Something in the USA has to Work Right: A Non-Profit Hospital in Virginia Actually Does

by John Stanton

It is easy to severely criticize the state of many things in the United States of America: the US President and Congress bowing to the demands of the national security community to exempt their $ 1 trillion (US) spending from sequestration mandates. The demise of Detroit, Michigan and another round of water shut-offs scheduled for April that will affect nearly 100,000 residents (the Detroit bankruptcy case judge's ruled that residents have no inherent right to clean water). The geopolitical brinkmanship with Russia and China that, if pushed too far, could lead to World War III. The odious double standards applied to "leakers" of classified military and intelligence information js repulsive: former US Army general and CIA director David Petraeus gets no jail time for passing off military secrets to his lover Paula Broadwell, yet former CIA analyst John Kiriakou gets two years in federal prison.

Then there is the much maligned Patient Protection and Affordable Care Act (ObamaCare), which happened to shed an unwanted bright light on the often seedy political/special interest mechanics of the health care industry. Open Secrets reports that for the year 2014 there were 392 hospitals and related organizations that employed 802 lobbyists (even the Carlyle Group known mainly for defense and energy related interests was a client). Over half, 54.1 percent, according to Open Secrets, of the 802 lobbyists were revolving door individuals, those that move seamlessly from government oversight of health care practice to lobbying positions in industry that seek to limit oversight of their operations. Former health industry employees move into government positions as well.

Even defense contractors have muscled their way into the health care industry. If they can track missiles, Lockheed Martin says, then they can track patients.

Is there anything in the USA worth positive coverage?

Chef Garrett: If not a Surgeon, a Chef

Inside the Washington, DC Beltway in Arlington, Virginia there is a medical facility known as the Virginia Hospital Center. It is a non-profit organization whose Chairman of the Board is a no-nonsense doctor and administrator named John Garrett.

He also is a practicing cardiologist/thoracic surgeon who takes on patients regularly (Chairman Mao would have applauded this back-to-the-fields approach for the benefit of the masses). In an interview with C-SPAN''s Brian Lamb in 2009, Garrett talked frankly and informatively about being at the helm of the Virginia Hospital Center and the issues that impact his surgical practice and the hospital operations he oversees.

It is worth tuning in to what Garrett has to say because the machinations of the health care industry in the USA, and the hospitals and practitioners who operate in that machinery, exist in a messy stew of complexity that also includes suppliers/manufacturers of drugs and medical equipment; lobbyists/lawyers, national politics, and special interests of all types ranging from the Academy of Nutrition and Dietitians to Naturopathic healers. His insights carry weight as all of us, rich or poor, or somewhere in between those poles, will ultimately turn to practitioners like Garrett, and the people and facilities he administers, to save our lives or, at least, minimize our pain and suffering.

And yet most Americans know very little about the nuts and bolts of the US healthcare industry or the people in it who brought them into this world and will likely see them out of it too. They know little abut the difference between non-profit and for-profit healthcare institutions or the challenges that medical professionals face. Americans generally are capable of talking up the soundbites from listening to many pro and con ObamaCare advertisements or the latest television commercial for 1-800-ambulance-chaser, but not what is on the minds of physicians as they ply their trade.

Roaming Clergy

Thirty days in Garrett's sprawling Virginia Hospital Center campus, as a sometimes delusional, onery patient, provided a golden opportunity to observe close-up his people at work.  Being hammered and immobilized by an MSSA staph infection is not the way I would have liked to conduct an investigation into the operation of a large hospital. On the other hand what better way to experience the healthcare system at work than by being immersed in it as patient and skeptical journalist/observer. After five surgeries, an induced coma, one failed escape attempt, in-home nursing care for two months, and umpteen visits to infectious disease, wound care, and thoracic specialists, I've earned some credentials as a veteran patient. As an assistant, teacher and coach at a high school my health plan is not gold plated, but certainly a fine one. The bills will come due shortly and there will be empty complaints on my part as the alternative involved ashes and wind. 

One oddity was notable during my hospital stay,  at least to me. Laying in the hospital bed staring at the cracks in the ceiling, I was interrupted now an then by unsolicited individuals who turned out to be lay clergy. My first encounter went something like this. Stanton: "Hello." Lay Clergy: "Hello." Stanton: "Who are you?" Lay Clergy: "I am a lay member of clergy, would you like a prayer?" Stanton: "No but thank you. What denomination are you?" Lay Clergy: "Episcopalian." Later there were members of the Catholic and Methodist Faiths who visited and one who was a multi-faith person.

At any rate, we turn to excerpts from Doctor Garrett's interview with Brian Lamb, edited for clarity.

"We are a not for profit hospital...not for profit hospital doesn't mean we don't make money. We have to make money. But it means that we don't have shareholders, that we're not responsible to anybody but our community. We are a 501(c)(3) organization, tax exempt, and basically what we do here is we try to either break even or have a small margin of profit. Last year we had a 1.6 percent margin. So what we do with that profit is we invest it back into equipment. You know we try to have the latest and greatest that medical science has to offer. Two years ago we purchased a $7 million dollar cyber knife. That's a very specialized piece of radiation equipment. But that's what we do with our money. We don't give it out to shareholders. But it's not to say that we don't need to make income...We employ a lot of people, and this is not charity..."

"So many patients just want you to do what you do, they're grateful for it, they don't need to know a lot of details, they're interested in when they can go back to work, they're interested in the likelihood of them dying. But a lot of the other details I think they're not too interested in, and so it really puts the burden on us to, I mean, we - there's certain things you need to know, and we try to tell patients those things even if they're not too interested."

