How did the U.S., which spends 17 percent of GDP on health care, corresponding to every American working one day per week to pay for health care, manage to run out of capacity from a bad season of a flu-like illness?
Part of the answer is that the U.S. was never in any danger of running out of hospital capacity as a result of coronavirus, even if we had pursued a Swedish-style policy (schools, restaurants, offices open; mass gatherings shut). We have had some overcrowded hospitals, yes, but they were in all cases only a short drive away from some uncrowded hospitals. If people could wait for hours in the ED, as most did, they could easily have survived a 30-minute or 3-hour bus ride (with a nurse and maybe some oxygen bottles) to an uncrowded hospital.
See “Monroe County hospitals prepare for coronavirus ‘surge’” for example. As of March 27, when New York City was already turning into Wuhan-on-the-Hudson and three days before the USNS Comfort arrived, 33 people were hospitalized in the Rochester, NY area, which has nearly 2,000 hospital beds on a normal day as part of its state-of-the-art hospital system and top-ranked medical school. Compare to this March 25 NYT article, about patients waiting almost 60 hours for a bed at a Queens hospital. It is a 5.5-hour bus ride to Rochester. If everyone at the Queens hospital who didn’t need immediate attention had been sent to Rochester, each patient could have received personal attention from an unstressed team of physicians and nurses.
See also “During a Pandemic, an Unanticipated Problem: Out-of-Work Health Workers; Across the country, plunging revenues from canceled nonemergency medical appointments have forced hospitals to furlough or cut the pay of doctors, nurses and other staff.” (nytimes) In other words, the typical American hospital is mostly empty of both patients and staff!
New York spends $88 billion per year on its Department of Health, but apparently has put no thought into load balancing. A friend who has worked in this industry: “People in government don’t want to do anything at all until there is a disaster. Once the disaster hits, they don’t want to do anything that they haven’t already done.”
The way that the U.S. has handled coronavirus so far combines the worst features of a megasystem (huge bureaucratic costs and long bureaucratic delays) and the worst features of a small island health care system (people must be treated at the single hospital that is closest to their home).
Could it be that the most important thing we can do to prepare for the next flu-like epidemic (which might just be the next outbreak of coronavirus?) is to have some buses ready with spacious recliner chairs and oxygen bottle holders next to each chair? (Argentina already has “business class” buses like this for inter-city transport, minus the oxygen bottle holders!) Combine this with a Florida-style system for tracking hospital capacity in near real-time and we can surely expand the U.S. capability of handling epidemics by a factor of 5-10.
An Andesmar First Class bus “suite”:
- “Mayo Clinic announces sweeping pay cuts, furloughs” (MPR), from the nation’s most successful (outcomes) hospital: The state’s largest private employer is instituting across the board pay cuts and furloughs to shoulder a projected $3 billion loss this year. “The decision to eliminate elective surgeries and outpatient visits was the right decision in terms of protecting the safety of our patients and staff, and also preserving limited PPE (personal protective equipment),” said Chief Administrative Officer Jeff Bolton. “But it has led to significant reductions in revenues.” Bolton said the hospital in Rochester is at about 35 percent of capacity, while capacity in Mayo’s surgery services is at about 25 percent. “If you go back to the Great Depression, the institution went through a very similar financial crisis, and salaries were reduced during that period of time,” said Bolton. “There were a lot of actions that were very similar to the ones we are taking today.”
14 thoughts on “Can we set up a load-balancing system for hospitals as prep for the next plague?”
I tested the buses in Argentina a few years ago and, at least in good health, they were more than okay for a 23 hour ride from Buenos Aires to Santiago de Chile!
In France, they transferred patients in high speed trains from crowded regions to less affected parts of the country.
I cannot believe you are not out doing COBAL and database stuff for some state government. Many very old state computers that handle unemployment compensation, etc. are in big trouble. They cannot handle the huge spike in applications and other paperwork. So thousands of people are not going to get any unemployment checks or $$ in several states. I bet your expertise could fix a lot of this quickly….
Please advise how you and your smart students and smart friends are going to do something beside set and gossip all day…
So much covid19 gloom – how about some good news from a happier topic, like divorce! The good news is that women are finally achieving gender equality, as demonstrated by singer Adel having to pay her ex-husband $140M of her reported $190M net-worth (due to the quirks of California’s divorce rules). Oddly, some feminists aren’t celebrating this milestone in equality:
In America, there are two realities depending on your income. If you can afford it, you have access to decent to good healthcare. If you can swing a decent lawyer and the exorbitant expense of litigation, 90% of laws might mean more than meaningless words in a book; you might not get stomped out by big business or railroaded into an extortionist criminal plea bargain. If you live in a decent zipcode, your children can get an education. The folks in the empty hospitals like it that way.
