays eighty cents for every dollar spent.”
Many independent hospitals lack the clout to get higher payments from insurers and steeper discounts from suppliers because they aren’t part of larger hospital systems, another peculiar aspect of the US medical system.
The Benefits of Local
Some argue that the closure of community hospitals has not negatively affected health outcomes, but those working in these hospitals vehemently disagree. One community hospital physician responded that this view “does not resemble my real world.” The medical profession talks about the “golden hour” after heart attacks, trauma and stroke in which treatment is needed to prevent loss of heart muscle and brain tissue. Closing community hospitals often eliminates the ability to provide critical medical care within that hour.
The anecdotal information about the health impacts of closing community hospitals is not insignificant. Stewart-Webster Hospital had served the small town of Richland Georgia and surrounding farms for more than six decades. With only a week’s notice it shut its doors in 2013.
A month after it closed Farmer Buren “Bill” Jones, fifty-two,
“I have heard our little hospital called a Band-Aid station,” But that little Band-Aid station saved my father’s life two times after heart attacks,” says Mike Pryor, judge-executive of Nicholas County Ky., which lost its small, rural hospital a few months before.
Six days after a nearby hospital closed in Bellhaven, North Carolina, Portia Gibbs
Empirical evidence suggests that smaller and more localized institutions increase operating efficiencies while not reducing quality. In 1976 one British doctor commonsensically
To which one might add that new clinical and technological developments mean that services such as kidney dialysis, ultrasound and MRI scanning can be offered in small hospitals.
Studies looking at the comparative efficiency of big and small hospitals ignore the direct and indirect economic impact of a community hospital. Directly it tends to be one of the largest employers in town, especially in rural areas. Indirectly, economic development is hurt because of the negative image to businesses of communities lacking a hospital.
Studies also ignore the substantial community-wide out of pocket savings of more localized medical attention (e.g. extra driving time and expense). And they ignore the also substantial collateral damage of community hospital closures. In 2005 University of California researchers looked at hospital closures in LA County between 1997 and 2002. Joe R. Hicks, Vice President of Los Angeles based Community Advocates Inc.
And then there is the unquantifiable satisfaction from the peace of mind of having a medical facility nearby where you know the personnel.
Doctors too have lost their independence and autonomy. Hospitals have been on a buying spree of independent physician practices for a decade. Why? Federal rules allow an office visit with a physician in a hospital outpatient department to be reimbursed at a rate 80 percent higher than the same procedure performed in a physician’s office. In May 2013, The Denver Post
“Hospital acquisition of physician practices leads to higher prices,” the Robert Wood Johnson Foundation
The majority of American physicians are employees instead of owners.
“Doctors really don’t want to sell their practices,”
In 2014 Medical Economics magazine intriguingly
Obamacare and Community Hospitals
All of which brings back the key question: what is the optimum configuration of a medical system? Most might embrace the vision of a network of well-equipped and locally owned or controlled hospitals that are part of regional networks of larger more capital-intensive hospitals that focus on specialized treatments.
The new buzzword in the medical community is “affiliation.” The key, as both Violet and Isobel might agree, is how to affiliate in a way that maintains local control and patient intimacy while adding access to specialized treatments and expensive technologies. Cooperative agreements come in hundreds of varieties. Mary Kay Clunies-Ross of the Washington Hospital Association notes a common joke among health policymakers, “If you’ve seen one affiliation you’ve seen one affiliation”.
One of the key strategies the Affordable Care Act has embraced to reduce health care costs is by encouraging Accountable Care Organizations (ACO), networks of doctors and hospitals that share financial and medical responsibility for providing coordinated care to patients in hopes of limiting unnecessary spending. The focus is on Medicare because it is a single payer insurance program where the government can establish the rules directly. Each ACO has to manage the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years. At the heart of each patient’s care is a primary care physician.
While ACOs are touted as a way to help fix an inefficient payment system that rewards more, not better, care, some economists warn they could lead to greater consolidation in the health care industry, which could allow some providers to charge more if they’re the only game in town.
Kaiser Health News
It is clear that Downton Abbey’s cottage hospital will merge with Royal Yorkshire Hospital. Viewers will never discover what happens then. When a hospital is taken over by a system, the parent company typically replaces local board members. Physicians may end up with less say. “If you have a strong parent, they make all the decisions,”
David Morris is co-founder and vice president of the Minneapolis- and DC-based Institute for Local Self-Reliance and directs its Public Good Initiative. His books include The New City-States and We Must Make Haste Slowly: The Process of Revolution in Chile.