Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Sunday, January 11, 2009

Why Not Run Hospitals Like Firehouses?

Have you noticed that everyone always says the same thing whenever there's a true medical emergency: "Go to the nearest hospital."

This implies that a hospital -- any hospital -- is qualified to provide some basic level of medical care. In fact, with all the assorted evidence-driven protocols out there these days, that assertion isn't too far off. So why is there so much duplication of effort? There are so many hospitals in such close proximity that they're all squabbling over the same patients -- and spending mega-bucks on advertising and other publicity campaigns. Why not make hospital care on par with protection from the fire department?

Each neighborhood has its own firehouse, charged with protecting a given geographic area of the community. There are uniform policies from one department to another. When necessary, they share resources, generally working well together. Because the training is generally similar from one company to another, you don't have huge, expensive advertising campaigns touting the superiority of the Main Street Fire Company over the one on Church Street. Where you live determines which firehouse protects you. If you do happen to have a preference, then you make it a point to live in proximity to your preferred fire company; just like researching the schools when you buy a house.

What if each community were in charge of providing hospital care? Hospitals would be funded like fire and police departments, provided with a set annual budget that would cover all medical services provided there, including the services of hospitalists, emergency physicians, anesthesiologists, radiologists, pathologists and so on. Think of it as the ultimate in capitation: pre-paid care at the community level.

Get rid of JCAHO and put a federal cap on pain and suffering awards for malpractice (which is working great in Texas) so that the only documenting you had to do would be what you really need to take care of the patient. Implement a nation-wide computerized Personal Health Record (not technically the same as an EMR) to avoid duplication of studies from one institution to another and you're in business. Everyone working there earns a decent living. The only difference is that there's no profiteering from cherry-picking better insurances or healthier people.

Think about it: no more coding or billing for anything received in a hospital. Doctors could see patients as many or as few times a day as they needed. Nurses could actually care for patients instead of wasting seven hours of their eight-hour shift documenting. All those Utilization Review nurses would be out of a job; actually, they could hit the floors and actually go back to nursing.

How to pay for all this? Once you eliminate the need for all that advertising and redundant administration, there would be plenty left to pay doctors, nurses and people who actually take care of patients.

So what's stopping all this? I guess there are enough people who think things are working just fine the way they are. Too bad it's mainly administrators, PR firms creating all those marketing campaigns and other folks who aren't actually involved in providing medical care. As long as there's so much money to be made with the status quo, I suppose patients and the people who care for them are just out of luck.


At Sun Jan 11, 03:26:00 PM, Blogger Unknown said...

Well, I certainly won't argue that there are problems, and that advertising, litigation and inefficient paperwork are contributing to them, but there is a fundamental difference between hospitals and firehouses: If a small fire starts in your house, have you ever been tempted to jack it up and move it to a city with a better fire department? Even with a mobile home, I don't see that happening. People, on the other hand, not only can travel, they normally do travel, quite a bit. So either you will have the problem that people who get sick while on vacation have to fly home if they want health care, or you have the problem of people choosing to live in a place where the cost (and quality) of health care is low, and if they get sick, taking a "special" vacation to a place with high-quality health care that they've had no part in paying for.

Health care is one of those things that's horribly frustrating, because it definitely could be made so very much better and more efficient and effective, but doing so is difficult for two reasons. First, the answers are complex. Second, there is so much money and power involved that it's hard to distinguish truth from propaganda. And third (ok, sometimes I'm not good at counting), it's a situation where it's very easy to have a solution that's good for nearly everyone in competition with a solution that's better for most, in competition with one that's best for some. In those cases, even if everyone is honest, it's hard to say what the right choice is.

At Sun Jan 11, 03:42:00 PM, Anonymous Anonymous said...

Great idea with obvious and practical benefits. For those reasons alone it'll never happen, not to mention the other reasons having more to do with politics than with anything useful.
Chuck Brooks
FutureWare SCG

At Sun Jan 11, 05:45:00 PM, Blogger GeorgeH said...

Maybe because competition is what drives humans to be superior.
Where are the great hospitals? They are places like Houston where there are multiple medical schools, and multiple specialty hospitals fighting for patients, money and reputation.

Firehouses have held up pretty well, but my guess is that hospitals would decline pretty quickly to the level of public schools. Look at what is left of medicine in what used to be England.

At Sun Jan 11, 07:57:00 PM, Blogger Nurse K said...

So what's stopping all this?


At Sun Jan 11, 10:49:00 PM, Blogger Lisa said...

This is an interesting idea, but there are some questions with it. Such as the one listed above regarding people being on vacation. If you life on one side of town, say for a church or a school, but you work on another, which hospital do you go to in an life threating emergency? Are hospitals in lower income areas funded at the same level that hospitals in affluent areas? If they aren't "why are those rich people getting better care?" If they are "why should we be expected to underwrite the medical care for all of those poor people?" My cardiologist is one of three in the city who is an expert in the heart condition that I have. My oncologist does the studies for the medications that I take. My nephrologist is just generally a very good doctor and he works well with my cardiologist. They practice in two different areas of the city. Whose district should I move into? Still, it's a very good idea.

At Sun Jan 11, 11:54:00 PM, Blogger Anne said...

It's an interesting thought. But, how would you fit something like a trauma center into this picture? Requires a lot of money to maintain a good level I trauma center, and many communities can't support such. Seattle has the only Level I trauma and burn center for 4 states. What counts as a community?

