The morning newspaper reports the bankruptcy of a large inner-city hospital in Philadelphia. Hahnemann Hospital—which has 496 beds and treats 56,000 patients a year in its emergency room—announced it had liabilities in the range of $100-$500 million and assets in the range of $10-$50 million (in other words, it is a financial disaster).
News reports state that the hospital has stopped accepting trauma patients despite statements from government regulators that this was not acceptable. One report says the state has issued an order for the hospital to “cease and desist” its closure plans. Along with court battles is the weighing in of one presidential candidate, Sen. Bernie Sanders (D-VT), who calls closure of the hospital “insane.”1
While I have no information about this confused state of events beyond that published in the media, my belief is that events like this are likely to occur from time to time—possibly with increasing frequency—in coming years. Many academic medical centers located within inner cities are meeting important healthcare needs of a community in which poor nutrition, obesity, drug use, limited education, chronic medical illnesses, and poverty are becoming increasingly common.
As regulatory requirements (think electronic medical records, compliance programs, etc.) and increasing costs overall drive up expenses, our society is increasingly unwilling to write larger and larger checks to cover the costs for those who are uninsured or underinsured.
I suppose fans of Darwin would say that this type of process is necessary to winnow out those institutions that cannot adapt to the changing realities of our healthcare system. Increasingly, for teaching hospitals in urban areas, the game is to provide excellent high-level care for complicated problems in order to attract complicated patients with good insurance who will travel to access this high-quality care.
Payments received for the care of these complicated patients can then be used to subsidize the care provided to local patients with “bread-and-butter” medical issues and whose insurance does not come close to covering the cost of care (Medicaid) or who have no insurance at all and lack the means to pay.
My reference to teaching in the paragraph above highlights one bit of collateral damage in this drama —the ophthalmology residency program in this hospital is being shut down. Though I don’t know a great deal about this particular residency program, it is clear that inner-city hospitals provide fertile ground for residents eager to learn by helping patients. Preventing or reducing vision loss from diabetic retinopathy and glaucoma—two common diseases that disproportionately impact these communities—allow residents to have a positive impact.
The ocular trauma that is unfortunately too common in our large cities provide residents an important experience. And few things are more delightful to an ophthalmologist-in-training than restoring the sight of a person with a severe cataract who cannot afford to pay anything. It will be stressful for the ophthalmology residents (as well as those in other specialties) if they must relocate to different programs in different cities, but in the past such residents have been assured of the ability to complete their training.
It is not good for our profession or the American public, however, if the number of training slots in ophthalmology is allowed to decrease. With the continued growth in the U.S. population, combined with the demographic tidal wave of senior citizens, this is not a good time for us to reduce the number of future ophthalmologists.
Peter J. McDonnell, MD
E: [email protected]; P: 443/287-1511
Dr. McDonnell is the director of the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of Ophthalmology Times.