What I am about to tell you is a true story. One that is happening now in a Rhode Island hospital.
An 81-year-old man who still worked ten hours a day and was as strong as a bull was hit by a car as he crossed the street from the restaurant where he worked to his house. The car was driven by a Brown student who said she was distracted by looking at her GPS, but some people think was talking on her cell phone. He had severe, life-threatening injuries, which left him temporarily paraplegic and on a ventilator. The surgeons at a Rhode Island Hospital saved his life. Then he recovered enough to regain control of his arms and legs and come off the ventilator.
At that moment, about a month into his hospital stay, he should have been transferred to a rehabilitation hospital, where he should have been able to make a pretty complete recovery, something he very much wanted to do. But at that moment, for a crazy set of bureaucratic reasons, he was not transferred to rehabilitation. (He was undocumented and uninsured. He doesn’t speak English – though his family speaks English quite well. The lawyer his family found for him didn’t understand how to get an insurance settlement from the student’s car insurance to pay for his rehabilitation. The hospital refused to release his medical records, quite illegally, and no one knew how to persuade them. And so on.)
So he stayed in the hospital. Where he remains, while his growing and likely over four-million-dollar hospital bill is being paid for with public funds. All of which I’ll write more about over the next few weeks but is not the subject of this commentary.
Stuck in the hospital, the single most important medical intervention needed to save his life was and is physical therapy, and lots of it. He needs three to four hours of physical therapy a day, therapy he wanted and wants desperately. But didn’t get and hasn’t gotten. The hospital had all sorts of excuses: they don’t have enough physical therapists. They don’t do rehab – you need to go to a rehab hospital for that. He had periods of confusion and couldn’t cooperate with physical therapy (like when he got a hospital acquired infection that went undiagnosed for five weeks, or like when he was overmedicated for pain by people who said he was in pain but didn’t speak his language or know his culture.) And so forth. So he didn’t get the one treatment in the hospital that could have allowed him recover enough to be discharged, and without which he is very likely to slowly die.
So the family went out and found a PhD level physical therapist licensed in Rhode Island to come to the hospital every day to treat him, which she started doing. Until the hospital ordered her to stop a few days later.
Say what? There was one treatment that could help him recover enough to be discharged, one treatment that actually might save his life, one treatment that the hospital itself wasn’t providing but the family had found a way to get him, and the hospital ordered that treatment to stop? Yup. That’s exactly what happened. It’s worse: the hospital’s decision was appealed internally. The matter was referred to the attorney general’s office and the Department of Health, but no one thought they had the authority to force the hospital to allow a licensed and skilled physical therapist to provide a critical and likely life-saving therapy that the hospital itself had been unable to provide. What the heck is going on?
What the heck is going on is this: health care has been taken over by bureaucrats administrators and lawyers, who know only how to protect (and some would say enrich) themselves and their organizations, people who don’t know anything at all about medicine, but feel embolden to make decisions that cost patients’ lives.
The hospital said the physical therapist couldn’t trat the patient because the physical therapist wasn’t employed or credentialed by the hospital, which meant the hospital perceived some potential liability in case something went wrong. They feared that the hospital could be successfully sued if the patient had a bad outcome and that bad outcome could be linked to the practice of this outside physical therapist. (They appear not to worry about their liability if the patient continued to decline because the hospital failed to provide need physical therapy and couldn’t get out of its own way to make sure the patient got the rehab he desperately needed, just saying.)
Viewed narrowly, some of the hospital’s arguments might actually be correct. Because of the way we have constructed our liability laws and our regulations, there might be some potential liability, conceivably. But viewed more broadly, isn’t the hospital’s main responsibility to save lives? Which makes us ask, who is in charge?
Once upon a time, hospitals were run by nurses and doctors, and existed for patient care, not for legal defense. Somehow, over time, administrators got control. First they pushed out the private duty nurses, who were available to give exquisite patient care to the patients (but only to those who could afford it, although it wasn’t that expensive, back in the day). Then they pushed out the primary care doctors, who would come to the hospital every single day to check on their patients and make sure disasters like the one described here didn’t happen.
So now hospitals are neat little businesses. With big billing departments. And full-time lawyers. About a third of their employees do billing or move money around or go to meetings. Patient care happens, but now legal defense and administrative control comes first, not patient care.
What could be crazier than that?
Michael Fine, MD, is a writer, community organizer, and family physician. He is the chief health strategist for the City of Central Falls, RI, and a former Director of the Rhode Island Department of Health, 2011–2015. He is currently the Board Vice Chair and Co-Founder of the Scituate Health Alliance, and is the recipient of the Barbara Starfield Award, the John Cunningham Award, and the June Rockwell Levy Public Service Award. He is the author of several books, medical, novels, and short stories, including On Medicine and Colonialism, Rhode Island Stories, and The Bull and Other Stories, You can learn more about Michael at www.michaelfinemd.com
Is there anything the average person can do something about this system?
We have to stand up for our rights.
Thank you Dr. Fine for this truthful insight into another frightening direction for health care. We have lost good doctors and nurses in RI who choose not to be a part of this “bottom line” approach to our health care.
It’s great that Dr. Fine is surfacing these kinds of situations. I’m hoping that he will suggest starting points and steps (who can best do what?) for alleviating them.
Your nostalgia is misplaced. After 50+ years in healthcare, I can tell you there certainly are crazier things. The current state of medical services delivery in the USA is the result of mismanagement and greed at the political level. The USA spends 2.5 times the next most expensive country (the Netherlands) and receives, for this staggering expenditure, worse results than 30 other countries. Political cowardice is at the root of it, and the greed part comes from the profiteering cabal among politicians ( the 2nd largest lobby in Washington is healthcare), insurance companies, which legally gorge themselves on government programs like Medicare and the providers (hospitals and doctors) who spend 2/3 of the national medical expenditure and basically police themselves, while killing (the technical term is “iatrogenic deaths”) at least 250,000 people per year. That, dear doctor is what’s really crazy. The hospital to which you’re referring is probably a community hospital – and they’re an endangered species. When doctors ran hospitals in the 1950’s and 60’s, the results were worse. “Defensive medicine” to which you refer, probably accounts for 10% of the waste in the system; the biggest single culprit (~25%) is the mind-boggling complexity, fragmentation and inefficiency. The social contract is null and void, and the whole thig will implode. Then, perhaps we can forge the single payer system we need. The US needs to wean itself from healthcare profits through reversing consolidation, enforcing anti-trust laws, eliminating insider trading loopholes for Congress, controlling insurance profits, funding public health and giving it the teeth it needs to enforce regulations. And all this is never going to happen until there’s an absolute disaster.
Thank you for sharing the knowledge, I got more than information in your Article, keep writing.
There seems to be a back story that’s unclear:
Dr. Fine is correct that there is a liability for the hospital to allow an outside therapist to work within the hospital. However, if the family were cooperative they could bring the patient home and have the therapist come into their home and rehabilitate the patient at home like the rest of us have to do when our insurance does not provide for therapy at a rehab hospital.
As interesting as the circumstances are this is a very sad story for this poor, elderly man. What might really be happening here is that the family has refused to accept the patient to his home. And that closes the door to a path forward because there are no options for the patient.
And they have literally handcuffed the hospital because the hospital cannot discharge this patient if he has no home to go to and has no insurance for rehab.