covered by the program was admitted for treatment. Now a complicated reimbursement program has been implemented over a multi-year span which is based on diagnostic categories of illnesses and is referred to as prospective payment.3 What this means is that hospitals will know in advance what Medicare will pay for the treatment of a particular illness. If the hospital can provide service for less than Medicare will pay, it can keep the balance as profit. Should their costs exceed the amount reimbursed, however, the hospital experiences a loss. As was predicted, most insurers have followed a similar fixed reimbursement formula.
In response, as you can imagine, hospitals and medical staffs are having to re-learn much of their way of providing health care. Some of these changes are positive and others will create further problems in the future. For example, tests which are not critical for the patient's treatment will no longer be performed. This should lower costs for everyone. On the other hand, hospitals have at times provided very humane services which will also necessarily be discontinued. The patient ready for discharge but who has nowhere to go will not be cared for in the hospital until other arrangements can be effected. Again, some illnesses may become viewed as desirable admissions due to their proven profitability for the hospital. Others, however, which become known as marginal, may be avoided. Today, many of the “for profit” hospitals will not provide pediatrics, obstetrics-gynecology, psychiatric or emergency services as they are known to be cost-inefficient.
Other outside agencies exist which seek to guide the development of hospitals. Federal and State cost containment and review groups must approve price increases, allocation of beds, and new construction in an effort to avoid an abundance of resources which would lead to ever increasing costs. By the mid-1970s these outside agencies made hospitals one of the most highly regulated enterprises in the United States.4 The response of the health care industry has left the neighborhood hospital where you were born ill-prepared to cope with the new structures which are emerging. The hospital will soon be only a part of the effort to treat and / or prevent illness. The emerging structure is that of the Health Care System, a corporate or holding company model.
The function of the “system” is to capture a significant portion of the health care market in its geographic region. It is a business approach with key notions being “cost containment” and “revenue production” without compromise in quality of care. To achieve these goals, the system must structure itself to accomplish two things. First, it must market health care, including preventive and rehabilitative functions. This means offering a diversification of services, some of which were originally provided by the hospital. This is a reversal in the earlier trend to center activities in the hospital. Second, each division in the system becomes a referral source to the hospital, in order to maximize occupancy rates, and, in turn, the hospital refers back to other parts of the system for its specializations.
The changes in the hospital structure relate both to its role in the system and the severe regulations described earlier which govern its functioning. Rate reviews, price structuring, and prospective payment, for example, do not currently apply to outpatient services but only to inpatient hospitalization. Consequently, the system will seek to “unbundle” hospital services and separate out any function which can be independently organized. Some of the more common services which have been unbundled are surgery procedures which can be done on an outpatient basis. “Surgi-Centers” are the result. Emergency clinics are another illustration. Not only can the system charge more for services provided by these facilities, but, should the patient require more serious attention, s/he can be referred to the system's hospital. If the patient has experienced a stroke and is treated at the hospital, upon discharge the patient can be referred to the system's “Wellness Center” or “rehabilitation program” for recuperative care.
Economic restraints on the hospital have resulted in the necessity to restructure health care delivery. Marketing this health care has fashioned a much broader, more wholistic approach. It is quite different from the single-minded acute care facility which has been the identity of most hospitals. In the system the hospital is only one dimension, although it remains the central one.
Obviously, other disadvantages await the neighborhood hospital which continues to try and stand alone. Larger systems will either link themselves in cooperative voluntary ventures or be owned/leased outright by corporate structures, as in the case of Hospital Corporation of America. By virtue of size, purchasing and personnel advantages abound. Supplies can be bought at such volume to assure discounts when compared to single unit purchases. It is hoped that these savings can be passed on to the patient. If this is true, then the patient will prefer to select admission to a hospital which is part of a larger system, and not the local, independent, neighborhood hospital. An idea which improves health care can be duplicated throughout similar facilities in a larger system. As well, the system may only have to employ one person with high-tech skills, sharing the costs, and make him available to all parts of the system. These are but a few examples of other advantages when systems are compared to your free-standing, neighborhood hospital.
The changes which this revolution represent are an industry's efforts to meet the need of providing health care services at a reasonable cost. These changes are in their early stages and their impact is not yet clearly known. They attempt to be more cost efficient for consumers while being businesslike in approach. Clearly, if the system fails in this country, the persons hurt most will be those who have the least ability to gain adequate care: the poor, the disabled, and those on fixed incomes.
Meaning For Ministry, Lay Persons, and the Church
Unlike the free-standing hospital of the past, which provided crisis intervention when illness or accident occurred, the system will market health care. Persons who wish to participate in maintaining or enhancing their state of health will find organizations such as Wellness Centers available. In this sense, the shape of health care will become more wholistic, which is a positive development. The dimensions of health which systems will find themselves least able to provide, however, have to do with life questions of meaning and purpose.
These are spiritual concerns which have as much to do with our health as good nutrition, proper exercise, and stress management. Although chaplains and social workers will continue to be employed by hospitals, the need for the Church's ministry during the crisis of illness will probably increase. This will be true because of several factors, all related to illness being a “teachable moment” that invites a re-examination of life values. First, the patient's experience of hospitalization will likely become more brief and intense. Inpatient days will be reduced. There will be less time in the hospital, both before and after the onset of illness or having surgery. Second, opportunities to review life experiences and reframe values and priorities will be minimized. Yet questions like “Why is this happening to me?” “What meaning does it have for my life?” “What have I learned?” remain important in the adjustment and recovery process.
What is being communicated here is not that pastoral ministry to ill persons is new or that pastors have neglected their parishioners. The message is that the need for the Church's ministry is heightened by the changes going on in hospitals. In his popular book Megatrends,5 John Naisbitt talks about the growth of high technology creating a corresponding need for “high-touch.” It is not the intent of hospitals to be less personal as they become more businesslike and as medicine relies increasingly on new technology. It will happen, nevertheless. The patient's need will grow for someone to enter his life who has no form for them to complete, no technology to be explained, no procedure to be done. The pastor is someone who can sit quietly, hear what the patient is feeling, respond with empathy, and relate it to a faith that enhances healing and wholeness.
This same need for “high-touch” exists for persons who work in hospitals. The new technology saves lives, but it can also prolong and unnecessarily complicate dying. It isn't simply that a respirator frustrates the natural occurrence of death. More critically, a machine that can breathe for you has almost become a part of the natural order. In the case of reversible causes, such as a drug overdose,
