Brief history of hospital structure in America vs the CNMI

Editor’s Note: Due to its length, the following letter to the editor is being published in three sections.

First of a three-part series

In the 1700’s Boston was the largest city in the democracy. Sailors had to be quarantined. Soon these quarantined places were where the mentally ill could be cast aside from society. The small time criminals and homeless beggars soon joined as well as those who were contagious, such as tuberculosis and polio. These early “hospitals” were more like jails. Johns Hopkins Hospital today started as one of these facilities and was known by its former name, The Public Hospital of Baltimore. In New York, one of these early hospitals was known as Bellevue.

It really wasn’t until a Catholic order, St. Vincent de Paul Sisters of Charity, founded by Mother Elizabeth Seton in 1809, saw a chance for spiritual salvation of these lost souls. This and other Catholic orders transformed hospitals into what we know today as health centers through their kindness and acts of altruism.

The Civil War saw many soldiers returning home who needed medical care. Thus the nursing profession grew, and hospitals grew, but still, these were places of the sick and needy.

Massachusetts General, New York General, and the Pennsylvania Hospital were formed by physicians in order to have a clean environment to perform surgery and obstetrics and to train medical students. Early administrators were custodian or janitors of the hospitals.

By 1986, 74 percent of the population had health insurance, according to author R. Stevens. Now the insurance companies were covering most of the costs by spreading the premiums over a large population. This led the way to larger hospital administrations to handle the cash and expenses and a medical inflation that persists to even today.

In 1966, Title XVII of the Social Security Administration Act gave rise to Medicare and Medicaid. Within 10 years, this government program saw hospital stays for patients 65 and older to be double that of patients aged 45 to 64, according to one author. The hospitals saw that caring for those 65 and older was profitable. The hospital administrations began to cut services for the non-profitable services. The charitable and spiritual side of hospital care rapidly declined and took a role of lesser importance. You no longer had to whisper in hospitals, yet we still whisper is libraries. Nurses stopped wearing white. Physicians began losing control of the direction of hospital medical care. (Just kidding about the wearing white.)

In the ’80s, groups of physicians sought to reclaim control of patient medical care and the loss of the doctor-patient relationship and began building small surgical centers. They were more profitable and efficient. Physicians could set the tone for customer service from the top down. This resulted in a substantial decrease in revenue for hospitals. In Washington, lobbyists were successful in influencing politicians to pass Medicare reforms that increased reimbursements to hospitals and decrease reimbursements to surgical centers for the same procedures, despite the differences in patient experiences. Enter the dawn of large corporations buying up hospitals for profit.

Hospitals began employing more and more physicians as salaries could be higher than the physician would make outside the hospital due to subsidies provided by the added hospital revenue services such as laboratory, radiology, and hospital bed reimbursement. These physicians were now subject to employment laws and the hospital administrations grew in power over the doctors.

To be continued.

Grant Walker, MD
Board Certified and Spine Fellowship Trained Orthopedic Surgeon
Idaho