"Greed, for lack of a better word, is good." Gordon Gekko in Wall Street, 1987
"We have assembled the most enormous medical establishment ever conceived, and people are sicker than ever!" Paddy Chayefsky, The Hospital, 1971
In The Hospital: Life, Death, and Dollars in a Small American Town, writer Brian Alexander takes a deep look into the continued validity of these statements in today's healthcare arena.
The Ohio native and author of the award-winning Glass House, which zeroed in on the decline of the once-thriving factory town of Lancaster, centers his narrative on individuals affected by the corporatization of America. He follows Phil Ennen, CEO for 32 years of Community Hospitals and Wellness Centers, as he attempts to keep his small hospital in Bryan, Ohio, open for business. There’s more than just healthcare at stake, as Alexander underscores:
"The hospital was special. It wasn't only a community asset in the legal sense; it was a community glue, a community economic powerhouse, a community source of employment, a community lifeline." (212)
Brian Alexander, the author of Glass House and winner of the Ohioana Book Awards, is a contributing writer to The Atlantic. He’s written for The New York Times, Los Angeles Times and Esquire.
Alexander interviews hospital board members, physicians and nurses for this book, providing context and texture about the predicaments encountered by clinicians as they went about their essential work—but it is the patient stories he tells that break our hearts.
One patient in particular stands out: Ohioan Keith Swihart had a home, a wife, a child with autism who was nonverbal, type 2 diabetes, and a job with health insurance. Alexander places Swihart's multifactorial experience with the healthcare system in the center of the narrative, a lens that magnifies the profit-driven mechanisms that threatened Ennen's hospital and Swihart''s life.
"He was prescribed insulin to help control his blood sugar, but it was expensive, even with his Hi-Lex-supplied health insurance," writes Alexander. "He couldn't see spending so much money on a drug if he didn't absolutely have to. So, though he used the insulin, he took less than the doctor prescribed." (8)
Step-by-step we see how outside events, corporate and political greed, and poor decisions left Swihart crippled and blind. There seems to be no mercy in this story but that’s not the fault of Alexander, who describes the tragic chain of events with clarity and empathy.
While the book hones in on problems on a granular and personal level, we get the big picture too. Alexander walks the reader through the historical factors contributing to the development of our current healthcare system. Racism, classism, income inequality and poverty play a continuing role in healthcare inequity.
In his opinion, one factor surpasses all the others.
Greed.
Ultimately, Ennen keeps the hospital running, but at a price. As technology and other advances affected the practice of medicine, prices rose. Medical device suppliers, technology companies, hospital boards, and administrators saw ways to generate income through competition by providing unique services such as CT and MRI scanners, cardiac catheterization labs, and stroke centers. Ennen established a few of these services, which did earn money, but he struggled to find physicians to staff them.
Alexander describes how hospitals began to merge into health systems with greater purchasing power. They hired their own doctors and kept referrals to generate more business, giving them bargaining power for reimbursement, supplies, and equipment. Those systems aggressively pursued and bought community hospitals and doctor's practices using threats, bribes, and any way they could imagine to capture all the patients in the area.
Insurance companies made deals with doctors and hospitals and created networks that forced people to use certain ones included in their plan coverage.
"There was no such thing as a free market for medicine in the United States, and there hadn't been for some time," Alexander says. (162)
The pressure on Ennen to consolidate continued to increase, especially as economic factors led to an exodus of high-paying manufacturing jobs, and the hospital's operating margin became precarious. The hospital board became restless as its mission in the community—smaller size, lower charges, good quality, community focus, and independence—became undervalued. They thought consolidation was the right thing to do.
Private equity involvement, Alexander believes, dealt the final blow to the idea of patient-centered care. Private equity had a well-earned reputation for using borrowed money to finance buyouts, raising prices, skimping on services, gutting the companies, and then walking away with the proceeds. Alexander presents damning statistics as he watches healthcare become profit-driven, with little or no care for patients, families ,or employees.
He tells us, "The consolidation of hospitals into big systems not only failed to reduce costs, it diminished quality and access. This was true for both rural and urban residents. The argument that a takeover of CHWC by a Parkview or a ProMedica would necessarily bring all sorts of health benefits was contradicted by reams of economic and health research. While it was possible that a takeover could improve the health of Williams County residents, such acquisitions often raised prices and reduced the quality of care." (168)
I worked in a few of the independent hospitals mentioned in this book as an Emergency Physician. As consolidation began, its effect on patient care was evident. Some examples: fewer nurses on shift, young lower-salaried nurses replacing experienced ones, equipment that changed monthly to cheaper brands, stickers and bar codes on the tiniest square of gauze, and quotas for admissions.
The Hospital: Life, Death, and Dollars in a Small American Town was certainly eye-opening. But it was also a challenging read because it questioned my trust in the goodness of man and my support of capitalism as a political system. I had to look clearly at some of my subconscious beliefs. I wanted to cry for all the people actively damaged by our current system.This book is an essential read for anyone involved in healthcare. If we are to bring about sweeping changes in this system, we must understand the forces involved. Alexander does a masterful job of using several perspectives to lay bare the greed at the center of it all.—Maureen Hirthler
Maureen Hirthler is a retired physician who holds an MFA in Creative Writing from the University of Missouri-Kansas City. She is the Managing Editor of Intima: A Journal of Narrative Medicine. Her writing has been published in Creative Nonfiction, the International Journal of Whole PersonCare, the Examined Life Journal and others. She resides in Florida with her husband and very sweet dogs. Hirthler is managing editor of Intima: A Journal of Narrative Medicine