# New tred of Mega hospitals pros and cons **URL:** \ **Category:** In My Humble Opinion\ **Created:** [October 30, 2014, 3:46am UTC](https://boards.straightdope.com/t/new-tred-of-mega-hospitals-pros-and-cons/702966 "2014-10-30T03:46:04Z")\ **Posts on this page:** 13\ **Page:** 3
**Author:** ![Derleth](https://avatars.discourse-cdn.com/v4/letter/d/b9e5f3/32.png) [@Derleth](https://boards.straightdope.com/u/Derleth)\ **Post date:** [November 4, 2014, 7:51pm UTC](https://boards.straightdope.com/t/new-tred-of-mega-hospitals-pros-and-cons/702966/41 "2014-11-04T19:51:07Z")
Maybe this has been said in passing, but it should be stated more clearly: Increased outpatient care isn’t solely due to insurance. It’s also due to improved medical techniques. A big example is the rise of laparoscopic surgery, which has much better patient outcomes in terms of bed rest needed post-surgically and post-surgical pain. Both of those factors push people out of the wards and back to their homes, because you don’t need a nurse just to handle uncomplicated dressing changes and a few pain pills. (And, yes, those pain pills would have been prescribed for outpatients anyway. You can’t have everyone with a bad back spend their lives in a hospital, and you didn’t have that kind of inpatient care even back in the Old Days.) Another example is how little time women in labor spend in hospitals. I don’t know if that’s improved technology, improved knowledge (they didn’t need to be in the hospital that long even back then), or both. ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [November 6, 2014, 4:21am UTC](https://boards.straightdope.com/t/new-tred-of-mega-hospitals-pros-and-cons/702966/42 "2014-11-06T04:21:10Z")
An article[about mega-hospital _systems_](http://www.forbes.com/sites/brucejapsen/2014/09/14/insurers-fight-hospital-mergers-as-obamacare-pushes-value-based-care/) and the pushback against them. ---
**Author:** ![TriPolar](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/tripolar/32/3008_2.png) [@TriPolar](https://boards.straightdope.com/u/TriPolar)\ **Post date:** [November 6, 2014, 4:24am UTC](https://boards.straightdope.com/t/new-tred-of-mega-hospitals-pros-and-cons/702966/43 "2014-11-06T04:24:57Z")
> [@DSeid](#): > > An article[about mega-hospital _systems_](http://www.forbes.com/sites/brucejapsen/2014/09/14/insurers-fight-hospital-mergers-as-obamacare-pushes-value-based-care/) and the pushback against them. Uh oh. Somebody let the cat out of the bag. > [@](#): > > Consolidation promises greater efficiency, but all that ever materializes is greater costs ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [November 6, 2014, 5:22am UTC](https://boards.straightdope.com/t/new-tred-of-mega-hospitals-pros-and-cons/702966/44 "2014-11-06T05:22:35Z")
Said by “Brendan Buck, former press secretary to Speaker of the U.S. House John Boehner, who was tapped this spring to be vice president of communications at America’s Health Insurance Plans” … Well duh he’d say that. Of course, and as stated upthread, hospital and/or physician systems want the insurer to view them as a must-have … and the insurer wants to be able to pit systems against each more and have their contact be what the other side must have. From the same article: > [@](#): > > Blue Cross and Blue Shield plans are continuing their long domination in the market of individual health insurance policies. Wellpoint (WLP) and independent Blue Cross and Blue Shield plans have the greatest market share or second greatest share in California, Colorado, Connecticut, the District of Columbia, Florida, Indiana, Maryland, Michigan, New York, Rhode Island, Vermont and Virginia. Mind you I do not disagree with the thought: the motivation for large hospital systems is to have bargaining power and hospital systems are not the best agent of change to deliver cost-effective care. [Physican-owned (or at least led) groups conversely are](http://www.californiahealthline.org/articles/2014/10/22/calif-physician-owned-medical--groups-have-lower-care-costs). [Why?](http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/accountable-care-organization/look-physician-led-acos-whats-driving-t?page=full) > [@](#): > > physician-led groups achieve savings differently than ones owned by hospitals. Physician groups work to save money by keeping patients out of the hospital by taking better care of them upfront. Hospital-led ACOs focus on better managing patients once they are admitted. > > “Physician groups may have more freedom to work out how to succeed in a shared savings plan than a hospital,” Kirschner says. … No silver bullet that either … as that article points out the physicians need to develop a culture of medicine delivery as a team sport and with the patient being the population as well as the individual patient, they need to have (or hire out for) a developed and sophisticated IT and administrative infrastructure. Meaningful and believable metrics need to be available and wisely utilized. “Hey kids! Let’s put on an ACO!” won’t do it. ---
