Coronavirus

"What Do Full Hospitals Really Tell Us About COVID?"

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Prof. Ed Richards, who specializes in (among other things) public health law at LSU law school, wrote this on a discussion list I'm on, and kindly agreed to let me repost it here:

This is a comment about Louisiana, although it applies in varying degrees to other states.

If you are a historian of hospitals in the US, or just an old health policy person, you know that post-WWII the federal government subsidized the construction of a lot of hospitals and created the expectation that every small town would have its own hospital. In the 1970s, health economists raised questions about the costs of running hospitals at 40-50% occupancy. This led to the passage of PL 93-641, the health planning act, and the Certificate of Need Program (CON). CON was intended to have community boards vet new hospital beds, etc., with an eye to reducing costs in the community by reducing excess capacity. CON was mostly a bust—everyone understood in theory why excess beds were a problem, but no one wanted to forgo a new facility in their community.

Market changes did what CON didn't and over the next 30 years squeezed out excess beds so that hospitals could operate at 90% capacity and make a lot more money. It was recognized at the time at time this was also removing the excess capacity that was a buffer for when there was a bad flu season or other outbreak. After 9/11 and SARS1, there were plans to build emergency ICUs outside of hospitals during outbreaks, including tents in the parking lots, to make up for the loss of beds. These plans were based on the assumption that there would plenty of people who could be brought in to staff the beds—sort of misunderstanding the PAN in pandemic.

Louisiana was a leader in the specialty hospital business, having neither an effective CON process or state regulatory system. The public argument for specialty hospitals is more expertise and lower costs because of efficiency. The real model was no emergency room, and thus no way for un- and under-insured people to get into the hospital. All of the financial benefits of being a hospital without any of the responsibilities. So we get women's hospitals, orthopedic hospitals, etc., sucking the profitable work from community hospitals, without taking any of the burden of community care for the indigent. General hospitals are even allowed to close their ERs in Louisiana.

The hospitals in Louisiana which take indigent patients and patients though the ER—pretty much all COVID patients—are slammed. The specialty hospitals have lots of staff and lots of beds and don't have much in the way of COVID patients, if there are any at all. They also do little to help the others. Thus Louisiana has a very small number of general beds that are available for COVID patients. It is a real crisis, but it is as much a crisis in health care resources as in COVID. While the Children's hospitals do have ERs, there are not many of them in Louisiana and there are very few total ICU beds. As another list member observed, you can have all the pediatric ICU beds full and still only have a tiny number of kids who are very sick.

The latest COVID surge is a serious problem, and I hope it prompts people to get vaccinated, since it appears that vaccination helps a great deal (even though it isn't perfect). But I thought that Prof. Richards' analysis was an interesting perspective on why focusing on this one particular metric might give a somewhat incomplete picture of the situation.

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  1. That’s a very interesting argument for why we have the number and kinds of beds we do, but how does it mean focusing on the statistic of general hospital beds, or ICU beds, available is misleading? Regardless of why, we have the number we have, and them being overrun is a huge problem.

    1. In the short term, nothing. In the long term, and in retrospect, it is why the denominator in the “patients / beds” is misallocated.

      Though, it is unclear if there is a good process to allocate, essentially, insurance capacity. We are all about JIT logistics, which works efficiently, until it doesn’t. Just enough beds works, until it doesn’t.

    2. According to the Kaiser Foundation, Louisiana is in the Top 10 states per capita for ICU capacity. My understanding is that all ICU beds are part of an ER. So I’m not quite sure what Prof. Richards relies upon for the conclusion that Louisiana is under-resourced for ER beds.

  2. Since government is hemorrhaging cash, I just assumed hospitals would grab at that to staff up new beds.

    I mean, we’re looking for something to borrow trillions for, and since we’re scraping the barrel with infrastructure trillions, we’re done with emergency beds?

    1. ” I just assumed hospitals would grab at that to staff up new beds.”

      How? Hospital beds require specialized skilled staff.

      Is there a large pool of unemployed medical professionals just sitting around with their thumbs up their asses?

      1. “Is there a large pool of unemployed medical professionals just sitting around with their thumbs up their asses?”

        I know that your question is rhetorical, and that the answer is obvious to most of us, but for those who actually wonder:

        No.

      2. Is there a large pool of unemployed medical professionals just sitting around with their thumbs up their asses?

        Judging based on all the virologists, epidemiologists, and immunologists posting on twitter, yes.

  3. When we scream, 90% capacity, it’s misleading. That is the minimum utilization for financial survival of an ICU. The hospital will thus pressure doctors to keep the ICU beds filled or risk the viability of the hospital. They brought boats, tents for COVID. They went unused during the height of the epidemic. Coincidence? Not a coincidence. There was no need, except to keep beds filled.

