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How best shall we serve?

As a nonprofit 225-bed facility serving a metropolitan population of 65,000, Oakcrest General Hospital is facing severe financial pressures created by the admission of sicker patients and lower reimbursement rates. Although Oakcrest is a predominantly middle-class community, the unemployment rate has been rising gradually, and more patients are either without health insurance or covered by Medicaid. Not surprisingly, the emergency room has witnessed a larger proportion of non-acute visits than in the past.

Oakcrest General has always prided itself on being responsive to community needs. The hospital's mission is to provide, commensurate with its resources, high-quality, cost-effective patient care to the citizens of Oakcrest. A recent capital gift campaign fell short of its goal, but the hospital was able to renovate its radiology and laboratory departments by using most of its remaining reserves.

Last week, one of the hospital's vice presidents submitted a comprehensive proposal to the chief executive officer to establish a community health clinic. She documented how such a clinic could expand access to primary care services, supplement existing resources, and improve the health status of local residents. The justification was very thorough and persuasive. Particularly noteworthy was a preliminary commitment by the city's public health department to provide partial funding. Nonetheless, it is apparent that the clinic will not be financially self-sustaining and the hospital will have to provide a significant subsidy.

Normally, despite the economic constraints facing Oakcrest General, the CEO would have been confident this program had sufficient merit to be considered favorably by the hospital's board of trustees. However, three other major requests are also under review, each with clinical and economic ramifications.

The surgery committee has documented the frequency with which longer surgical lengths of stay can be attributed to delays in scheduling cases. Adequate anesthesia and nursing staff do not seem to be a problem; instead, operating room time has not been available. Even with more procedures being performed in the outpatient surgery center, there is clear evidence that another operating room is needed.

Like many hospitals, Oakcrest General is experiencing a steady increase in its Medicare case mix, with concomitant need to provide a higher level of care for sicker patients. Almost without exception, the medical intensive care unit is 100 percent occupied. Consequently, the ICU medical director is devoting an inordinate amount of time and energy trying to determine which patients would be least compromised by being transferred to a routine medical floor. Expansion of the ICU appears essential.

The third request is, at least in part, related to the other two. All of the budgeted respiratory therapist positions are filled, but the personnel are routinely working overtime and often double shifts to administer treatments ordered by physicians. An analysis has verified the need for a minimum of six more positions, three on the day shift and three on the evening shift.

While acknoledging that these four disparate proposals vary in their funding requirements and revenue-generating capacity, the CEO has determined that only one can be supported. In addition to making a standard cost-benefit comparison, what ethical criteria should be considered in evaluating the competing proposals? Are there generic as well as specific issues that should be raised? What role does the hospital's ethics committee have in the decisionmaking process?

--Paul B. Hofmann, Visiting Scholar, Stanford University Center for Biomedical Ethics, Stanford, Calif.
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Title Annotation:hospital care for uninsured patients; includes commentaries
Author:Hofmann, Paul B.; Rabkin, Mitchell T.; Bayley, Corrine; Beauchamp, Dan E.
Publication:The Hastings Center Report
Date:Mar 1, 1993
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