**Author:** ![WhyNot](https://avatars.discourse-cdn.com/v4/letter/w/c77e96/32.png) [@WhyNot](https://boards.straightdope.com/u/WhyNot)\ **Post date:** [November 6, 2014, 5:37am UTC](https://boards.straightdope.com/t/new-tred-of-mega-hospitals-pros-and-cons/702966/45 "2014-11-06T05:37:59Z")
> [@Derleth](#): > > Maybe this has been said in passing, but it should be stated more clearly: Increased outpatient care isn’t solely due to insurance. It’s also due to improved medical techniques. Very true. > [@](#): > > Another example is how little time women in labor spend in hospitals. I don’t know if that’s improved technology, improved knowledge (they didn’t need to be in the hospital that long even back then), or both. From the nurse’s perspective, what they’ve done is shift from determining discharge by nursing goals to determining discharge by medical goals. The schedule is determined by the doctors, while the nurses scramble to complete their checklists on someone else’s timetable. My oldest teachers and mentors tell me that they spent days on patient education with new mothers. Feeding, changing, bathing, burping, circ care, infant development, nutrition while breastfeeding, schedule feeding vs. on demand (very out of vogue for a while, all the best scientific mothers trained their babies to a strict schedule!) …and the whole time they were doing it, they were doing nursing assessment for “baby blues” (what today would be considered postpartum depression) and the mom’s coping with her new role, as well as physical healing and watching for complications. That agrees with my grandmother’s tales of two weeks in the hospital after an uncomplicated vaginal delivery. She can’t even recall seeing the doctor for more than the delivery and one day after; all that time was spent on nursing care. Now they have videos you can watch on the TV in your room, often on some sort of “Baby Channel”. Nurses are still monitoring for complications while you’re there, but not for long. And the time for all that teaching is really really cut short. They have checklists, but I know from two babies that they didn’t actually teach or find out if I was competent at all those things the paperwork said they educated me about. But I was medically stable, as far as the doctors and my insurance company were concerned, and so I was discharged. I have almost never seen a client after a hospital discharge who even knew what their admitting diagnosis was, much less learned anything about how to manage their condition. Most of them aren’t even clear on what medications they should be taking at home. I don’t mind, it’s my bread and butter figuring it out and teaching them, but it’s definitely education that wasn’t done at the hospital, no matter what the checklist said. Not effectively, anyhow. ---
**Author:** ![clairobscur](https://avatars.discourse-cdn.com/v4/letter/c/839c29/32.png) [@clairobscur](https://boards.straightdope.com/u/clairobscur)\ **Post date:** [November 6, 2014, 6:12am UTC](https://boards.straightdope.com/t/new-tred-of-mega-hospitals-pros-and-cons/702966/46 "2014-11-06T06:12:36Z")
> [@Dewey\_Finn](#): > > I get the impression that, in the US at least, the number of beds in hospitals is down from decades past even though they’re treating more patients. For example, for a conventional birth, the mother stays in the hospital for less than 24 hours. Many surgeries are done on an outpatient basis. Improvements like endoscopic surgery mean that patients recover more quickly. It seems from what I read that it’s a general tendancy in all western nations, except for some reason in Germany, where hospital stays are _much_ longer than anywhere else. It’s quite obvious to me when I talk with people who are/have been hospitalized. They get some serious surgery (say, kidney removal) and they’re out of the hospital three days later, while when I was younger I would have expected a couple weeks. I wonder if it’s driven more by medical advances or by concerns over cost. Are surgery/post-sugery care/drugs so much better now that what was a concern back then isn’t anymore nowadays? ---
