Following a long run of defeats in the cost-cutting wars of the 1970s, medical economics has swept into the new decade with a luminous innovation: the application of the soil-bank concept to hospital care.
Based on giving hospitals a bonus for each unoccupied bed -- just as the soil bank rewarded farmers for not growing crops -- the scheme has made its debut in New York, where, as elsewhere, regulations, pleading, threats and penalties have proved futile against ever-growing hospital bills. The cost surge continues, of course, because there is no contending with a system that deifies the doctor's judgment and ensures that whatever he or she orders for the patient will be delivered -- for eventual payment by faraway insurers, including state treasuries.
This guarantee of reimbursement applies, too, to what the hospital trade refers to as "gravy days," shorthand for the extra day or two -- in the range of $150 to $300 per day -- that patients are sometimes kept on, not for medical necessity, but for the sake of the hospital's bank balance.
Since nothing else seems to work against these revenue-raising tactics by houses of healing, New York's health planners have concluded that everyone can save money if hospitals are paid for unoccupied beds. Or, as a state health official told The New York Times, "If you decide to pay hospitals a bonus for empty beds, then what you are going to get is empty beds. If you continue to pay hospitals for filling beds, then they are going to be filled."
Apart from its ludicrous aspects, the adoption of this last-ditch system of payment for non-service merits notice for what it says about some of the hidden-away realities of the American health-care enterprise. Certainly, many physicians and hospitals have no part of the devious tactics that inspired New York's bizarre bonus scheme. But enough of them partake to an extent that caused one of the most experienced health-planning systems in the country to conclude that it's easier to buy off hospitals than it is to get them to practice reasonable thrift.
While the hospital industry and the private-practice segments of the medical profession insist that we'll all be better off if they are allowed to continue to police themselves, the evidence is that this just isn't so. Hard-pressed to amortize the expensive equipment that physicians demand in the hospitals to which they send patients, hospital administrators quietly signal back about the need to keep up the flow of revenue-producing patients. And when there aren't enough patients, the temptation to exploit "gravy days" can be irresistible, especially when any decision can be passed off as professional judgment about what's best for the patient.
A persistent characteristic of the medical profession is that it runs a lively and strongly opinionated private grapevine about the quality of individual doctors and hospitals. For the well-being of their families and friends and themselves, the people inside the system know the good ones from the bad ones. And they are not hesitant about letting loose when they are with each other or confidentially offering their views to selected outsiders.
But when the issue arises of setting up a formal system to let the general public know about sharply differing mortality rates in community hospitals and other matters of medical quality, the club closes ranks and insists that its own professional standards are the community's best safeguard.
If that's the case, why is New York paying a bonus for empty beds?