Around the Web

A survey this year found that only 2% of all graduating medical students plan on going into primary care, because of the grinding hours and relatively low pay. Primary care, considered the backbone of American medicine, is crumbling nationwide from an increasing demand of aging boomers and a decreasing supply of physicians. Some healthcare reformers say the need for the medical home model of primary care is huge.

Hospital CEOs tend to be mission-oriented people. They chose a career in healthcare to make a difference. Maybe they can't always provide every service line they wish they could provide, but they can, however, set the tone of the organization when it comes to caring for the community. Do you welcome all patients regardless of financial status and ethnicity? Yes, hospitals are required to provide emergency services to all patients regardless of their ability to pay. But that's not what I'm talking about.

The cornerstone of hospital mission statements nationwide is to provide quality healthcare to the community. But which members of the community? For instance, it's one thing to have a charity care policy, but if the patients who genuinely need charity care don't know about it, the system of care is difficult to navigate, and if financial assistance or counseling are not freely offered, then the underlying message is, "We really don't want you here." As a result, these patients will often seek care elsewhere or not at all.

I can hear the response: "We offer charity care, and we treat everyone who walks through these doors exactly the same." That may be true. What is also true, however, is that hospitals are, in effect, discouraging indigent, uninsured, and underinsured patients from walking through the doors in the first place if they focus all of their community outreach efforts in nearby affluent neighborhoods, don't volunteer information about charity care policies, or simply don't offer culturally sensitive services.

I read an article in the Wall Street Journal earlier this week about Mount Sinai Hospital in Chicago, which has become a safety-net institution for many of Chicago's disadvantaged residents. Reportedly, the hospital's demographics shifted dramatically in the 1960s as its Eastern European Jewish patient base relocated to the suburbs. The neighborhood's new African American population didn't feel welcome at Mount Sinai—warranted or not—and as a result traveled farther away to seek care, said former CEO Ruth Rothstein. So in the early 1970s, the board of trustees and senior leaders made the decision to renew the hospital's commitment to the community. That meant joining community organizations and launching programs to help these new members of their community.

It also meant becoming the place where disadvantaged residents felt welcome, resulting in tighter operating margins. Choosing to stay in a certain community rather than relocating to more affluent suburbs is a commendable choice. However, I can't fault other organizations for not wanting to become the de facto safety-net institution; a jump in the number of Medicaid or uninsured patients can threaten the long-term viability of just about any organization. I also can't blame hospitals for seeking out patients who are insured and can afford to pay. It's good business. What CEOs wouldn't like a more favorable patient mix? It makes things easier.

At the same time, it also places the burden of caring for the indigent in the hands of fewer healthcare institutions and restricts access to care for the patients themselves.

During the past few months, I've written about how the economic crisis is impacting the hospital industry—hospitals are laying off employees, cutting services, postponing construction projects, and even closing. Although hospitals may be taking necessary steps to ensure their long-term viability—after all, some services are better than no services—ultimately it's the patients who suffer. At least when a hospital closes there is a visibility to it, Dennis P. Andrulis, PhD, MPH, director of the Center for Health Equality and associate dean of research at Drexel University School of Public Health, told me earlier this year. It's when services slowly start disintegrating that patients can fall through the cracks, quality of care may suffer, and disparities in healthcare can increase, he says. "Part of the business of healthcare is related to an obligation to do good and try to help those who need assistance."

If the decision is to a) close the obstetric unit or b) close the hospital, I think the community at large would vote for option A. But if the decision to close the obstetric unit is entirely based on improving the bottom line, then that is a little more subjective. How many days cash on hand is worth cutting a service to the community? That's an enormously difficult question to answer, as hospital executives facing painful decisions in these challenging times can attest. I certainly don't have the answer. But hospitals not in imminent danger of closing should at least consider a third option: keep the service line and accept a narrower margin. That may not always be possible—and it definitely falls into the "easier said than done" category. But easy or not, it may be the right thing to do for your community.