**Author:** ![Gestalt](https://avatars.discourse-cdn.com/v4/letter/g/90ced4/32.png) [@Gestalt](https://boards.straightdope.com/u/Gestalt)\ **Post date:** [November 6, 2014, 6:41am UTC](https://boards.straightdope.com/t/new-tred-of-mega-hospitals-pros-and-cons/702966/47 "2014-11-06T06:41:36Z")
> [@clairobscur](#): > > I wonder if it’s driven more by medical advances or by concerns over cost. Are surgery/post-sugery care/drugs so much better now that what was a concern back then isn’t anymore nowadays? While cost may not be the only concern, it’s definitely a major concern. And I think it’s because Medicare (and therefore every other insurer) will reimburse a lump sum of X amount for a hospital stay for Y diagnosis, regardless of how long that stay is. So a hospitalization for pneumonia for 2 days and a hospitalization for pneumonia for 7 days will net the hospital the same amount of money. ---
**Author:** ![Dorjan](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dorjan/32/12440_2.png) [@Dorjan](https://boards.straightdope.com/u/Dorjan)\ **Post date:** [November 6, 2014, 3:17pm UTC](https://boards.straightdope.com/t/new-tred-of-mega-hospitals-pros-and-cons/702966/48 "2014-11-06T15:17:00Z")
Guys, I believe I have found an ER up to [Sweat209’s standards!](http://img3.wikia.nocookie.net/__cb20120318013659/memoryalpha/en/images/e/e7/EMH_in_Enterprise-E_sickbay.jpg) 😃 ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [November 6, 2014, 3:24pm UTC](https://boards.straightdope.com/t/new-tred-of-mega-hospitals-pros-and-cons/702966/49 "2014-11-06T15:24:27Z")
> [@clairobscur](#): > > I wonder if it’s driven more by medical advances or by concerns over cost. … Both. Some of the “medical advances” are not better technology but better system approaches. A bit less of a doctor rounding once a day and deciding ad hoc for the next 24 and more established best practice procedures and order sets in place. More hospitals and medical groups now have doctors whose specialty is being on site and moving those protocols along. Better realization that people really do not _need_ X day of antibiotic IV and that giving it by mouth works as well and the ability to give IV antibiotics at home if they do need it. The reality is that hospitals are great places to be when you absolutely need to be there and great places to get out of as soon as possible. A current major driver of health system behavior right now is the Accountable Care Organization (ACO) model. ACOs are co-operating groups of hospital(s), physicians, and other providers, who are responsible for the care of large populations of individuals. If the group can deliver on meeting various quality care benchmarks and cut costs of care to the complete population while doing so by defined amounts they get to share in the savings. Obviously this is a major step different than a fixed reimbursement for an individual’s single admission; in this model getting the average length of stay (and thereby cost of care) for pneumonia down get the system, including the hospital, more money. Preventing pneumonias within the covered popultion in the first place gets the system, again including the hospital, even more. So far the model is giving [modestly good results](http://www.brookings.edu/blogs/up-front/posts/2014/02/07-results-medicare-shared-savings-program-kocot-mostashari). Early days and early data. The system is Medicare driven but as noted where Medicare goes the others follow. The system working however requires, as noted, a mindset and cultural shift among the different parts of the systems, not merely consolidating into a larger bargaining unit. It is a process. ---
**Author:** ![Dewey\_Finn](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dewey_finn/32/4222_2.png) [@Dewey\_Finn](https://boards.straightdope.com/u/Dewey_Finn)\ **Post date:** [November 6, 2014, 3:26pm UTC](https://boards.straightdope.com/t/new-tred-of-mega-hospitals-pros-and-cons/702966/50 "2014-11-06T15:26:23Z")
> [@DSeid](#): > > Better realization that people really do not _need_ X day of antibiotic IV and that giving it by mouth works as well and the ability to give IV antibiotics at home if they do need it. The reality is that hospitals are great places to be when you absolutely need to be there and great places to get out of as soon as possible. The patient may actually be better off recovering at home, because of the risk of a hospital-acquired infection. ---
