The Poverty of Riches: Medical Care in America

THE OPEN MIND
Host: Richard D. Heffner
Guest: Robert Newman, M.D.
Title: “The Poverty of Riches: Medical Care in America”
VTR: 1/22/89

I’m Richard Heffner, your host on THE OPEN MIND. And I suppose that if I hadn’t lain for 17 hours and more on a stretcher in the absolutely jam-packed Emergency Room of a most prestigious major teaching hospital here in New York some months ago – because there just wasn’t a bed available, even for a seeming heart attack victim in that great but incredibly over-crowded institution – I might not be quite so motivated to do this program. I wouldn’t have known – nor could I have fully believed what a horror story so many of our large urban hospitals represent today. For not even all the news stories about nursing shortage, about filled-to-capacity-and-then-closed Emergency Rooms, inadequate ambulance response time, too early hospital discharges, impossibly out-of-sight costs and charges and shortfalls, and on and on…not even these daily reports have one whit the impact of just lying there for hours literally inches away from others far more profoundly and desperately ill and hurting, for whom our hospitals simply do not have the resources to care adequately.

Yet I was lucky. I was able finally just to get myself off that stretcher, say “to hell with this”, drag myself out of the hospital…and get away with it. But I resolved, too – without making it just my story, because I’m okay – to use THE OPEN MIND to examine this matter of our nation’s overcrowded hospitals with one who cares intensely, who has dedicated his life to preserving and bettering the lives of so many others.

Dr. Robert Newman is the President of the Beth Israel Medical Center and of Doctors Hospital here in New York. The problems he and his dedicated associates face, however, occur all over urban America.

Now it wasn’t Dr. Newman’s medical center that pained me so. But, he might concede that it could have been. And I want to ask Dr. Newman just how in the world we got here. Can’t we as a nation medically care for ourselves? Dr. Newman?

Newman: Well, I think we do, and I think while you certainly listed the major problems that do face hospitals in New York City and throughout the country, and while there are occasional horror stories in this field as in any other, on balance I’m convinced that the medical care that our hospitals provide is very, very excellent indeed. And for every patient who has a story such as yours, there is probably ten, twenty, fifty others who have a happy ending, and who say “I received the care that allowed me to continue to live”. And, in fact, hospitals and the medical profession in general today are able to do more with more illnesses, for more people than has ever been the case before. But for sure, it is a tough job being a hospital administrator, and for sure there is a host of problems that the hospital industry, in general, does face. There’s no question about that. It’s not a boring job, I can assure you.

Heffner: Now I don’t want you to poor-mouth hospitals here in New York or around the nation. That wasn’t my purpose.

Newman: It’s a deal. I won’t.

Heffner: Okay…alright. And I’m sure you prefer that I not use the anecdotal because the anecdotal gets us into trouble. But how do you account, then, for so many of the front page stories? Is this just the nastiness of the press in reporting the problems?

Newman: No, not at all. I think to some extent there’s a tendency not to give a balanced view. The countless patients who come into a hospital, either through the Emergency Room or through the Admitting Office, and who are excellently treated, who have an excellent result, that’s not news, so inevitably the news media reporting is not going to be giving a balanced view. I think the basic problem we have, certainly in New York, but also in many cities throughout the country is that the stresses, the strains on the hospital system are enormous. Certainly the very high census which we have in New York City, and, as I say, which also exists in a number of other cities, when you’re operating that close to capacity, or at capacity, for sure it becomes very, very difficult to continue to provide the consistently high level of care that hospitals are committed to providing, certainly in my own institution.

