To appreciate how difficult it will be to solve the complex and interwoven problems besetting hospitals in Western New York, consider just a couple of basic questions: What are hospitals? And what is health care?
Neither answer is as obvious as it may seem, but both are tied up in the economic mess that has produced a catalog of absurdities, but none more destructive than this: Western New Yorkers have agreed to underwrite second-class care.
Hospitals are not what they once were. Faced with declining revenue, a sicker patient base and unprecedented oversight -- or interference, depending on your point of view -- from insurance companies, hospitals are changing, but changing into what? The answer is unclear.
The basic product remains health care, of course, but how do we define that? Is health care a right, like voting? Is it a public good, like highways and police departments? Or is it simply a commodity, like soft drinks or cell phones?
Add to those academic questions several others of a more practical nature: Should governments pay more than they do for treatment of Medicare and Medicaid patients? Should private insurers be pressured to increase the rates they pay hospitals, especially in Western New York, where reimbursements are significantly lower than those paid in other regions? Should hospitals that perform more surgeries than comparable facilities, or that keep patients longer, or that deliver substandard care expect to be penalized for their practices?
All are important, difficult issues in Western New York, where rates of surgery are high, where patients do tend to stay longer, where mortality rates are disturbing and where hospitals are paid less than other regions in New York for identical procedures. These problems, and dozens of others, are so dense and intractable that the temptation is to shrug and walk away, accepting that we are saddled with a system so calcified as to be beyond reform.
But it's not true, because the pressures on hospitals are already forcing them to change. The question is whether they, and the public, are going to influence those changes, or whether hospitals will simply be left to the indifference of the economic hurricane that is battering them.
Tough choices ahead
To their credit, hospitals in this area are already working on the problem, or at least elements of it. They have taken rooms out of service, reduced staff and are working to decrease average lengths of stay. Mortality rates for heart surgery have recently improved. But administrators are moving slower than conditions demand, while the public -- and through them, public officials -- too often resist one of the most important, concrete actions the hospitals can take: closing buildings.
Western New Yorkers may believe they are acting in their own best interests when they try to block the closure of hospitals, but in fact, they are subsidizing inferior care. Hospitals have little chance of attracting the best doctors, buying and maintaining the best equipment and staffing with enough nurses for as long as they have to shoulder the costs of old, underused buildings.
Hospitals here, and around the country, have already acknowledged they have too many beds. Western New York is certified for 5,188 beds, but only 3,850 of them are in service. But closing off beds, while important as a first step toward controlling costs, is ultimately inefficient. The cost of maintaining the building does not change, and each building has fewer patients paying the freight for expensive, high-tech equipment and other capital costs.
The region demonstrably has too many hospital buildings for its population. Even with the conversions of Columbus General and Our Lady of Victory to other medical uses, Erie County has 75 percent more hospitals per capita than the Raleigh-Durham area of North Carolina and 55 percent more than the Syracuse area. About the only good thing you can say about it is that it's better than Niagara County, whose hospitals per capita is even higher -- 64 percent higher -- than Erie's.
The result is that the region's hospitals sink an inordinate amount of their resources into maintaining buildings, which are often old. With less money to spend on equipment and salaries -- and, for that matter, on buildings designed to meet the economic and technological demands of the 21st century -- the quality of health care inevitably suffers.
The public seems to have little understanding that its insistence on keeping all hospitals open works against its own interests. Opposition to proposed closings can be fierce and ugly, as it was two years ago, when the Catholic Health System recast Our Lady of Victory from a traditional, acute-care hospital to an urgent-care center.
Nevertheless, the task is crucial. Western New York hospitals are losing money faster than those in any other part of upstate. While 1999 losses are not as severe as the previous year's, they still totaled $47 million, and that doesn't even count the $26 million taxpayers forked over to subsidize Erie County Medical Center's operations and debt. That cash crunch makes it difficult for hospitals to make farsighted decisions.
Closing hospitals is not easy. The hard truth is that it takes money. Expensive equipment has to be moved even as hospital debt, which tends to be high in Western New York, may continue to mount.
Seeking a careful balance
What is more, closing a hospital can have unintended consequences. While closure may bring the community to a more appropriate number of buildings and beds, it could also leave the region without enough emergency rooms, obstetrical units or other specialty services.
And some areas of the nation are experiencing significant stresses as hospital cutbacks and closings, together with nurse shortages, force emergency rooms to divert ambulances. That's not an uncommon occurrence in winter, when flu and snow-shoveling jack up hospital admissions, but this year is worse, according to some reports.
Closing hospitals is a community high-wire act where carelessness can have devastating effects. But in the end, there is no choice. We are obese with these buildings and it is killing us. We can have healthier hospitals and better health care with fewer of them. The public not only needs to allow this change, it needs to insist upon it.
MONDAY: The impact on quality.