It's easy to say hospitals should economize.
But what does a hospital -- specifically, Georgetown University Hospital in Washington -- do when a patient comes along whose care costs $26,000 for 20 days?
The answer, says Dr. Jack Stapletone, medical director: care for him, tide him over a crisis, repair his failing heart.
The $26,000 patient's desperate condition, and bill, are by no means unusual.
His story shows why modern hospital care can cost so much. It shows how dollars are gobbled up by people, by technology and by some overbuilding and waste.
This recent $1,300-a-day patient at Georgetown Hospital was Edward Cousins of Alexandria, Va. Age 55, father of 15 children ranging in age from 3 to 26, Cousins now possesses a new heart valve made from material taken from a pig at a cost to him of $910.
But the $910 was only for the valve itself; it did not cover that $26,000 in what you might call installation charges: an $18,999.90, 20-page hospital bill and the rest for the doctors.
More than 200 persons helped give the care. The lowest paid were the orderlies at $4.39 an hour. The highest was a surgeon, whose operation and care cost $4,750. Too high or too low, those are going rates.
The legions of people -- three today for every one 30 years ago -- are required mainly to tend the machines sold or leased to the hospitals by Pfizer, Philips, Cordis, Travenol, Data General, GE.
Edward Cousins' surgical operation, the tests, the care were the kind we all want when we are sick, even as we complain that our hospital bill, and the nation's, are too high.
The X-rays, heart trachings and blood tests began only minutes after he was admitted last June 25. His admitting physician was Dr. Stapleton. Cousins was suffering from such severe shortness of breath and chest pain, Stapleton remembers, that "he couldn't walk 10 steps without resting."
June 26. Patient Cousins was taken to the Cardiac Catheterization Laboratory, where slim tubes were threaded through blood vessels into his heart to assess his condition. The readings showed that one valve in his heart had become virtually clogged, and his heart was pumping only half normal output. The blood pressure thus building up in his heart and lungs was almost ready to kill him.
The hospital's charge for this information: $602. The total value of its "cardiac cath" room and equipment: $550,000, including a $179,135 Philips Cardio-Diagnost machine to take image-intensified X-ray movies, and a $23,100 International Vido midi-computer for immediate analyses.
Cousings was rushed to the Coronary Care Unit. That very night he went into collapse. He blood pressure fell and his heartbeat was irregular. Intravenous theraphy, drugs and fluids brought him back.
The life-saving care was given by a platoon of doctors and nurses in the $400,000 Coronary Unit, which is only one of several specialized units in a new $21.7 million Concentrated Care Center.
Counsins' erratic heartbeats had sounded an alarm on this unit's $72,709 Menner-Greatbatch Physical Sentinel. For some hours he had been watched virtually every moment by two doctors and two nurses for their addition to the hospital's total personnel bill: $44.5 million of its $61 million a year budget.
June 29. He was transferred to Surgical Intensive Care. Another $400,000 unit. A cardiologist and technician inserted a nylon catheter into an artery in his arm, then all the way to his lungs to record blood pressure. He also was given a pulmonary function test to see if his lungs could withstand surgery. And cardiologists passed still another catheter into his heart to be attached to a bedside electric pacemaker.
June 30. Major heart surgery. Surgeons connected blood vessels to artificial heart-lung machinery -- a Travenol pump and oxygenator -- to free his heart of blood flow temporarily. Noted heart surgeon Charles Hufnagel then removed his clogged and calcified heart valve and substituted the $910 Edwards-Carpenter Porcine Bioprosthesis.
Finally, Dr. Hufnagel bestowed on Counsins a permanent Cordis-Lambda-Omni-Stanicor Internal Pacemaker (at $2,900). Its leads were sewed into his heart. Its main element, the size of an old-fashioned pocket watch, was tucked beneath the skin of his left upper abdomen.
Cousins' operating room fee: $2,568, to cover his five hours' occupancy of the $500,000 "OR," the services of 20 people and the time on its $75,000 worth of General Electric X-ray equipment, $15,000 G.E. monitoring system, $5,000 worth of instruments and other paraphernalia.