Heffner: You see, I understand that, but when you say “on balance:” is that an adequate answer that for everyone who experienced what appears in the front pages of the newspapers, there are tens or dozens or hundreds whose treatment is exemplary. That’s not really…

Newman: Absolutely. No, for sure, in the field of medical care, individual medical care, institutional medical care, there should be zero tolerance for errors. No question about it.
On the other hand, I think the public as a whole has to understand that when a system is so stressed, is working at so close to capacity on such a consistent basis, and has the problems that the hospital industry does have, that there will be occasions when there are going to be difficulties in terms of delivering the care, and there are, as you indicated, there are a lot of problems. There are financial problems, for sure. There are personnel problems in terms of the adequacy of the numbers of people to fill the positions that hospitals have, nurses, technicians, physicians’ assistants, and there are also predictions today that there will be a physicians shortage, particularly in certain specialties in the future. And the other major area of difficulty that hospitals face is the patient population we’re serving is older, is sicker and has diseases that are extremely difficult to manage, and sometimes defy cure. AIDS is the most recent example, chemical dependency, but it’s a much sicker, more difficult population to provide care to, so all these stresses inevitably will have an impact on the services that hospitals and the medical profession, as a whole, will be able to provide.

Heffner: You mentioned dollars…

Newman: Yes.

Heffner: …to start with, but you don’t stop there.

Newman: Absolutely. I should have.

Heffner: Does that mean that we’re not just talking about the, a poverty stricken nation, or a nation without the material resources?

Newman: Absolutely. It’s not just a financial problem. On the other hand, I think the people in our country have to realize that the excellence of the medical care that they demand, and rightly demand, and have a right to receive, is today a very, very expensive proposition. We have made enormous strides in the last ten years, twenty years, thirty years, in terms of what we can do to help people with medical problems. But a great deal of the technology that goes into providing that help is phenomenally expensive. So for sure, money is a problem and there’s an understandable reluctance on the part of the general public and their elected officials to simply say “Here hospitals, here medical profession, all the money you need, it’ll be available to you” because the government also has to balance different priorities.

Heffner: Do you that that if that notion, and as President Bush said in his inaugural, just the other day, we’re going to have to find ways other than the expenditures of more monies than we are spending now…

Newman: Yes.

Heffner: …to solve our problems. Is it a recognition that is called for in the usage of hospital resources?

Newman: I think, for sure, hospitals have to figure out more efficient ways of providing service. One of the reasons why my own institution over the years has been so successful is that we haven’t simply sat back and lamented the fact that we’re not getting enough money from this third party payer or from this insurance carrier. We have accepted the reality that determines the environment in which we have to provide services, and we have found more efficient ways to provide services without compromising care, and that has to be done across the board by all the hospitals in the country, and increasingly it is being done. I think what determines the more successful and the somewhat less successful hospital, just in terms of bottom line, is how quickly institutions can adapt to the changes that are occurring. But there has to be adaptation. The hospital industry and the medical profession can’t simply sit back and say “Hey, we’re going to provide services the way we want to, and you, the community, will simply have to pay whatever it costs”. The public understandably and rightly is not going to settle for that.

Heffner: What are the specific areas where adaptations haven’t, generally enough around the country, been provided?

Newman: Well, one recent example is the increasing utilization of ambulatory surgery. In other words, performing surgical procedures on an out-patient basis without the need for somebody to come into a hospital, stay overnight, have the procedure, and sometimes stay another night or two nights before being discharged,. Today there are a whole host of surgical procedures, that used to require hospital admission and sometimes extended hospital stays, that are being done on an out-patient basis, without compromising care, and yet at a very much more economical, on a very much more economical basis that if hospitalization were required. And, again, my own institution, Beth Israel here in New York City, before it became financially necessary to adapt and to switch patients from an in-patient to an out-patient surgical setting, we did this back in 1981 because it made good sense, strictly from a medical standpoint. If you can avoid hospitalization it’s not only more economical, but it’s also generally better medical care. That type of adaptation has to occur and it has to occur in a whole host of different ways.

Heffner: Is it tradition, stick-in-the-muddedness, that prevents others from making these kinds of adaptations?

Newman: Well, first of all I don’t want to suggest that my institution is the only one that has made these adaptations. Happily we have done it generally earlier than a lot of other institutions around the country. I think it’s human nature, number one, to be slow to change the way in which you perform your work. That’s human nature, when you’re talking about big institutions; my own institution has almost 1,200 beds that we’re responsible for. Big institutions have an even greater amount of difficulty in general in changing, in adapting than if it’s just a single, small office with one person or two persons in charge. So the size of the institution, the complexity…it’s not just a change in general that an administrator or a Board of Directors can make. When a hospital changes the way it does business there are enormous numbers of employees at all levels, physicians, nurses, technicians, people who work in the dietary service, housekeepers, everybody had to change the way they do things in order to adapt, so it’s not easy. But it has to be done, and the public has a right that it insists that it be done.

