Allocation of Resources: Economic Factors

A "wino" with pneumonia and septic shock arrives in an emergency department, obviously requiring admission to an ICU bed, but the hospital has no available beds. The emergency physician calls a private hospital about five miles away and asks them to accept the patient in their ICU; he makes it clear that the patient is completely destitute.

The next available bed is in a hospital 25 miles away. Should the physician in the private hospital accept the transfer? Should he, instead, pass the decision on to the chief of staff to make? Does the fact that the physician will not be taking the brunt of the financial loss make the decision easier?


Commentary

There are weighty reasons for not putting the physician in the middle of these resource allocation decisions. The physician's primary task is to use available resources as best as possible to treat patients. He or she should not have the burden of deciding which patients are entitled to more or fewer resources.

That decision should rest with the institution on whose staff the physician practices. In my judgment, it is the citizen-taxpayers and the hospital administration (including the hospital trustees) who should shoulder the responsibility. Thus I do not believe that the responsibility for accepting or denying admission should rest with the physician or the chief of staff. It should be governed by institutional rules.


And these rules should be governed by the state's an­tecedent public policy determination regarding the obligation of different types of hos­pitals to accept and treat emergency patients, especially the indigent.

With respect to this case, we know nothing about the state's policy regarding care of the indigent, nor do we know much about the health care institution's policies. Often, in the absence of a strict institutional rule against turning indigent patients away, patients who cannot pay for their care are "shunted off" to a public hospital — even if in doing so they are exposed to additional risks through longer travel time.


The result of this practice is that some hospitals find that they treat an inordinate number of patients who cannot pay for their care. In this situation, the sensible approach for the hospital would be to do one of three things: (a) arrange to share the load with neighboring hospitals; (b) seek governmental reimbursement through an all-payer system (for ex­ample, several states, including such disparate ones as New York and Florida, have resorted to different arrangements to raise a pool of money from a tax on hospitals, insurance premiums, or hospital admissions, which is then reallocated among hospitals in accordance with the amount of charity work they perform); or (c) take its story to the community to solicit some "philanthropic" funding.

The case of the wino with an acute condition is complex, since it represents a class of cases which can entail thousands of dollars in treatment costs. An important question, then, is whether our society is rich enough to provide individuals such as the one in this case with quality care. My answer is an unequivocal "yes." A nation that will spend about $415 billion per year for health care should not find it particularly difficult to deal with this patient.


The next question is whether all hospitals or only designated hospitals — such as public hospitals — should be required to provide such care. Since we do not have national health insurance, and since Medicaid fails to cover about half of the poor, the issue of who pays for an uninsured patient is a key open issue.

My preference is to institutionalize three arrangements: (a) broaden the coverage for Medicaid; (b) avoid relying on public hospitals to treat all of the poor; and (c) make use of all-payer systems (or some similar device) to help nonpublic hospitals to treat their share of indigent patients. Together, these three approaches would provide adequate access to care for the indigent in a way that distributes the financial burden fairly.


The final issue is how much money should be invested in bringing patients such as this one through their acute episodes. I would say that the answer depends in part upon the patient's age, history, capacity to cope on the outside, and other subjective factors. For instance, I do not think that it makes a great deal of sense to invest very large sums in episodic cures if the patient is likely to reappear in a few weeks in the same or worse state. I would try to moderate treatment in accordance with probable long-term outcomes.

The question can be raised whether this structure applies to the patient with money as well as to the indigent patient. I believe that citizens with money are entitled to buy, without restriction, whatever goods or services they desire. However, prudence requires that the expenditure of public money be assessed in terms of the value of alternative uses to which it might be put.


In this case, while it would have been preferable for the first hospital to admit the wino to an ICU bed, the hospital still could have admitted the patient and sought to stabilize him and only later moved him to a public hospital.

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