Can Care and Community Continue to Co-Exist?

The news that the Cleveland Clinic is closing Huron Hospital in East Cleveland (NY Times, June 7) is the latest evidence of the dramatic changes transforming the U.S. health care system. Rising costs, an aging population, shortages of nurses and primary care physicians, and the emerging implementation of the Affordable Care Act of 2010 are among the forces radically reshaping the landscape for everyone from patients to payers, caregivers, and community leaders.  A shuttered hospital is just the tip of the iceberg.

Earlier this year the venerable St. Vincent’s Hospital in New York closed its doors forever after years of financial difficulty. In Boston, the Caritas Christi Health Care network of hospitals was acquired by a venture capital firm in 2010 and moved from non-profit to for-profit status. Institutional consolidation is on the rise. The local hospital, long a nexus of both care and community in cities and towns across the country, may be an endangered species.  We cannot – and certainly may not want – to stop change  but we can approach it intentionally and thoughtfully.

These alterations, some good, some bad, and some simply inevitable, are a crucible for examining the many health care relationships that are now being renegotiated. Community hospitals have been under financial pressure for years – must they maintain services and capacity which cause them to lose money simply because the community takes comfort in their presence and convenience? How will the move from mission-driven to profit-seeking change patient,  employee, and community expectations and experience? Where will vulnerable populations turn for care? As more and more services can be delivered through technology, where will humans fit in the health care system?

Each of these changes are interrelated:  Americans are getting older – baby boomers are entering their most health care-intensive years and driving up demand. Facilities competing for these patients invest in expensive new buildings and equipment to attract them (and to lure top talent). They need money to build those castles of care and pay those professionals, and so turn to outside investors who, naturally, expect returns on their investments. Insurers, including the federal government, try in turn to hold down costs by limiting reimbursement for specific services – yet patients demand the latest tests and procedures which keeps the cycle going.  As health care negotiators with more than 50 years of collective experience, we have seen these dynamics many times but never on the scale on which they are manifest today.

Somewhere in this maelstrom we may be losing the clarity of purpose and values that we have treasured in the current, imperfect system: doctors who take an oath to “first, do no harm”; nurses who pledge themselves to “the welfare of those committed to my care”; community hospitals that would not turn away patients no matter their financial status, insurers who would pay for needed care, and patients who could trust that their treatment was best for them, not least costly or most profitable for those providing or paying for the care.

The current system is unsustainable. We must, however, be certain that from the many ideas offered for reform we design a health care system that serves all stakeholders. Do we really want Congress – or venture capitalists or insurance company executives  to design the details of the next incarnation of our health care system? Certainly not. Yet as much as the public rails against each of these groups we must acknowledge that they must be part of the solution. So, too, must physicians, nurses, technicians, attorneys, administrators, activists, and, yes, patients.

We are beginning to see this in bottom up change to the system: the rise of solo medical practitioners  like Dr. L. Gordon Moore who dramatically streamline their practices – foregoing receptionists and billing clerks – in order to make spending time with their patients financially viable. A hospital system in Wisconsin that has engaged Dr. Pamela Wible to help it redesign itself through a series of open meetings at which all stakeholders are invited to answer the question,  “What does an ideal hospital look and feel like for you?”

Complex systems must emerge; they cannot be imposed. In East Cleveland, and across the country, we must come together to negotiate – engaging in collaborative problem solving that recognizes that our needs are changing as are our methods for meeting them –  to achieve a system that is as compassionate as it is cost efficient and cutting edge.

Dr. Leonard Marcus and Dr. Barry Dorn also contributed to this post.

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