My theory why small, regional hospitals are disappearing

During the course of the past ten years many smaller hospitals have either closed their doors or merged with larger hospitals. There are various reasons for this, but I think one of the main reasons is corporate cronyism. It's always existed to a certain degree, but it has been put on steroids since during the Obama administration. This is not a criticism of Obama, it's just an observation.

Okay, so money has always played a significant role in politics. You will always have corporations that make a lot of money, everybody always wants more (I don't care who you are) and the lure of making more money is always seductive. 

Now, I don't have a problem with corporations making lots of money, and I never will.  I believe there is plenty of money to go around, enough so that every person, every corporation, in the world could be rich if they made the effort; if they sacrificed their time, and took the risks.  I mean, that's what American Exceptionalism is all about. 

So you have corporate cronyism, or socialist cronyism, or capitalist cronyism, or whatever you want to call it.  This is where large corporations, those with a lot of money like Walmart, send lobbyists or consultants to Washington to make sure laws are passed that benefit them; laws that might help them make more money. 

It is in this regard that Walmart supported a higher minimum wage.  Walmart executives know that they can afford the higher wages, while many of their smaller competitors may not be able to afford it.  In this way, Walmart is able to beat their competitors without having to beat them in the marketplace.

In other words, even if Walmart competitors have a better product, Walmart can beat them because it can afford to make deals with politicians, while their competitors cannot. (Ironically, Walmart's profits have stagnated, and they are now blaming the minimum wage hike.  Go figure!)

This is the same in healthcare.  You have large hospital groups that can afford to send lobbyists and consultants to Washington. They can afford to make deals with politicians. They give thousands of dollars to this politician, or that politician.  They even support laws that they otherwise would not support because they know they can afford it.  

For instance, Obamacare has required hospitals to hire 20 or 30 new people just to make sure they are in compliance with all the new regulations. They can afford to make all the changes that are required, while their competitors cannot.

Not helping here is that Obamacare made it easier for hospitals to merge, almost encourages it.

Because they cannot afford it, smaller hospitals have had to make decisions to either close shop or be bought our or to merge.  It is by this means that large hospitals have become larger, and smaller, regional hospitals have become a thing of the past.

I'm not saying here that I agree with Obamacare or not, this is just what is happening, or has happened. Money is important to get elected and re-elected. Money is important to get your agenda passed, and right now, like it or now, Obama is selling. 

Buying laws is important to benefiting your business.  So, so long as this is legal, it will continue to occur. And, like it or not, it has occurred under the Obama administration more so than in the past.

Further reading:

• Forbes: What '60 Minutes' Didn't Say: Hospitals Will Charge You More Under Obamacare 
• National Review:  An Arm and a Leg

Why healthcare costs have increased since 2010

So large hospital groups have succeeded in beating out the competition by supporting big government, which in turn creates laws that create regulations that smaller hospitals cannot afford. This, in turn, causes their competitors to either close their doors, or they have no choice but to merge with the larger groups. This, in turn, has resulted in higher healthcare costs.

This is contrary to the promise that healthcare costs would go down under Obamacare. Yet Obamacare has made it easier to merge, and easier to charge high prices. In fact, Obamacare almost encourages it through incentives. Check out here some quotes from Forbes.com.

This has had a great impact on the healthcare industry.  This is how larger hospitals have beat out their competition -- gobbled up the competition -- without even having a better product, or regardless of having a better product.

Here's a quote from Forbes:

The average day spent in a U.S. hospital costs five times as much as it does in other industrialized countries. That’s not because U.S. hospitals use higher technology or better care. It’s because they charge more for the same technology and the same care. Because they can get away with it.

Making matters worse, as I noted above, is that Obamacare encourages hospitals to merge, giving hospitals an even greater incentive to charge higher prices. This is due to less competition. According to Forbes:

The next thing Obamacare does is it encourages hospitals to merge, thereby giving hospitals even more market power to charge even higher prices. A study by Jamie Robinson of the University of California found that highly concentrated hospital markets–where one or two hospitals controlled most of the patient volume—hospitals charged an average of 41 percent more for common procedures than they did in more competitive markets.

Furthermore, as noted by Forbes, since Obamacare there has been a spike in hospital mergers. Forbes noted:

The spike in hospital mergers is being driven by two things. The first is that Obamacare expands government-sponsored insurance, like Medicaid. Government insurance pays less than private insurance pays, so hospitals seek to merge so they can gain more leverage on private insurers to charge whatever they want. In 1993, for example, Harvard’s two main hospitals—Massachusetts General and Brigham and Women’s—merged, and immediately began jacking up prices to the privately insured and uninsured populations.

The second is that Obamacare creates a government program, called Accountable Care Organizations, whose explicit goal is to encourage hospitals to consolidate the provider industry, thereby giving them more leverage to charge higher prices. In 2011, a Federal Trade Commissioner called attention to this problem, noting that “the net result” of ACOs “may therefore be higher costs and lower quality health care.”

Some say that the best way to bring down prices is for Obamacare to add price controls. Although all that would do is cause hospitals to stop offering services that are under priced offer procedures that are over priced.

The real resolution to this problem is to try increasing competition, something that has never been tried in healthcare. This would entail breaking up the large hospital groups with antitrust proceedings, loosening up restrictions on hospitals, repealing Obamacare, and allowing the sale of health insurance and hospital services across state lines. This would get hospitals and insurance groups to compete with one another, and the ones that offered the best quality service at the lowest price would prevail.