Heffner: Am I going to hear from our viewers that there was a kind of “Pollyannaish” quality to our discussion because you are such a positive and optimistic person? Because what we do get, as you yourself concede, from the press, and from a fellow like me who introduces a program with this awful tale of lying on a hospital stretcher for all those hours, are you too fast because you have to maintain your equilibrium and your optimism…

Newman: (Laughter)

Heffner: …to run a great institution?

Newman: No, Richard, as a matter of fact my optimism is a result, not of my inherent nature, but rather my experience in running an institution that has been able to adapt to these changes. I think the medical profession and the hospitals in general…what…the strength lies in their commitment to providing the very best care. That’s the commitment that I think is characteristic of institutions throughout the country and that will lead them, that has to lead them, to adapt and to change according what the public insists on, and I think that commitment is absolutely critical.

Heffner: But Dr. Newman I’ve never read anywhere an indictment of the people involved. I’ve never read anywhere that the dedication isn’t there. What one reads constantly is just the whole darn thing is so big…

Newman: Yes.

Heffner: …so complicated, the pressures are so great, the dollars are so few, that medical care, hospital care is declining.

Newman: But I think again you can look at the experience throughout the country. The number of procedures that are not, that do not require hospitalization, the length of stay…I mean a hernia operation, even when I was in medical school, and it’s not such a long time ago, generally required a week’s hospitalization at a phenomenal cost. The length of stay throughout the country is coming down. It shows that the medical care in general is being provided in a more efficient way and I am convinced that that decrease in length of stay is not at the expense of quality care. So we know that institutions do change, and we know that these who work in the institutions, physicians, nurses and everybody else, that they are changing. So while we recognize, for sure I recognize, that there are major problems, major challenges, there are also major opportunities, and I’m convinced that the industry, in quotes, the hospital industry is up to meeting those challenges, and the main reason is that they have to in order to continue to provide the type of care that they’re committed to provide.

Heffner: Well, you put quotes around “industry”.

Newman: Yes.

Heffner: But what has been the impact of for-profit hospitals upon the rest of the hospital world, and upon care generally?

Newman: Well, you know, the general implication is that for-profit institutions have to worry about money, and the rest of us, Beth Israel Medical Center and all the other big teaching hospitals in New York City and throughout the country, that for us money really isn’t important because we’re non-profit, we’re not proprietary, we don’t have to worry about financial considerations. That’s obviously nonsense. I mean everything that we do in our institution, obviously costs money. We have to pay the people who work in the institution. We have to have the resources, financial resources, in order to buy the latest technology, in order to continue to provide first-rate care to all our patients. So every hospital, whether they’re lumped together with the for-profits, the proprietary, or whether they’re in the voluntary sector, or the municipal sector, every hospital has to be keenly aware of the financial situation, otherwise they won’t be able to survive and continue to provide services.

Heffner: Dr. Newman, a peculiar question. If I have to be hospitalized, and I can make my choice for that emergency to take place, East or West, North or South, large urban area, medium sized urban area, small town, what’s your advice?

Newman: Well, I would hope that it would be somewhere in the vicinity of my hospital so I could personally make sure that you don’t have the type of experience that you described earlier. But in fact I would not break up the country into geographic areas and say “This area is better, this area is not so good”. I would not break up hospitals according to their auspices, whether they’re municipal or proprietary or voluntary. I think hospitals, like anything else in our society, vary. There will be some outstanding institutions; there will be some relatively mediocre institutions and then there’ll be a whole range in between. I hope if and when you have another emergency, you’ll be near a hospital that’s on the absolutely superb end of the spectrum.

Heffner: Oh, I’m thinking of staying home.

