by James Fieseher, M.D.
Dr. Fieseher writes extensively about America’s healthcare system and the need for equal, affordable access to all citizens. This piece originally appeared in Seacoastonline.
"It's just business nothing personal." ~ Mario Puzo.
The reality of for-profit medicine has come to Frisbie Hospital and the communities it has served so well. For those who believe that hospitals should be allowed to make a profit, you might want to consider where that profit comes from and what that means to the communities served.
All hospitals, especially community hospitals, operate on a tight budget. There is very little room for “fat” or unnecessary services or personnel. New medical equipment is costly and used equipment, while cheaper, may need to be maintained and repaired at a higher rate. The trained staff: doctors, nurses and technicians with specialized skills need to be recruited and checked not only for proper credentials, but without any “red flags” that might endanger patients. Additionally, there is the problem of reimbursement of services from medical insurers and financially strapped patients.
So how does a hospital stay solvent or make a profit?
Well, one way is to form a system, such as HCA or Mass General, that can combine services across multiple hospital facilities. Unifying billing departments, IT departments and employee benefits can reduce overhead costs for multiple facilities. But that can only take you so far. Any additional profits require “cutting corners” and examining services that provide either the most or least revenue.
Hospital services that bring in the most money from medical insurers involve procedures such as colonoscopies, joint replacements, radiology procedures, cancer treatments and cardiac (heart) procedures.
Non-procedural services involving diagnostic medicine such as primary care, neurology, pulmonology, and endocrinology (to name a few) are reimbursed at a much lower rate and tend to be “loss leaders,” or services that attract patients, but operate at a financial loss for the hospital. These services are seen by insurers as being more difficult to quantify despite requiring knowledge across a wider array of medical subjects combined with interpersonal skills to obtain the necessary detailed information to make an accurate diagnosis. This difficulty in objectifying or quantifying results may account for the lower insurance reimbursement rates.
All hospital administrators understand this, but in a for-profit system, increased profits come from “squeezing” more services from those loss leader services such as primary care. This means cutting support staff such as MA’s (medical assistants) and nurses while simultaneously demanding that those practitioners (doctors, nurse practitioners and physician assistants) see more patients per hour.
Since outpatient services such as primary care are designed to promote healthy lifestyles and prevent medical problems, reducing those services has the added financial “benefit” of increasing the demand for in-patient hospital services.
HCA waited several years before instituting these cost cutting measures in Portsmouth. This included outsourcing their endocrinology department (diabetes specialists), pulmonology department and downsizing primary care and neurology by as much as 75%. Much of the Portsmouth community had to look elsewhere for those services, many of whom still don’t have a primary care doctor.
But with its increase in business profits in New Hampshire, HCA felt comfortable making a bid for Frisbie Hospital. Many of the primary care physicians at Frisbie Hospital apparently felt that trying to do more services with less support would lead to a lower quality of care for their patients with an increased chance of making harmful medical errors in judgement.
The importance of primary care providers to the community cannot be overstated. Ready-care centers such as Convenient MD and Clear Choice address problems that arise but are not set up to prevent medical problems or promote a healthy lifestyle.
The professional integrity and personal care of those primary care physicians at Frisbie Hospital will be missed. For example, Dr. Deborah Harrington is a past-president of the NH Medical Society and typifies the quality of care that will be lost to our communities.
Ironically, the recent hospital mergers on the seacoast (Frisbie with HCA and Wentworth-Douglass with Mass General) illustrate the financial advantages of a more unified healthcare system, both to the facilities and the patients. But to make a profit, a hospital system has either to charge higher prices or reduce expenses by pushing primary care providers to see more patients with fewer support services beyond reasonable abilities.
As long as profiteering is a quality that we tolerate in the field of medical care, we will continue to lose non-procedural medical providers and preventive care services.
About the author:
Dr. Fieseher has been a primary care physician for 30 years, starting with Dover Family Practice in 1990. He has practiced in Dover and Portsmouth for most of his professional career, but also spent three years in the Veterans Health Administration and two years at Dartmouth-Hitchcock in Manchester. He retired in March, 2020, “but can be coaxed out of retirement if I don't have to travel too far.”