    I speak of lawyer rent seeking. I cannot even face the rent seeking of the health industry. It is 10 times bigger, 100 times more lethal, 10 times more violent and dangerous for dissenters, and twice as costly and wasteful. With no additional knowledge or technology, I can cut health costs in half. Give everyone, including the poor, gold plated top of the line care, and on demand. You would have to be willing to fire 2 million people and to take a $trillion from violent people. Promoting new technology would save far more.

  4. I hear there are also shortages of hospital staff.

    1. This is an interesting feature because those hospital beds need staff. I have never been in the army but I have read that the army rotates troops out of the battle zone routinely to maintain effectiveness at the front. Hospital staff however are just told to keep pushing. They are paid well but at some point the will just gives out.

  5. There is no question that as an analytical measure, Prof. Volokh is correct in that utilization is not a good metric and can give a misleading conclusion. In addition to the reporting he includes in his post, it may well be that admission criteria is sufficiently different so that individuals are admitted to hospital who are do not necessarily need admission, but who have good insurance and doctors who want to help hospitals do well financially.

    The real news here, I think, is the revelation that hospitals can get rid of indigent patients by limiting or eliminating ER facilities. What does deliberately denying care to the most vulnerable and needy of our fellow men and women say about us as a people?

    1. Well, it probably mostly tells us that providing health care for the needy through emergency rooms is really stupid, but that just opens up the discussion about how dumb the American health care system is overall so probably isn’t super productive here.

      1. Are you upset that emergency room providers responded in the obvious way to federal law (EMTALA) that demands they provide uncompensated care?

        1. Not sure how you got that from my post. There’s a lot of really dumb things about our health care system; the fact that we expect that the way health care providers are supposed to support the health needs of their communities is primarily by operating loss-making emergency rooms is certainly one of them, but I find it completely unsurprising that many hospitals would rather not do that.

        2. See they don’t provide ER services to anyone. Which is a really stupid way to respond to the situation of uncompensated care.

          I sincerely hope you do not find yourself in a community where you need ER care and find that the local hospital does not offer ER care because they are afraid you are unable to pay for it. I imagine that if that is the case you will modify your views, assuming, as I hope, that you live to express them.

  6. I think the appropriate measurement is how full are the hospitals compared to how full they were immediately before the most recent surge in cases. You need both numbers to determine the extent to which things have changed.

    1. How about the reasons for admission?

      How about verification of the reasons proffered for admission?

      1. If the reasons for admission were covid, would you believe it, or would you just say it’s fake news?

        1. My response would hinge, in part, on the contents of the verification of the proffered reasons for admission.

          1. And how, pray tell, do you verify why any particular patient was admitted?

            “Patient was admitted with a burst appendix.” Do you take everyone’s word for it that it was a burst appendix, or do you insist on somehow verifying that the patient really did have a burst appendix?

            1. That the mechanism(s) to be employed for verification of the reasons a patient was admitted present some challenges is no reason to abandon the project.

              1. People such as yourself don’t get to demand proof that someone was admitted to a hospital for a particular reason.

                Either you trust medical professionals to accurately diagnose their patients and do their jobs, or you’re an idiot.

                1. Color me an idiot who recognizes physician and hospital error as one of the leading causes of death.

                  Maybe you are okay with iatrogenic death?

                  1. You have to count pretty far down to call it one of the ‘leading’ causes of death.

                    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7351940/

        2. If the reasons for admission were covid, would you believe it, or would you just say it’s fake news?

          Would that we could even have the opportunity to tackle that question. At this point, the CDC and every state I’m aware of just reports admissions/beds with a positive COVID test result, not whether COVID was the actual reason for admission. (CDC used to track % of ER visits for “COVID-like illness” — as it currently still does for “influenza-like illness” — but as far as I can tell scrapped that in February of this year and now just reports “positive patients” per above. And that’s one step removed from hospital admissions in any event.)

          1. LoB, ever give any thought to the fact that a Covid-positive car wreck patient still has to be isolated and treated according to the protocols for treating Covid? And hence is properly classified for the purpose of measuring Covid treatment capacity.

            Why is that a problem for you? Let me guess. Because doing it that way adds one more case to the ledger documenting Trump’s disastrous mismanagement of the pandemic. I suggest you give up on that one.

            Trump’s pandemic blundering is headed for the history books, destined all by itself to drag to the very bottom history’s assessment of his place on lists of presidential performance. He maybe ought to get an asterisk, for somehow not preventing crash-schedule vaccine development. But sensible judges will point to his efforts to discourage use of vaccines, so no asterisk anyway.