Newman: But, I…that generally is not an option, and again, I think the implication that when you go to an institution you’re really taking you life in your hands, and that this is a terrible fate if you have to be hospitalized, I think that’s simply wrong. Overwhelmingly, hospitals throughout the United States provide absolutely first rate care in absolute terms, and certainly relative to what hospitals could provide, ten years, fifteen years, and twenty years ago. The capabilities have grown enormously, and when I say “hospitals”, hospitals are just facilities. I’m really talking about the people who are in those hospitals who are the ones who actually provide the services. The hospital is just the framework within which those services are provided. I think they do a terrific job.

Heffner: You mean it’s not true that going to the hospital is bad for your health, necessarily?

Newman: (Laughter) I put it even more positively than that. I think most people in our society, here in the United Sates, who have a medical problem, who need hospital care, will get it and will be very, very satisfied with the outcome. That, as a generalization, I believe is absolutely true. Are there going to be instances where that’s not the case? Of course there will be. Hopefully, those instances will be few and far between.

Heffner: What has been the impact of AIDS upon hospital care, and of drug abuse upon AIDS?

Newman: Well, first of all, the drug abuser today is the primary source of spread of AIDS to the heterosexual population and to infants. So the drug abuse problem and the AIDS problem are very, very closely interconnected. Both of these problems have compounded difficulties which hospitals and the medical profession already had been facing in areas like New York where there’s tremendous over-crowding. That problem has been enormously compounded by having AIDS as a new illness, as well as chemical dependency on top of the other problems that we’re dealing with. The situation in New York in terms of over-crowding, for sure, is in large measure a reflection of this new illness, and a very substantial number of people with AIDS that are being cared for. But it’s also a reflection of the lack of resources that patients need outside of the hospital itself. Home health care services, nursing home services, there is a limit, and this is not just a New York phenomenon either. There is a limit to the availability of those resources which means that patients who do not really require continued hospital stay can’t be discharged because the support is not out there to allow them either to go home, or to go to a chronic care facility. That’s a major problem which hospitals face, but which hospitals can’t correct and deal with. That’s something that the society has to do to ensure that these other types of facilities are available. There’s a big need for it.

Heffner: Is there any indication, you say there’s a big need for it…

Newman: Yes.

Heffner: …is there any real indication, to give us hope that that need is being matched?

Newman: I think the need will be addressed for many reasons. Number one, we have a growing, very rapidly growing elderly population within the United States, a population that is very politically active, that votes and that’s going to demand the resources that it needs when it requires long-term or nursing home facilities. The politicians, for sure, are going to heed that demand that exists. Let me just say, again, as an example of what institutions can do to help serve their patients better. Beth Israel, like most hospitals, certainly in New York and for the most part across the country, has had a problem in having nursing home beds to which it can discharge patients who are ready to leave the hospital, and just within the past month or so, we have acquired a 230 bed nursing home which we will be operating and which will make it possible for us to have patients who are ready to leave the hospital to be cared for in a high quality, chronic care facility. I think that’s something that increasingly hospitals will have to do, either develop nursing homes, acquire nursing homes, affiliate with nursing homes, and it’s going to be essential in order to free up the desperately needed space to care for those people who can only be cared for in an acute care center.

Heffner: But you make the point very well that the elderly population votes can vote…

Newman: Yes.

Heffner: …has political moxie. But you’ve also made the point that one of the major causes for the over-crowding of our hospitals is the matter of AIDS, and there isn’t a voting constituency, is there?

Newman: That’s right. Well, AIDS has had a voting constituency in terms of the very well organized, very committed, first-rate Gay and Lesbian rights organizations that have been a very, very influential political force. The chemical dependency…

Heffner: Yes.

Newman: …population has absolutely nobody speaking for them. I think the key is it’s not only, not only humanitarianism that has to motivate our society to provide the services that patients with AIDS require, that patients with a chemical dependency require, it’s self-interest. If our health care facilities are overwhelmed because of patients with AIDS, because of patients with chemical dependency, the impact is on everybody including somebody like yourself who hopefully has none of those problems, but who requires acute care hospitalization, or believes that he requires it, goes to an emergency room, and can’t be accommodated. So the need for facilities to care for patients with AIDS, to care for chemical dependency, to prevent AIDS, to prevent chemical dependency, the need for that is not just for humanitarian reasons, but because if we don’t address these problems every single American is going to be sharing in the cost.

