17-04 Segment 2: Public Hospitals

Medical beds with patients in the ward at the hospital

 

Public hospitals have a poor reputation, but in some fields, especially trauma, they are often among the best hospitals in the US. Two experts discuss reputation vs. reality and the threats public hospitals face.

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Guests:

  • Mike King, author, A Spirit of Charity: Restoring the Bond Between America and Its Public Hospitals
  • Dr. David Oshinsky, Director, Division of Medical Humanities, New York Univ. Langone Medical Center and author, Bellevue: Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital

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Public Hospitals: Reputation vs. Reality

Nancy Benson: Public hospitals get a bad rap these days and have for decades. They’re in major cities throughout the United States and are funded at least in part through taxpayer dollars. But society perceives public hospitals as being run down, poorly managed and poorly staffed and equipped. They also have a reputation of providing mediocre medical care that only the poor seek out because they can’t afford anything else. But experts say, this scenario is a myth.

Mike King: The quality and care issues were much more problematic for public hospitals 30 and 40 years ago, when all you had in them was essentially attending physicians from medical school that were training these physicians and not sort of the highest level of care that was available in the community. That’s changed a lot in the last 20 years.

Benson: That’s Mike King author of A spirit of Charity: Restoring the Bond Between America and it’s Public Hospitals.

King: For the last 20 years I think a lot of major public hospitals around the country, whether it’s Bellevue in New York City or Grady here in Atlanta or Cook County Hospital in Chicago, there’s some high quality healthcare going there and it goes on in 3 of 4 very specific areas of expertise. Trauma care – we associate trauma care with public hospitals because almost all of them have major trauma component to it, we associate stroke neuroscience care because again, in major inner cities the incidence rate of stroke is pretty high therefore the expertise around stroke care is often available in public hospitals as opposed to private hospitals.

Benson: But that’s not all, King says there are other important services that public hospitals excel at providing.

King: HIV/AIDS which is almost always affiliated with public hospitals as well, burn care – sort of the high level of expertise necessary that’s too expensive for a non profit hospital to maintain their own units are maintained in public hospitals.

Benson: In fact when King’s own wife was diagnosed with breast cancer, she selected a public hospital over a regular one. She felt the public hospital offered better, more personal care.

King: We went to Grady, my wife, talked to her at length 2 hours one day and came away feeling very comfortable with her a surgeon. So the surgery was performed at Grady and went off without a hitch.

Benson: And when you need an emergency room, King says there’s usually no better place than a public hospital.

King: The best trauma centers around the country are almost always in public hospitals like County. It’s interesting what has happened with trauma care in some parts of the country, this hasn’t affected county in Chicago and it really effected Grady here in Atlanta very much but in public hospitals in Texas and in Florida and a few other states, we’re beginning to see a breakdown in difference between what doctors refer to as blunt trauma vs. penetrating trauma. It is exactly what it sounds like – blunt trauma meaning those people who are hurt in car accidents whose bodies slam up against the windshield or against the steering wheel and have not visual injuries but are obviously injured and penetrating trauma being knife wounds, gun shot wounds.

Benson: King says many hospitals, especially those owned by for profit companies, have moved their ER’s almost exclusively into blunt trauma care, leaving the most costly penetrating traumas for public hospitals to clean up.

King: That can be somewhat of a problem because, as you might expect, those people who are brought into trauma centers suffering from gunshot wounds or knife wounds are less likely to be insured than those who are coming in for falling at home or being involved in a car accident. So once again, American medicine begins to move towards where the payment is and sometimes that leaves public hospitals out of the equations.

Benson: King says, 50% of patients at public hospitals have no insurance at all or they have Medicaid only, which reimburses hospitals only 70-80% of their costs.

King: So they actually lose money in many cases with Medicaid. When you’re dealing with a patient population mix of Medicaid and uninsured, then you’re coming from a deficit right off the back. In regular hospitals, in regular non profit hospitals and for profit hospitals, that figure of uninsured and Medicaid is probably gonna be somewhere below 20% often 15-12%. So that’s a huge difference.

Benson: Regular hospitals look for paying patients, but King says anyone who shows up in any ER with a life threatening condition must be treated til their stable whether they can pay for it or not – that’s the law.

King: And what happens in those hospitals is they do in fact uphold the law, they treat then stabilize them and then suggest they get their follow up care at a public hospital.

Dr. David Oshinsky: Bellevue and other public hospitals obviously take the pressure off voluntary hospitals, in other words, during the great AIDS epidemic for example, Bellevue was ground zero when other hospitals were turning patients away and there are many hospitals that, to be perfectly honest, frown upon people who are undocumented, uninsured and undomiciled or homeless. And so Bellevue and other public hospitals do fill that need; they provide a kind of medical care to really what you would consider the lower parts of the lower class. Not only of the working classes but, in many cases, people who have extremely mental disabilities and people who have very hard time being treated somewhere else.

Benson: That’s Pullitzer Prize winning author Dr. David Oshinksy, Director of the Division of Medical Humanities at New York University Langone Medical Center and author of Bellevue: Three Centuries of Medicine and Mayhem at Americans Most Storied Hospital.  

Oshinky: It is the ultimate safety net hospital, it’s 300 years old; oldest public hospital in the United States and every immigrant group in the country has come through there at one time or another – the Irish in the 1830’s, the Germans in the 1850’s, the Jews and Italians around the turn of the century and today the hospital is virtually all Latino and from various parts of Asia including China. Any time a new immigrant group comes through New York City and comes into the country, Bellevue is usually the place that takes care of the most destitute among them. That I think has really been the mantra of the hospital for three centuries.

Benson: Oshinksy says the surviving public hospitals around the nation have improved in recent years and now provide excellent care for the poor and insured alike. But public hospitals are still endangered.

Oshinsky: People who go to public hospital like Bellevue other than, you know, the police and civil servants and those who are basically sent there by the city because the care is so good when they’re injured, most of the other people who are there are not what you would consider to be constituents who have a lot of political clout. So if you want to talk about budget cuts, it’s much easier to talk about cutting the budge of a public hospital than is the transportation system or the parks, the sanitation. So in that sense, it’s always on the razors edge and I think that the battle over illegal immigration is sort of steeped into medical issues as well, which makes for an even more precarious situation.

Benson: Oshinsky says public hospitals are desperate to attract insured patients through their doors and to do that, they often specialize in specific areas. Whether its neuroscience and stroke care or infectious diseases, but King believes that even if public hospitals are able to attract more insured patients this ultimate safety net won’t make it on insurance reimbursements alone.

King: It’s an expensive process to provide trauma care, it’s an expensive process to provide HIV/AIDS and other infectious disease care, so it will require a renewed commitment on the public’s part to understand that there’s still a need for these essential services out there.

Benson: You can learn more about our guests Mike King, author of A Spirit of Charity and David Oshinky, author of Bellevue, by visiting our website at RadioHealthJournal.net. Our writer this week is Polly Hansen. Our production director is Sean Waldron. I’m Nancy Benson.

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