Tuesday, January 8, 2008

The Ethics of the Hospital Safety Net (2)

The U.S. hospital safety net is under siege. Today’s New York Times reports on yet another safety net hospital - Grady Memorial Hospital in Atlanta - that is teetering on the edge of disaster. This posting takes up where my December 3 discussion of similar issues at the University of Texas Medical Branch in Galveston left off.

Grady has been serving the poor in Atlanta since 1892. A quarter of Georgia’s physicians have had at least part of their training at Grady. The hospital has 953 beds. The Grady Health System, which includes nine neighborhood health centers, does 921,000 outpatient visits per year.

Grady is in dire straits. It has major managerial problems, including allegations of corruption. A consultant’s strategic plan, presented in June, 2007, is painful to read. Grady is deeply in debt and hemorrhaging money each month. The consultant recommended radical managerial surgery, but the governing board, subject to strong political pressures, put off action. In November the board voted to turn Grady over to an independent 501(c)(3) corporation, but that effort is currently embroiled in complex local politics.

From the perspective of ethics, Grady, like the University of Texas in Galveston, faces a classic dilemma, which will not go away even if Grady solves all of its managerial problems. Like the Galveston program, it could improve its financial status by dropping the biggest money-losers. But doing this would violate the charitable mission for which it was founded. The impact of internal resource allocation choices go beyond what a society as wealthy as ours can or should accept. But the wider community is reluctant to reallocate its own resources, whether through increased taxes or other means.

Our fragmented health system makes it all-too-easy for us citizens and our leaders to avoid responsibility for what happens. Grady can blame the outside community. Politicians can blame Grady’s management. Atlanta can blame the suburbs. One has to suspect that one of the purposes of our stupifyingly complex system is just this – to give all parties deniability about the bad things that happen.

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