Heffner: What, of course, distresses me are my memories. As a historian, I think of Franklin Roosevelt’s Quarantine Speech in which he made very much the kind of point that you made back in the 30s, “When your neighbor’s house is on fire, you get out your garden hose and you help put out that fire”, you quarantine the aggressor in his terms.

Newman: That’s a dangerous term…

Heffner: Why?

Newman: …when we’re talking about AIDS because…

Heffner: The “aggressor”, you mean?

Newman: …well, “quarantine”.

Heffner: Quarantine.

Newman: Quarantine…because it suggests that this is a problem that can somehow be sequestered from the rest of us “good guys”, that somehow we can deal with it by putting “those” people somewhere where they’ll be out of sight, where they won’t fill up “our” beds, where they’ll somehow be pushed aside. You can’t do that. You can’t do it with patients with AIDS. You can’t do it with patients with chemical dependency. We have to provide services for those people.

Heffner: Dr. Newman, I’m glad I gave you the opportunity to say that. That isn’t what I mean, that isn’t what I meant. It was a poor use, a poor metaphor. I was really thinking though, about our inability, as a people, so frequently, to realize that the hip bone is connected to the thigh bone…

Newman: Absolutely.

Heffner: …etc., etc., in terms of what you just said.

Newman: Absolutely. Absolutely. And I’ve been, as you know, I’ve been very much involved in the treatment of chemical dependency for many, many years, and I’ve always made the point it’s not just to help people with a chemical dependency problem that should lead the community to not only welcome, but demand these services. It’s out of pure self-interest because all of us pay the price of having a problem like chemical dependency go unattended, without preventative services, without treatment services. We all have a common stake in dealing with that problem, in dealing with the problem of AIDS, in dealing with the problems facing the geriatric, the elderly in our society. We have to be our neighbor’s keeper, because if we’re not, the neighbor is going to get sicker, and we’re all going to be sharing an increased cost of helping that person later.

Heffner: Now you start off with a maximum of optimism. How goes this crusade, if I may call it that, that you’ve been involved in for so many years to make us understand that, and to bring about the kind of support for the kind of care that one needs for drug abusers, for the victims of drugs?

Newman: I’m not always optimistic, and certainly the long-standing struggle that I’ve been involved in to make help available to those with chemical dependency who need it has been a long and very difficult struggle. But I am more optimistic today than I’ve ever been before and the reason is that we have major spokespeople for the community, editorial writers for major newspapers, politicians, presidential commissions , who recognize the reality that we must make help available, and on the AIDS front I’m really very pleased that our country has not, barring some extremists, who I think have made calls for totally irrational approaches, we have not attacked the problem by attacking the people who have the disease. We have, as a nation, I think, responded very, very positively, very well, and there are not very many countries around the world who have done that. There are some who have imposed very, very harsh approaches to dealing with the problem of AIDS and drug users. That’s not true in our country, and I think it’s to our credit, and I think we’ll benefit because of it.

Heffner: Dr. Robert Newman, I’m glad we can end the program on that positive a note, and I want to thank you for joining me today on THE OPEN MIND.

Newman: Thank you.

Heffner: And thanks, too, to you in the audience. I hope you’ll join us again next time. And if you care to share your thoughts about today’s program, today’s themes, please write to THE OPEN MIND, P.O. Box 7977, FDR Station, New York, NY 10150. For transcripts send $3.00 in check or money order. Meanwhile, as an old friend used to say, “Good night and good luck”.

Continuing production of this series has generously been made possible by grants from: The Rosalind P. Walter Foundation; The M. Weiner Foundation of New Jersey; The Mediators and Richard and Gloria Manney; The Edythe and Dean Dowling Foundation; Lawrence A. Wien; The New York Times Company Foundation; and, from the corporate community, Mutual of America.