Patient Cousins spent 15 more days in the hospital for an "uneventful" recovery, if uneventful can be applied to an existence with a half-dozen tubes and catheters in his body much of that time.
His total Special Care, Intensive Care and Concentrated Care Unit charges: $7,220. Central Supply charges: $3,419. Laboratory charges: $1,835.50. Inhalation therapy: $1,100. And much more.
Connecticut General Counsins' health insurer, paid all but $1,681 of his bills. This is the kind of comprehensive insurance coverage called a blessing by patients who have it, and a "disincentive to economy" by those who think Americans should have to pay a larger share of their medical bills in cold cash to avoid saddling, the country with so large a tab.
Even for ordinary patients at this advanced teaching hospital, the average cost of care is $381 a day. Again, high technology is part of the story.There is $1,179,300 worth of Philips X-ray gear in radiology; a $425,816 Pfizer CAT scanner X-ray machine; a $488,323 Varian Radiation LINAC, or linear acelerator, a medical atomsmahser to attack cancer cells.
"But it's not really these price tags that hit us," said Charles O'Brien, administrator. "They're only one-time costs. The cost is really the people to run these things."
The American hospital is the place where more than half of the country's health dollars are spent, counting both hospital bills (40 per cent of the nation's health bill) and doctors' charges.
Cases like Counsins' aside -- it is still too early to assess the long-range value of his treatment -- critics of medicine say billions are being wasted in a kind of super-American technological frenzy which piles drug on drug, machine on machine and operation on operation, often to extend life only slightly.
Even where machines like the new half-million-dollar CAT scanners -- computerized X-rayers that "see" a slice of any part of the body -- have undeniable value, they multiply far beyond need, it is argued.
Many of the machines are underused. A study of 15 Boston hospitals found that use rates of five types of new equipment -- diagnostic X-ray units, cardic catheterization units, patient monitors, computers and automatic blood analyzers -- averaged no more than 50 to 60 per cent. The rest was down time.
Hospitals everyplace also have empty beds.
Georgetown Hospital has been running only about 75 per cent filled, which means a wasteful fourth of its beds are empty, on the average. This is a kind of growing cancer in both Washington and its suburbs, caused by unrestrained hospital building and expansion.
At the same time, Georgetown Hospital had to pay $844,786 in interest charges last year on $16,569,923 in loans for some of its new building and equipment.
Some of the capital and interest charges show up, unidentified, on every patient's bill, just as they do in other hospitals. Every patient's bill, including Edward Cousins', would be somewhat smaller if the hospital were more fully occupied and "unit costs" were down.
Empty bed-itis has unfortunately become an All-American hospital sickness. A Blue Cross-Blue Shield "National Bed Check" found national hospital occupancy only 74 per cent, meaning that if the 1.5 million beds in the nation's 7,000 hospitals, 390,000 are empty on any average day.
Federal health officials think half the empty beds could be shut down without peril. Dr. Walter McClure of InterStudy, a leading health policy research group, thinks one hospital in five could be closed.
In a typical state -- Maryland -- "the hospitals have made every effort to prevent us from influencing the amount of capital construction," John S. Cook, state rate analyst, has said. "They want to build every Taj Mahal they can get."
Bankers, insurance companies and other financiers compete to lend hospitals the money for their new equipment and buildings, because -- with the Medicare, Medicaid, Blue Cross health insurance system -- it is almost impossible for a hospital to go broke. Blyth Eastman Dillon Health Care Funding Inc., "investment bankers to the health care industry," boasts in an ad in a hospital journal that it floated a massive $95 million loan for Cedars-Sinai Medical Center of Los Angeles.
So the intensive care units, the coronary units and the machines multiply, and some -- including Georgetown Hospital's -- remain under-used.
No one is questioning the use of the machines on an Edward Cousins, who needs help today. But the statistics are piling up too on the nationwide waste.