Saratoga Hospital has done itself little service through a narrative that assumed a trusting, gullible and unsophisticated citizenry. That revealed, it has only served to create suspicion, generally not a good thing. The Hospital — which is to say, the community healthcare interests it necessarily represents — would have been better served by being more forthright with this community and adopting a more collaborative strategy for advancing its long-term aspirations.
I have spoken at length with a number of knowledgeable physicians with long histories in the profession. Some are local doctors, while others have served as institutional medical practitioners and administrators in other municipalities. The story they tell me is that the emerging trend in the industry, one which we are witnessing here in Saratoga’s environs, is for hospitals to buy the practices of doctors and for these doctors to in turn become employees of the hospitals. This serves a number of functions designed to benefit both sides of such transactions.
For the doctors, it reduces the increasingly onerous burdens of the administration — the “paperwork” — that inheres in contemporary medical practices. For example, the requirements of multiple insurance carriers that carry the costs of care in any given practice necessitate increasingly complex and increasingly expensive software to handle billing and record keeping. Just as important is the need of each practice to effectively deal with the insurance companies that are, to say the least, aggressive in reducing or even denying the reimbursement for services. Hospitals that employ an army of doctors are in a far better position to negotiate with the many funding sources that their patients necessarily introduce into modern medical practices. As if participating in a compulsory Darwinian scheme, doctors are thus increasingly forced into working for hospitals.
There is also the increasing cost of the ever more sophisticated technology to actually provide care. The greater efficiency of shared equipment (and its costs) reduces overhead through aggregated fiscal burdens.
For the hospitals, medical testing is a super powerful engine for generating income, and thus for operational carrying costs, making it essential to the survival of hospitals. Having hundreds of doctors on their payrolls exposes an economic reality that both requires and incentivizes medical testing by a given hospital. I am told by the medical professionals I’ve interviewed that medical tests supply the life blood (i.e., money) for today’s hospitals. Consistent with this model, Saratoga Hospital has been engaged in an ambitious and successful campaign of buying practices in all areas of medicine, from orthopedics to cardiology. The success of this campaign is reflected in the plainly amazing growth of our Hospital; be it a bricks-and-mortar project or acquisition of the aforementioned areas of specialization, the trend is as obvious and irresistible as gravitational pull.
This is meant as no criticism of the Hospital but it forces a reckoning: this strategy is driven by economics rather than care considerations per se. Clearly, it seems, for it to provide care, our Hospital must have adequate financial resources and, given today’s “health care” system (I use the term health care with bitter irony), the Hospital is compelled to adopt an operational and strategic template which effectively (and perhaps necessarily) dictates both the climate and the menu we have before us.
Forwarding to the present debate, Saratoga Hospital representatives argue that building a new set of offices close to the main facility — the mother ship, if you will — will likely save some information technology costs. Whether in the long term it will do that, and how much it will save, is necessarily an open question given that every design may be influenced by competing ideas and consequent choices. The sheer scale of operating costs suggests it is a fair question to ask for more information bearing on the proposition advanced: namely, that the savings and community benefits will be sufficiently great to justify material alteration of old Saratoga neighborhoods.
The above notwithstanding, I’m here to suggest this: what it will not do is improve the coordination of care. The patently absurd fantasy promoted by the Hospital — that these doctors will be meeting together to better coordinate the care of shared patients — is utterly transparent, and certainly not self-evident as a logical proposition. Most of us have been touched by the problems of acute and complex illness whether in our own lives or in the lives of the members of our families and friends. We have seen firsthand how little communication there is between doctors in different specialties. Oncologists meeting with cardiac doctors over balancing the needs of a patient with cancer and heart disease? There are a few places that provide this kind of tightly-coordinated medical care, in institutions like the Mayo Clinic, but they are in the experience of most people an exception rather than the norm.
There is a nascent specialty in medicine in which certain medical professionals are called “hospitalists.” They practice medicine in a variety of specialties and they work entirely in the setting of the hospital. They are the ones that you see most of the time when you are admitted to the hospital for care. You may be operated on by a surgeon that you select who has privileges at the hospital but the general care you will receive will be done by these hospitalists. Commonly, these people work three twelve hour shifts a week. This creates problems with continuity of care because a patient will see whichever doctor is on call that day. The physician and support staff in turn would presumably not regularly meet with off-day staff, but more routinely read charts at their disposal to guide them. For many years, predating computers and hospitalists, physicians have quipped, “one doesn’t go to a hospital to get well”. Even if the verity of that irony is inescapable, the people in this community may demand a credible assurance that we are planning and designing something better than we had before, and not simply dressing up an old problem in new clothes.
So I recognize and accept an honest argument about why Saratoga Hospital needs to provide the best environment they can to attract individual doctors and practices. I can also understand why they found the land owned by D.A. Collins near their facility so attractive. What I do not accept is that their convenience (rather than the real care of patients) seemingly trumped the needs of their neighbors or the city. There are other places they can find to address office space expansion. Close proximity to the Hospital is not essential in this age of telecommunications and in a city where traffic, while irritating, is not an enormous obstacle.
The Hospital has confused the enormous power they have with the assumed righteousness of their cause. If they had been up front to begin with — which is to say, had the Hospital engaged its own community — about their need to find a good place to put their offices in this area and to develop a plan, this conflict (or the intensity of it) might have been avoided altogether. They have only themselves to blame for the enormous waste of resources they put into a plan that is dead, at least for the immediate future.
The failure of Saratoga Hospital to embrace Commissioner Mathiesen’s call for reassessing the Comprehensive Plan to come up with a sound strategy only serves to show how little they have learned behind closed doors. Of course, it is possible the hospital will use its considerable economic and political muscle to force something on another group. Admittedly, this is skepticism borne of experience in this matter, and thus I am not hopeful.