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Commentary By Paul Howard

Medical Drama


Man, Woman, Birth, Death, Infinity Plus Red Tape, Bad Behavior, Money, God, and Diversity on Steroids

by Julie Salamon

Penguin Press

"It was crowed, really crowded. A melting pot mayhem - Hasids, Chinese, Pakistanis, Haitians, Russians, Bulgarians." And in the air, "strange spicy odors he couldn't place."

A New York fast food restaurant - or an hospital emergency room?

From journalist Julie Salamon's chronicle of a year in the life of Maimonides Medical Center in Brooklyn, it's hard to tell the difference.

Given unprecedented access to the physicians, administrators and patients at Maimonides, Salamon is out to discover "the financial, ethical, scientific, sociological, personal and cultural matters that determined what kind of care people received."

Her question couldn't be more pressing, as researchers at Dartmouth recently found that Maimonides is one of the nation's most expensive hospitals - at least when it comes to the cost of caring for chronically ill patients.

Medicare spent on average $107,000 per patient for the last two years of their life at Maimonides, compared to $53,000 at the Mayo Clinic in Minnesota, $91,000 at New York-Presbyterian and the US average of $46,000. As Congressional Budget Director Peter Orszag asked about the discrepancy, "how can the best medical care in the world cost twice as much as the best medical care in the world?"

The answer is that, in many cases, there's no consensus on how to best treat chronically ill patients. At hospitals like Maimonides, patients may get more care, but they don't necessarily get better care.

Salamon notes Maimonides' decision to open a comprehensive cancer center, complete with a "$5 million linear accelerator for radiation therapy," meant to give the best care, and of course rake in some dollars.

But the center turns out to be a money loser because it isn't getting enough patients referred for radiation treatment - which is reimbursed more generously than chemotherapy. The folly? Before building the center, administrators commissioned a study that found that "only 26 percent of the people in the surrounding area" visited Maimonides for cancer care. The hospital hoped to boost that to 45 percent, but was there really a need, with other hospitals like Memorial Sloan Kettering in the area? Would Maimonides be doing anything other than shifting dollars away from its rivals?

While Salamon praises the work of individual doctors at Maimonides, she notes that insurance plans encourage a system in which patients are rushed out the door like a restaurant turning over tables.

As the chief of surgery relates to her: "You take any two hospitals, if I can do a coronary bypass and get a patient out into a secondary location - home, rehab, family - a day shorter than Lutheran, I've put another $10,000 in my pocket. Every discharge across the board is at least another $10,000 to a hospital."

Everyone at Maimonides feels the pressure to drive turnover. "All these [administrators] crunch numbers every day," a neurosurgeon tells her. "There's a number on your head of how many cases you did in the last month."

Throughout "Hospital", Salamon laments that health care has become a big business. "The system," she writes, "was tainted by callous disregard for decent and equitable care, by money lust, by corporate influence and by lack of political will." At times Salamon suggests that a single payer system would solve these ills - but forgets that Medicare is part of the problem.

Salamon presents Maimonides as a caring institution, run by smart people working under very difficult conditions. But until we have a system that empowers patients and gives hospitals the right incentives to both innovate and save money - as in other sectors of the economy - our health care system will remain maddeningly uneven.

This piece originally appeared in New York Post

This piece originally appeared in New York Post