Doing those things yourself is better than the stuff you can buy. No I don’t have a ventilator. I’m not fat, so I shouldn’t need one, and if I do with the odds I’d rather stay home and fast it off. But you are right the people who consume low quality healthcare, education and legal advice are worse for it. The cure is less of those things or doing them yourself.
SP: That’s a great theory, but how can you explain the nation’s best children’s hospitals having more than half of their patients insured by Medicaid? (roughly half the revenue, but Medicaid pays a bit less than private insurance so this means Medicaid patients are the majority)
Similarly, for patients over 65, Medicare is the primary payor.
All the big hospitals have to take Medicaid and Medicare. An older American who wants to visit the best hospital in the US can take a $100 flight to the Mayo Clinic in Minnesota and get the same care that an Arab royal would get (maybe not the same room! And they won’t take out of state Medicaid for the young/poor)
Philg – children are beloved and innocent, don’t want to clue them into the harsh reality of our society until young adulthood. St Jude, Jerry’s kids, etc. I’ve never seen a commercial on TV requesting help for grown American’s who can’t provide for themselves in need of medical care, even thought the numbers must be dis-proportionally staggering in comparison to kids. All kinds of exceptions and allowances are made for sick children–Americans have a soft spot for animals and kids(who aren’t yet responsible for their own health and well being, like pets of any age). I would think that whatever the proportion of children in need of medical care, is a very small percentage of the hospitalized population. And, they are probably suffering from relatively rare, chronic conditions that would bankrupt anyone prior to lifetime limits?
I’d love to see a documentary about a regular Joe from out of state trying to get into the Mayo Clinic!
Does anybody know how many people die per day in NYC before the virus?
I live near a Mayo hospital and clinic in Scottsdale and Phoenix. Mayo is facing a $3B loss. So they are cutting salaries and laying off people due to no selective surgeries and medical work. They are not doing enough Covid 19 work to make up the other short fall. Most of the local patients are going to the other hospitals in the area.
The Mayo clinic patient selection policies and focus on medical tourists are causing them issues. Plus they routinely charge about 10-20% more than other hospitals. So if you are on Medicare or low cost insurance you need a special recommendation from a previous doctor to get into Mayo. So most AZ locals go to other doctors and hospitals.
> Julio Jimenez, 35, spent six hours in the emergency room on Sunday night after running a fever while at work in a New Jersey warehouse. He returned on Monday morning to stand in the testing line in the pouring rain. On Tuesday, still coughing, eyes puffy, he stood in line for nearly seven hours and again went home untested.
Interesting. In Germany, where I live, I belive he would have been told in no uncertain terms that he does not qualify to be tested and sent back home (in fact, it’s not hard to find compaints from people who have been in this exact situation; often they would call the emergency line first, hear that they will not be getting a test but, unbelieving, still come to the hospital to be told in person).
Whatever your opinion on the ideal design of the medical system, surely making people wait for hours in a crowded emergency room is suboptimal.
The U.S. medical system clearly is not ready for any complex situation (at least in the bureaucratic sense.) Your observation that there are empty hospitals in other parts of the country is quite on point. But I do suspect that most people in the ER will not be admitted to the hospital, so it remains to see how effective the transport solution could be – you need to bus after your are sure that they actually need the hospital, at which point perhaps it’s too dangerous for a bus.
Yes, that is a great point, Ilya. The U.S. system is optimized for extracting $400,000-$4 million from Medicare and/or private insurance for each of a handful of patients, e.g., a 92-year-old with 6 different conditions who can be kept alive for 4 additional weeks via the ICU. Anyone who ever tried to set up a hospital as an assembly line geared for efficiency on simple cases would quickly go insolvent. https://philip.greenspun.com/blog/2019/11/03/the-hospital-25-years-from-now-a-tower-of-icu/ talks about this a bit. The future of the hospital is “a tower of ICU”. Each patient will have to generate a minimum of $250k in revenue or it won’t make sense.
@ilya, in Germany, would such a person be able to successfully sue the hospital and walk away with large sum of $$ (probably less then the lawyer will get)?
@George Surely you guessed the answer 😀 of course the patient has no way to sue a hospital in such a situation when hospital is correctly following the guidelines.
There are also neither punitive damages nor juries in Germany; there is a “loser pays” principle for the lawyers and I don’t believe the judicial system is able to certify a class law suit (the legislature can). You go to the court when you are wronged and return whole – not with an extra million or two!
“they could easily have survived a 30-minute or 3-hour bus ride (with a nurse and maybe some oxygen bottles) to an uncrowded hospital.”
But my regional HMO won’t cover service at a non-network hospital 3 hours away, or even 1 hour away.
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