"...we offer all private rooms to patients, regardless of their need to or ability to pay...I think it's unacceptable to share a room in this age with another sick person. It's better for the patient to have a private room. That's the main reason we did it. 

Medicare and Medicaid Woes

"...about half of what we do here is Medicare and Medicaid, so about half of our admissions in this hospital [are for] Medicare and Medicaid...we lose money on all Medicare and Medicaid patients. Medicare and Medicaid covers at best about 80 percent of the cost, not the charges, but the cost...And so the thing that I guess I want to tell people is that so far what we've seen is the...government controls cost [and to do so] they just pay you less, and we take that, we accept that, but we would have to change what we do if not for the private insurance carriers whom we aggressively negotiate with to get rates that are 140 percent of Medicare. Because we're able to do that, we're able to make our 1-1/2 percent margin so that we can buy a cyber knife for $7 million dollars...If we did not get extra money from your company [C-SPAN health insurance], if all we got was what Medicare paid, then do the math. We lose 20 percent. Well, we're a business. We can't lose money. So we either go out of business or we offer less so that we can break even. Well, offering less in healthcare means that we don't give you the latest and greatest, which you know is not as good."

"...Doctors charge separately in the hospital. So, if I do a Medicare operation, a Medicare coronary bypass surgery, I accept what Medicare pays me: It's about $2,000...Surgeons are paid globally, so you know if I operate on you, I get one payment and you and I are married, So, for that month or until I get you well, that's what I get paid. So, I can see you 10 times a day, I can you know if you have complications, come in in the middle of the night, do whatever it is, I get that one payment...And for the hospital it's similar. They get what's called a DRG payment, and it's based on the diagnosis. So, for bypass surgery, I think it's about $18,000 that the hospital would get from Medicare to pay for whatever happens to that patient...it costs more than that. I'm not sure exactly how much more than that. I mean, my - we're way beyond what we charge, What we charge and what we collect is totally different..."

"There used to be more money in the system...medical care gets better and better every year, New technology, it's expensive, but it's better and better. Things used to be cheaper, but you know we're of the mind that there's nothing that's too expensive. We want the latest and the greatest. We're willing to pay for it, and we have. But that occurs at the same time in parallel that we're getting paid less, the hospital's getting paid less.

You know I - most doctors--truly did not go into medicine to make a big income. I think at least the physicians in my generation were attracted to medicine by you know what you can do for people, and the idea that you could be independent, work for yourself, sort of be your own person...what we do in a hospital as our default is to help, is to save people, and in doing that we don't think about the money. We don't. It's the last thing on a physician's mind is what money we're spending to bring someone back."

Young Americans

...young physicians see a different horizon than guys and girls in my era,...and I think they're much more protective of their private time. I think that they're much more eager to be employed, to not have the responsibility to run their practice. I think part of that's because... it's hard, the opportunity to hang out your own shingle now is very difficult. It's too expensive. You can't afford it. And so you know young people don't want to take that risk, and there's more of a shift mentality you know. In my group, we sort of never get away from it, even on our nights off, you're still a little bit on edge. It's what you do. It's part of your life, and I think that the newer generation of physicians, there's more of a you know you work your shift, they're long hours, but at the end of things you really are off and you have your life. That is what it is."

Chumley, Get me Out of Here

"...a lot of people that come into emergency rooms don't want to be there, They didn't plan to be there. It's not like you have a relationship with me, you picked me as your doctor, I operate on you and something doesn't work out right, that's different. Emergency room, you come in, you don't want to be there, you don't know anybody, nobody knows you. If it's really a bad situation, there's lots of things going on, things can drop through the cracks without tight protocols.

"...what motivates someone to have a for-profit is to profit, but I think not-for-profit is the best for the country because I think it's cheaper. I think if not-for-profit hospitals can adopt some of the fiscal restraints that for profit hospitals have, it would be a valuable thing to do. But keep that savings as opposed to giving it out to shareholders. But in a full profit system, that money savings goes to shareholders. In our system it goes back into this hospital."

Scary Things

"...the thing that scares me the most [about the healthcare debate] is just the thought of having sort of like a massive [government] Medicare or Medicaid [system] and having all of the inefficiencies that brings, and ending up with a system that is poor, a hospital system that's poor and having no ability to offer really the best to our patients. That's what scares me the most...we lose 20 percent on Medicare admissions, and so if we lost 20 percent on everybody that came in, we'd have to do something different, and as part administrator, the first thing I would do is limit our capital budget. So, the new stuff that we buy, every year we buy $30 million dollars worth of new equipment here, that would stop. It would have to stop. We would have to lay off people because we'd have to ...make up that 20 percent, so the easiest way to make it up is to not buy new stuff, and that's what we do in our personal life. But when you're talking about healthcare, new technology is expensive, and the people that are driving new technology expect a return on their investment."

"I think everybody needs insurance, so you know if you don't have insurance, you need to get insurance....I'm not a politician, but there's something to be said about insurance reform and making insurance more competitive so that even people that don't have a lot of money can have some insurance...You know the only person that ever asked me about how much something cost was someone who had money but no insurance. They want to know what's it going to cost because they're going to write a check for it...Somehow we all need to feel some of the pain of other than writing a check for the insurance company. We need to feel that cost issue. But I do think there needs to be insurance reform, and I think everybody needs insurance, but I would start with trying to make there be more competition between insurance carriers so that there's affordable insurance."

John Stanton