**Author:** ![GrumpyBunny](https://avatars.discourse-cdn.com/v4/letter/g/bc8723/32.png) [@GrumpyBunny](https://boards.straightdope.com/u/GrumpyBunny)\ **Post date:** [November 6, 2014, 5:21pm UTC](https://boards.straightdope.com/t/new-tred-of-mega-hospitals-pros-and-cons/702966/51 "2014-11-06T17:21:26Z")
> [@sweat209](#): > > I have had chest pain and breathing problems and have waited to it got really bad before I gone to the hospital :(:mad::(because I hate spending 4 to 8 hours in the ER room with 20 to 30 people wanting to see the doctor. Than spending time ER room looking like [http://www.baconsrebellion.com/wp-content/uploads/2014/01/er.jpg](http://www.baconsrebellion.com/wp-content/uploads/2014/01/er.jpg) > > Yes 10 to 15 of those little open rooms with curtain well the doctors and nurses walk around in and out of those little open rooms. > So it normally goes like this 30 to 60 people in Triage a hour or two hour wait. > Than 4 to 6 hours in ER room like this with 20 to 30 people waiting like this [http://medcitynews.com/wp-content/uploads/ER-waiting-room.jpg](http://medcitynews.com/wp-content/uploads/ER-waiting-room.jpg) > > Than hour or two in open rooms with curtain like this. > [http://www.baconsrebellion.com/wp-content/uploads/2014/01/er.jpg](http://www.baconsrebellion.com/wp-content/uploads/2014/01/er.jpg) I don’t know where you are located or how old you are, but normally breathing problems and chest pain in an adult bumps you to the front (or close to the front) of the line (behind chest trauma, obvious heart attack/stroke, and people spurting blood from a major artery). And sorry it takes a while, but when you have chest pain and breathing problems, part of treatment _is keeping an eye on you to make sure you don’t get worse_. I’m asthmatic, and even on a busy Saturday night, it rarely takes more than fifteen minutes for me to be taken to the back; I normally see a doctor in 30-45 minutes. They do keep me around longer than I’d like, but it’s to make sure that I keep breathing and that my peak flow doesn’t drop again. I also wonder how sick you are – sorry, but when my asthma flares up, the last thing I give a damn about is the décor. I could be getting treatment in a room with wallpaper from 1974 and dingy linoleum, and I wouldn’t give a rat’s patootie, so long as the oxygen, breathing meds, and sweet, sweet IV steroids and magnesium show up. I’ve been in some really ugly ERs, and in some gorgeous, state-of-the-art ERs, and guess what? Care has been the same at both. tl:dr – the ER is not there for a fashion show nor for privacy nor for your personal aesthetics; it’s there to save your life. ---
**Author:** ![GrumpyBunny](https://avatars.discourse-cdn.com/v4/letter/g/bc8723/32.png) [@GrumpyBunny](https://boards.straightdope.com/u/GrumpyBunny)\ **Post date:** [November 6, 2014, 5:26pm UTC](https://boards.straightdope.com/t/new-tred-of-mega-hospitals-pros-and-cons/702966/52 "2014-11-06T17:26:12Z")
> [@sweat209](#): > > I would rather be sick at home than be sick at the hospital than spending a day in room like this > > [http://www.mobridgehospital.org/images/contentmgmt/ER\_web.jpg](http://www.mobridgehospital.org/images/contentmgmt/ER_web.jpg) > [http://www.livetradingnews.com/wp-content/uploads/2014/06/SVMC-ER-MainOperatingRoom-e1338921334793.jpg](http://www.livetradingnews.com/wp-content/uploads/2014/06/SVMC-ER-MainOperatingRoom-e1338921334793.jpg) > [https://ufhealth.org/sites/default/files/Chest-Pain-ER\_JSJ\_IMG\_4671.jpg](https://ufhealth.org/sites/default/files/Chest-Pain-ER_JSJ_IMG_4671.jpg) > > I would rather have breathing problem and chest pain than making trips to the hospital. Then you are going to be sick at home a lot. Those are normal hospital ERs; they are clean and functional. No, they won’t merit an article in Architectural Digest. If those ER bays is your definition of “third-world-country”, you should get out more. ---
**Author:** ![Bouncer](https://avatars.discourse-cdn.com/v4/letter/b/9d8465/32.png) [@Bouncer](https://boards.straightdope.com/u/Bouncer)\ **Post date:** [November 6, 2014, 8:21pm UTC](https://boards.straightdope.com/t/new-tred-of-mega-hospitals-pros-and-cons/702966/53 "2014-11-06T20:21:54Z")
> [@sweat209](#): > > I’m not saying it has to look like star trek voyager sickbay has money would have to grow on trees for that :eek::eek:but those hospital ER look very much like they are run on little money and borderline third world countries. > > I have some hospital in my area that looks way better than that and some that look bad like that. I’m also going to nitpick you. The photos referenced show an open design that easily allows for multiple people and lots of portable equipment to be added to the treatment area as necessary. Which means a patient undergoing a more serious event (that is noticed or develops while in the ER) can immediately be attended to without being moved to another location (which may be busy with other critical care patients). It also provides for easier sanitation and body fluids/medical waste cleanup. It’s pure functionality. I grant you there is a noticeable lick of frolicking kitten posters, but this is an ER ward, not a family care office. Regards, -Bouncer- [Previous page](https://boards.straightdope.com/t/new-tred-of-mega-hospitals-pros-and-cons/702966.md?page=2)