Dr Michelle Caughey, SMCMA President, is 

working with Save the Children in Banna

Allai, Pakistan, for several weeks. In her

absence, Dr David Goldschmid, SMCMA 

president-elect, is guest author of the President's

column.

Why a County Hospital?

by David Goldschmid, M.D.

Do we need a county hospital? The simple answer is "yes." Why? San Mateo Medical Center provides superb care to a lot of people who otherwise would not get it. The question asked repeatedly is "can we afford it?" We can in my view. Affordability is probably too complex to define in any scientific way given the lack of agreement on the parameters used to measure it. Once having challenged the affordability of the hospital, people who study such matters propose the notion that the patients at SMMC can get the same care in the private sector. They quote statistics on the excess capacity in the private sector—empty beds—and couple that with criticism of the inefficiencies of SMMC. They raise the concept that San Mateo County should be a payer for care and not a provider of care. They site examples of other counties that have closed their county hospitals and imply that if that model works elsewhere it will work here. Let me try to outline the problems with some of those concepts from my perspective.

We in this county have been blessed with some of the best local politicians in California. As compared with the rest of the state, they have been unusually sensitive to the needs of the people of the county and have done a rather good job of managing the affairs of the county. That is how we got to where we are. That is why we have a county hospital. That is how we provide superior care to the medically underserved. Being a payer for care lets you distance yourself from the critical decisions and human issues involved in care. It replaces face-to-face, hard-nosed decision-making scenarios with a sterile paperwork office cube scene. It is far easier to deny payment or service from behind a desk than it is to deny service to a person who presents ill. The proponents of the county as a payer know this. I have little doubt they would exploit it to balance the budget. I have little doubt that a significant part of the population currently served by the county would undergo a rapid loss of eligibility. Those people would not go away. They would surface in the county’s emergency departments and exacerbate the current crowding. Few of us in patient care would welcome another payer. We need more active participants in the delivery of care and not financial managers of the insurance industry fold.

Let’s talk about excess capacity. Who would like to work in an Emergency Department near SMMC if it were to close? Do you suppose that service in such a department would improve? Not likely. Let’s hope that increased wait times get credited to those who would close SMMC, and let’s hope those serious service issues get considered in the question of "affordability." I am well aware of the statistics in the county showing significant numbers of empty beds in the community. I am an Emergency Physician. Why is it that when I go to work I am often confronted by a bed shortage? Beds are full of patients. Why is it that many of my colleagues in the county tell me the same? How do you explain the desire of Palo Alto Medical Foundation to build a new hospital if we are over-bedded? We need a significant number of empty beds as measured by averages of empty beds per day per year to be able to flex up and down to meet changing demands throughout the year. It is unsafe to have too many filled beds on average. Finally, how many physicians in this county are sitting around waiting for more hospital patients? None. According to my sources, demand for uncompensated care is going up. So where is the excess capacity? How would the impact of closing SMMC affect the county’s ability to serve the public in the event of a disaster? It would create a disaster!

Finally, I should mention the precedents set by other counties that have closed their county hospital. Some have done well, others not so well. My own experience is that the physicians of the county in which a county hospital was closed (in the valley) were saddled with a burden they could not meet. They did not have the extra time needed for additional patients and, as county budgets became more difficult to balance with time, were asked to work at unacceptably low rates. We work in an expensive place and find physician recruitment difficult, making it unlikely that underfunded patients can access the care they need.

We need to work together as a community to improve the economic viability of SMMC. The consequences of closure would affect the entire community. It could have a broad impact on access to care. We should approach this issue as a community with representation from business, unions, politicians, and most important, providers of care.