Further reading:

• Forbes: What '60 Minutes' Didn't Say: Hospitals Will Charge You More Under Obamacare 
• National Review:  An Arm and a Leg 
• National Review: Hospitals are to blame for obscene healthcare costs

Contemplating large versus small hospital

It's been an arduous task to find inspiration for blog writing recently with a new baby and other children who need the attention of this father and RT. And yet, as I finally get back to work after three weeks off, I find that the patient load is still nearly non-existent. And, thus, the vacation -- in a way -- continues at work.

Yet it's still work of course. (When you are some place you don't want to be at 1:34 in the morning just so you can make money it's work).

It's ironic the way a hospital like this, that has seen it's busy days, can be so slow, yet I read the writings of other Rt bloggers, like the anonymous RT over at Respiratory Therapy 101, writing about how busy it is where he works to the point that he has no time to teach his student.

In an email to me about a year ago he pretty much summed up the difference between a large hospital and a small one like where I work: "There are definitely advantages to both paces though: a fast-paced place makes the day go by and lets you see a lot of intriguing things, but a slower-paced place has a friendlier atmosphere and you can often get to know your patients and co-workers better."

True. Another advantage to working for a smaller hospital is there is less staff. That means that you do not specialize in any one particular area. You are it. That means that you have to be the Ventilator expert in the critical care, the Intubation expert in the emergency room, the breathing treatment pawn who has to make sure all treatments are done on time, the Incentive spirometry expert, the ABG expert and anything else that might come up. You will never set your feet in one department.

You have to walk (well, all RTs do this). You have to climb stairs. You might even find yourself in the ambulance setting up an adult vent, and five minutes later in OB setting up a vent on a newborn infant, and then doing a breathing treatment on a patient in MRSA isolation, and then rushing to a code way downstairs in CT (arent' those the worst?).

Oh, and along with taking care of adults and adult vents, you also have to be able to swiftly and seamlessly shift your mindset over to pediatric care and neonatal care in a heartbeat. One moment you might be setting up a ventilator on an adult head bleed, and the next you might be setting up a newborn on a ventilator with a tital volume of 4 in pressure control.

The concept of taking care of neos and peds and adults is the same, but the way they are each set of on ventilators is different. The worse part about taking care of sick neonates and pediatrics at a small hospital is not setting them up on a ventilator, it's the fact that you hardly ever set them up. Therefore you have to practice and be ready. And, if needed, you need to have your cheat sheet available.

Still, 90% of the time, when you have a bad baby -- as I did last night -- you will not have your cheat sheet available. For some reason you will have set your clipboard down and not have it with you. The nurse -- if she wasn't so panicked -- would hear you curse, or do the Homer Simpson, "Doh!" You will then have to go by the wisdom you have wrapped up in the back of your mind.

The anonymous is RT right, though, that working for a small town hospital allows more time for the small things like spending quality time with our patients. However I'm sure there are times that the best RTs can find time to do this in larger hospitals too. This is where prioritizing and protocols come in handy (of course some doctors can hamper those things too I bet).

Keep in mind, however, that if we RTs have more time for small things, the RT Bosses also have more time to make a big deal when the small things are not charted properly. After all, in a small town hospital patients are harder to come by, and that means money is often on shorter supply (hence the difference in wages). And that can be the most frustrating part of the job -- along with the dreaded hospital politics (of course there's politics with every job don't forget.)

Sometimes I think I would like the change of pace of working for a large hospital. It's not that I would like feet that burned in the morning, but knowing that I will only have to work one area of the hospital one night instead of everything and everywhere. It would be nice knowing that I didn't have to work ER EVERY night. It would be nice to JUST do ABGs, or JUST intubate, or JUST work the critical care. Just once that would be nice.

It would be also nice, as the anonymous RT wrote, to see more things. Instead wrapping and stabilizing the head trauma and the head bleed or massive MI, it would be nice to keep those patients and see how things turn out.

But keep in mind --all you RTs who receive the patients we smaller hospitals ship, it's equally hard to stabilize and ship. The hardest part is HIPPA, and never getting an update on how the patient is doing, or at least how well we did at packaging the patient up. (However I've never heard a complaint either).

Most larger hospitals -- as far as I know -- tend to be more up to date when it comes to the latest equipment and technology and wisdom. We small town hospitals -- I honestly think -- tend to be 10 years behind. We still use the Bird IPPB for example (thankfully not as often anymore) while the larger hospitals sent those things to Ethiopia 12 years ago. Plus you guys get paid better (unless you own us).

There are many times I look forward to going to work just so I can relax. Can you imagine that? I bet no RT from a large hospital would ever be caught dead saying that. Yes. As I said, it's pretty hectic around my house right now with that new baby. And coming to work with only four patients and a (fingers crossed) slow ER of late is something to look forward to (why the heck is it so slow lately? That's a discussion for tomorrow night perhaps).

So, here I sit listening to Aerosmith on the radio, looking out at the patient and staff parking lots nearly empty of cars as most of the beds are NOT filled with respiratory patients. I'm leaning back in my chair with my feat up on the top of the computer typing away on my frivolous and for the most part senseless RT blog -- and getting paid for it. That's something you'd never hear a large hospital RT saying either.

But I work alone. You can't do this on day shift at a small hospital either. You have to hide out. But only until the bosses leave. Ah, the advantages of working for a small town hospital are tremendous. If you can find something to do; if you like to gossip (which I don't); if you like to socialize (which I'm not so good at); if you like to blog (ah, there you have me), if you like to read (you got me there too).

This is one of the nice things about capitalism is you get to choose between so many different environments -- big or small, busy or slow, friendly or not so friendly. And, at times, all hospitals share all four environments, as we sometimes get as busy as a large city hospital. But not lately. Lately it's been slow as a frozen snail. Yet I'm not complaining.

That, my friends, is the thought of the day.