FYI, wife has worked the trauma floor (and some other floors, too) of the metro county Level 1 trauma hospital as well as pool/temp/agency/whatever nurse for several of the hospital systems in the metro area. She has made a few observations and come to a couple of conclusions.
1. County hospital, where most of the funding comes from county sales tax, has been the most cost-conscious and focused on getting the patient out of bed, well, and out the door so they can get on with their life. Private hospitals, not so much.
2. Quality of care was highest at the county hospital and she would rather be treated there for just about anything (save pregnancy). Despite the much less pretty and less comfy physical plant.
3. Patient-contact personnel (nurses, docs, techs) were of higher quality at the county hospital, despite lower pay relative to private hospitals. Admin were worse, however, as they were political graft jobs for the local dominant NAM.
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We discussed this a bit.
A. In the case of trauma, it is no great mystery. Most traumas are NAMs doing stupid NAM tricks: GSW, knifings, beatings, driving while drunk/high/stupid and similar dumbassery. Many of these are rather catastrophic and Medicaid will cover only a fraction of what it truly costs to get Ghetto Joe out the door on crutches with a colostomy bag after a rival crack dealer gut shoots him...after 6-12mo of intense and costly treatment. Private hospitals want no part of these.
B. In many of the other cases we speculate it is a function of who pays the bills. For the county hospital, local folks who live and buy in the county pay a large proportion and put pressure on the hospital to be efficient. Medicaid and insurance companies are smaller players.
C. CMS is of the Devil. The private hospitals worship CMS and the patient satisfaction surveys. Those surveys have an impact on Medicaid reimbursement. A drug-seeking patient at the county hospital is dealing with nurses and docs who know the score and will keep him out of pain, but will not get him high out of his mind. Nurses and docs will also risk patient ire in order to get them out of bed and moving, so they recover faster. The same patient at the private hospital will be catered to and kept in a state of drooling bliss for fear of negative CMS survey results. These patients are generally not particularly severe and taxing, med problem-wise. They can be costly PITA to the personnel but cost the hospital less than the severe trauma cases. Risk patient ire by calling them on their drug-seeking and insisting they get out of bed to walk? Heh.
D. Private hospitals cut costs on quality of personnel. LOTS of foreign-born and taught docs. The typical case is the Indian woman who could not give a damn about her patients and pretty much hates doctoring altogether. But family back in BFI and the ticket to America required a MD and a job as a doc. Then there is the female doc from the USA who realizes she would rather be doing almost anything else...but has student loans to pay, pay, pay. My wife is of the mind that she wants no female, foreign, or NAM doctor treating her or those she loves. [Nursing & techs are another matter.]
E. County hospital can have a sense of mission the private hospitals lack. The former top dog of the county hospital was a big name in the oldest S Baptist church around town. He liked getting paid, but he burned with a sense of mission that pay can not provide. That permeated management through to the docs & nurses. [After he retired and was replaced with a typical health care mgt professional from back east, that sense of mission has suffered. Especially as racial cliques were allowed to develop for fear of race-grievance allegations. The old guy would have none of that crap and had a ZFG attitude WRT race-hustling in the patient-contact personnel.]
F. American-born docs and doc students working in a team. Greater proportion of docs were American-born and the local med schools had them train at the county hospital. Each patient had several docs, ranging from baby-docs to ancient docs who had to ride scooters to/from surgery to patient bed. When patients had difficulties, there were several docs who knew the score, not just one foreign-born doc who went to med school in Lower FGM-istan who doesn't really like doctoring or patients.
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I think cost-pressure is at the heart of the issue when it comes to health care spending. The county hospital has pressure imposed on it from local folks, whereas the private hospitals have pressure imposed only from insurance companies and more distant gov't entities. Neither has pressure from patients, as the better-off have insurance and the indigent live their lives subsidized from cradle to grave by fed.gov and its more diffuse taxpayers. Even disregarding the massive web of regulations, there is now no real market pressure to bear from the end-user of health care to keep costs down.
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And as far as cost & outcomes vs other first-world countries, get back to me when Australia has 30%+ NAM patient population with the attendant violence and poor lifestyle habits.