At Mon Jan 12, 04:06:00 AM, Blogger The Happy Hospitalist said...

Dr Dinosaur, Have you been reading some of Happy's old stuff?

It's OK If You Were

At Mon Jan 12, 04:18:00 PM, Anonymous Anonymous said...

As a consumer rather than a provider, I like this idea. At least it is an idea. Doctors seem to complain endlessly (and justifiably) about the state of healthcare in the US, but few seem to come up with any solutions.

Of course people will travel to other areas. No solution is perfect. If you wait around for that, you'll be waiting forever.

At Tue Jan 13, 10:59:00 AM, Blogger Bookhorde said...

Sounds good to me!!!!!

(And some infectious diseases are rather like fires, too, come to think of it. )

At Tue Jan 13, 04:31:00 PM, Anonymous Anonymous said...

Oooh that's almost socialist.


From a proud Canadian, with a smattering of not otherwise obvious sarcasm.

At Tue Jan 13, 09:01:00 PM, Anonymous Anonymous said...

Well the simple problem with your argument is that all volunteer fire departments are 70.1% of the total in the US. Care to volunteer some time at your local hospital Dino?

At Fri Jan 16, 06:24:00 AM, Anonymous Anonymous said...

I could go for local primary care clinics but anything more will results in every neighborhood thinking they need the latest and greatest at their facility and it'll cost a fortune.

How many times have I walked past a minor fender-bender and had to stop because three fire engines and rescue vehicles, from three nearby jurisdictions are rushing to the scene - all in their 8 mpg trucks that I'm funding?

Here in MD/DC where I live people who live in DC contribute to the Chevy Chase Rescue Squad (part of a Firehouse) in MD and keep that number on their fridge so they can avoid calling 911 and getting the DC squad. Perhaps you read the story of David Rosenbaum the late NYT journalist, who was mugged, picked up by the DC squad, taken halfway across the city because the EMT wanted to swing by her apartment and get some Vicodin for her toothache, parked in a very busy ER, forgotten until he started convulsing from his un-noticed headwound?

So no - I love Firemen, still have the red plastic hat my son got at a visit to the FireHouse, but think health care has enough problems already.

At Fri Jan 16, 07:38:00 AM, Anonymous Anonymous said...

Hmmm. Imagine if all those fire departments were not public and imagine if fire departments could compete for your service (your monthly fee, for example). Actually, I think I would like THAT. Imagine if there were competition in putting out fires, innovation, new technology, etc.. - you've really opened up my eyes.

At Fri Jan 16, 03:15:00 PM, Blogger Beach Bum said...

I wrote some thoughts that take off from this post.

At Sat Jan 17, 09:18:00 AM, Anonymous Anonymous said...

The first thing that would happen is that people in less prosperous neighborhoods would file lawsuits because your hospital is better than their hospital. They will accuse you of being mean and discriminatory, and perhaps genocidal for not providing equally expensive health care for the poor. Remember what happened with the schools. It would be a lot more serious if you didn't give people their choice in health care.

At Sun Jan 18, 06:20:00 AM, Anonymous Anonymous said...

I think your idea is one that would work if only all communities where created equal. The funding would have to come from the Fed and be based on a per person per year average. The average would have to take into account age, economic statues and many other variables to determine the operating budget.

I support universal single payer health care and believe that at least in spirit you are on the right track.

Michael Chapman, RN

At Mon Jan 19, 09:28:00 PM, Anonymous Anonymous said...

GETTING RID OF JCAHO ... my fantasy
Can I be the First to notify them of their demise???? their hairbrained ideas have caused me more mental anguish than you will ever know., off to the paperwork,to hell with patient care, just document document document....
RN of 30 yrs +
as for the firehall idea. I'm in.

At Fri Aug 07, 07:53:00 AM, Anonymous Anonymous said...

England - we already done that.
Anyone want a NHS? It was ok when it only included essential care, but now if your doc signs off that you'll go mad if you don't get a boob job, you can get one of those, or a sex change, or infertility treatment etc etc. The NHS should only be for essential care - not for cosmetic treatments or other stuff you can't be bothered to save up for. And I don't care if it does make you depressed.

At Sat Sep 12, 09:38:00 AM, Anonymous Anonymous said...

There is healthy competition and decision-making in schools, fire, police and libraries. There is healthy competition in post office, who btw DOES use FedEx and UPS for very healthy economic reasons. There is plenty of trouble with Socialism, Capitalism and Religion just on the face, that any true change has to come from the very foundation of federal, state and local governments.

Healthcare professionals are paid along the the entire spectrum -- just as are teachers, firemen and police. The post office and other federal employees are paid a little more uniformly, or so it seems, but still along the spectrum of region, state and local levels.

In our hearts, we all want to see change. If bickering about $1.2 trillion vs. $900 billion is going to halt foundational reform, the foundation is cracking without the number crunchers on the 20th floor even feeling the tremors.

To take the analogy further, with your patience, why are cement workers, IT geeks, receptions and all the others who work between the furnace room and the 20th floor there?

That is why there are teachers who get paid a lot and those who get paid what the community can afford. Why some communities have volunteer firefighters and others are highly train, Trauma 1 specialists.

We all make choices at an independent level, based on our individual families' priorities.

No extreme words, please. My thoughts are much too mundane to excite the vitriol and hatred of name callers and the like.

Let's start at the bottom, together. Thanks, Dr Dino, for starting this train of thought.


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