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Hospitals are in trouble around the country, and in Western New York they are in deep. They need help.

And while help will have to come from several sources, one vital component of that aid must be an increase in the low rates paid to hospitals by insurance companies and government. Even though this community benefits from the low cost of health care, a slightly higher cost of insurance is the lesser of evils. The greater danger to our community is the stress that threatens to undermine an unstable health care system.

But higher reimbursements can't come free and clear. Given the mash of problems convulsing hospital care here, and the sluggish approach of doctors and hospitals to dealing with some of those issues, any increase in payments should come with strings firmly attached. Conditions are aligned for the legitimate needs of hospitals, insurers and the public to come together in a plan that progressively trades dollars for specific, verifiable reforms.

No one disputes that reimbursements from government and private insurers are depressed in this part of New York. Even the insurance companies acknowledge the fact, though some hospital critics say that while payments per case are indeed lower than in other regions, the total amount paid by insurers is much closer to average. That higher figure is a result, those critics say, of inefficiencies such as the region's higher rates of admission and surgery, longer lengths of stay and hospitals' reluctance to close buildings and adopt procedural standards known to improve the quality of care.

Therefore, Washington, Albany and private insurers should be prepared to negotiate higher reimbursements in exchange for meeting targets on such fronts as lowering mortality rates, requiring adoption of quality-enhancing medical routines, reducing rates of surgery, shortening lengths of stay and cutting out capacity - meaning fewer buildings, not just fewer beds.

Let's be clear, though. Providers must act even without that incentive. Figures on hospital use in this region clearly demonstrate that, even without higher reimbursements, doctors and hospitals have a lot of room to improve quality and efficiency.

Doctors share responsibility for problems

Doctors need to understand their responsibility for the region's excessive rates of admission and surgery; after all, it is they, not the hospitals, who make those decisions. Meanwhile, hospital administrators have to move more aggressively to close buildings. And both need to commit to adopting quality-enhancing programs such as clinical pathways, which standardize the most efficient medical procedures while allowing case-by-case flexibility.

Closing hospitals is not easy. Politicians, the public and many doctors resist furiously, even though Western New York's oversupply compromises both the economic health of the system and, therefore, the care it delivers. And the logistics can be complicated. A building that may be "excess" by some definitions, such as its number of beds, may be important by others. Erie County Medical Center, for example, provides the region's only designated trauma center.

Still, under unrelenting economic pressure, hospitals have begun the job. Despite intense public criticism that often tilted into abuse, the Catholic Health System eliminated inpatient care at Our Lady of Victory Hospital in Lackawanna two years ago. The world did not end.

Kaleida Health's long-term plan foresees it rethinking the scope of inpatient care at Millard Fillmore Gates Circle between 2003 and 2007. The open secret is that the plan is to close or downgrade the hospital. CHS should take similar action in the Northtowns, and the possibility of closing or converting Erie County Medical Center ought to be examined as part of a comprehensive look at how this region provides health care.

That doesn't have to mean abandoning neighborhoods. In many cases, clinics or other outpatient services can provide the necessary health-care presence while diverting to the remaining full-service hospitals the patients - and dollars - they must have to achieve not just economic stability, but improved quality.

Opponents of reform mobilizing

Predictably, the usual suspects are already lining up against further changes, making them more difficult to pursue and further weakening Western New York's hospital care. Physicians at Millard Fillmore Gates Circle have publicly threatened to send their patients to the Catholic Health System if Kaleida closes the hospital.

A little farther north, elected officials have begun to pressure CHS not to make any changes at Kenmore Mercy Hospital. Officials of the hospital system, still sore from the pounding they took for downgrading OLV, unwisely pledged last year not to close or downgrade any Northtowns facility, which will put them in the position of either breaking a promise or maintaining facilities neither they nor the community can afford.

But in the face of a crisis, the hospitals' movement is agonizingly slow, partly because they, like any other business, are competitive creatures. They don't want to lose market share, and on its own, any closure could prompt just that. Add in the threat of the Millard Fillmore physicians, and the result is to drag out decisions that are economically and medically necessary, threatening the entire Western New York health system with atrophy.

Competition is usually healthy, even among hospitals, but in this case, it's also dangerous. Hospitals in Western New York are conducting health care drag races with machines that can't handle the stress. When they crash, bystanders - which is to say, the community - will be hurt.

Balancing competition and cooperation

What is necessary here are state and federal policies that balance the beneficial aspects of health care competition with carrot-and-stick strategies that encourage bloated systems to shrink. Nowhere are those efforts more important than in economically struggling Western New York, where hospital capacity is extravagant, surgeries are excessive and quality is too often mediocre.

To be sure, there are real bright spots in Western New York's hospital care, cancer treatment and neurosurgery prominent among them. And no one suggests that the players here - doctors, administrators, politicians and the public - are purposely seeking to sabotage hospital care in this region. Indeed, all may believe they are protecting it.

But we are walking the road to ruin, nonetheless. Hospitals are not job machines or neighborhood stabilization devices or doctors' lounges. They are, literally, life-and-death institutions that need to be evaluated in a way that provides maximum benefit for individuals and the community. Protecting an oversupply of buildings and resisting improvements to quality don't do that.

Unless all of the above, especially the public, wakes up to these issues, we are liable to discover, and soon, that the threat to our economic health is not our biggest problem, after all.

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