The American Hospital Association, a School for Scoundrels

Years ago, hospitals were truly focused on patient care. Non profit community hospitals were truly non profit. The hospital administrator was a mother superior, the protestant equivalent or a dedicated administrative or accounting type, sometimes a physician or nurse. The medical staff played a major role in standards and nursing staff in operations. Both were highly organized and dedicated to patient care. The Joint Commission for Accreditation of Hospitals was an effective inspector general auditing standards of care, despite resistance from the AHA since 1995.

Progress imposed by the Medicare bureaucracy, limited beds requiring a certificate of need, and hospital administrators became more organized. Seeking greater authority, ability and pay. Administrators organized accredited schools for hospital administration and a national association of administrators dominating the once venerable American Hospital Association, founded 1898. The national organization gave hospitals bargaining power in the purchase of supplies and the sharing of knowledge, a great help in the running of widely dispersed hospitals. However, the imposed limitation of hospital beds gave hospitals an unintended monopoly and hospital administrators nearly unlimited power in wielding that monopoly.

There was always a natural tension between hospital administration and both of the professional staffs. Now, with the power of monopoly the cartel of administrators became CEOs with  the wet dream of displacing both physicians and nursing staffs’ authority in defining patient care, into a source of power and financial benefit for themselves. The American Hospital Association directed a disinformation campaign against organized medicine claiming medical societies were in violation of antitrust laws they themselves were violating. First they removed the requirement that any hospital staff member be a member in good standing with the local county medical society, effectively castrating the medical societies’ ability to regulate and discipline its members. They did the same with their organized nursing staff limiting salaries, numbers and authority, no longer management. Then and maybe worse still, CEOs converted the nursing lounge, physician and surgeons lounges into “all employee lounges” or eliminated them altogether with new hospital design, thus eliminating or limiting  collegial communication and to a real extent continuity of care.

CEOs’ salaries now nearly all exceed a million dollars a year. Patient care now evolves into administrative priority and profit. Nosocomial infection rates soar as do medication errors and wrongful deaths. Autopsies are a thing of the past. Conveniently, patient confidentiality eliminates bedside teaching, accompanied rounds and access to the patient chart. Electronic health records confuse the patients notes with volumes of extraneous data. Specialists caring for the same patient don’t talk to one another. Hospitalists, now in the employ of the hospital, are needed to keep track of what’s going on. Nurses, now unionized and diminished to non-exempt hourly employees, don’t share patient information between shifts – no pay for the overlap – and no longer a voice in patient care. Doctors staff privileges are now at the discretion of the BOD, which in effect falls to the CEO. Universal precautions – a thing of the HIV epidemic and patient privilege of information, now replaces isolation, wherein any laps of technique or sanitation, means no infectious disease protection at all.

So, with the SARS-COV-2 pandemic, there comes no surprise that hospitals are overwhelmed. Supplies are lacking. Operations fall back on the professional staff but without control of the logistics necessary to ramp up isolation, testing or expanded ICU. To their credit professional staff rose to the occasion. With financial relief for hospitals, however, will we do more than secure the CEO’s obscene salary? CEOs should be demoted to administrators, preferably hourly with operations, decisions involving patient care and logistics once again in the hands of professional staff. The public health statistics of US health care compares unfavorably, to the rest of world’s  industrialized nations. This pandemic may provide an opportunity to reevaluate and restructure our health care systems, not by further privatizing, monopolizing and incorporating, but by recognizing health care as a vital universal infrastructure.