            1. SL, it’s not at all clear what ultra-clever point you think you’re making or how much you really understand about the subject matter at hand, but what is crystal-clear from your screed is that TDS is alive and well. Maybe try getting out for some fresh air every so often if your jurisdiction still allows that.

  7. “They brought boats, tents for COVID. They went unused during the height of the epidemic. Coincidence? Not a coincidence. There was no need, except to keep beds filled.”

    So you know next to nothing about what actually happened in NYC, and why Javits only ended up treating a little over 1,000 people and USNS Comfort just under 200? That neither was initially set up to accept COVID patients? That when they were converted to finally allow COVID patients, about 3 days before NY’s peak, they admitted patients at a fairly brisk pace for those facilities, but the strain subsided shortly after? That USNS Comfort has a fairly poor history of being a useful supplement to existing hospital networks on a short term basis (it did almost nothing for PR after Maria, despite massive destruction to healthcare resources there)?

    And you think you could go in a cut costs and improve care in the medical field?

    1. Hey, this should’ve been in reply to DaivdBehar

      1. Naw, I never read those – this is a much better place for it! 😀

      2. There’s a reason for the mute function.

        And it’s him and Kirkland.

    2. Whey, you provided the numbers that make my point. Thank you. I do not see any disagreement. Yes, I can cut health costs in half and provide top care to everyone, without waiting. Just have a blood test done. You will see the places where to start cutting for yourself.

      1. Whey, do you have any numbers for “with Covid” vs “from Covid?” Guy is shot in the head, or crashed his motorcycle. Gets COVID on the death certificate. Hospital gets $35000 for nothing. Imagine what would happen to a doctor employee who refused to sign that death certificate.

        1. I speak of the greatest fraud heist of $1.7 trillion to the tech billionaires in 2020, by hyping this fake pandemic and causing a shutdown of the economy, and killing millions by starvation overseas.

          Someone needs to also retrieve the federal payments made to hospitals lying on the death certificate.

        2. Ah, you’re one of those dolts that thought a half-dozen examples of misdiagnosis caught in review were evidence of some widespread conspiracy to risk thousands of medical licenses to get a slight bump in low-rate reimbursables, because hospitals love low Medicare reimbursements over the high-earning specialty units that all had to be shut down.

          There should be a picture of you next to the entry for Dunning-Kruger effect.

          1. Those are just personal remarks, after a request for numbers. The base death rate of nursing home patients is 26% a year. Times it 15. million, that makes, around 400000. That should be deducted from the COVID deaths. That leaves some 100000 excess deaths. Almost all were from undiagnosed and untreated cancer and heart disease patients denied care from the lockdown.

            The pandemic is the biggest fraud heist in history, and the fastest biggest mass murder. The $4 trillion drop in world GDP killed 100 million by starvation. The tech billionaires of the US took in $1.7 trillion. Those of China took in $2 trillion.

            Personal remarks commit the Fallacy of Irrelevance.

            1. I think it’s absolutely relevant that your claim (that some material number of those identified as dying from COVID did not actually die from COVID) is false. How could it not be?

              26% of 15 million is 3.9 million, not 400,000. Did you mean 1.5 million?

              And there were hundreds of thousands of nursing home deaths last year not attributed to COVID, including that of my own grandfather. I’ve seen his death certificate from July 2020, no COVID listed. Why are you asserting that they were all attributable to COVID, exactly? I mean, other than that you’re incompetent.

          2. Actually, you can go to the CDC’s COVID Death tracker website, and check yourself.

            Go look at the number of deaths labelled as “COVID Deaths” that have death cause codes in the V-xx or X-xx sections – the ones for vehicular accidents, drowning, or gunshot wounds.
            At this time last year, it was about 4%. Now it’s down to about 3%. That’s a bit more than a “half-dozen examples of misdiagnosis”.

            I do not presume to speak to motives for this inclusion of auto accident or murder victims in “COVID Deaths”, but it certainly happens.

      2. You: They brought boats, tents for COVID. They went unused during the height of the epidemic. Coincidence? Not a coincidence. There was no need.

        Me: Actually it’s because they initially weren’t set up to deal with COVID patients, and did not accept them. By the time they did, NY was just hitting the peak, and while they provided some relief by getting transfers as fast as they could, the need *that absolutely existed* had abated by the time they got the processes worked out.

        Yo

        1. You* claimed they sat empty because their was no need. I argued there was a need, but that they initially sat empty because they weren’t set up to address the need, and by the time they were converted to address it, the need began to abate.

          1. Whey, without violating your privacy, can you tell us if you were in healthcare in NYC? I have a lot of questions if you were.

            1. Not during the COVID pandemic, but I know plenty of people that were.

  8. If government wants spare capacity and service for the indigent (both fine things, really) … it can … pay for those?

    (“But it’s expensive!” … yes, it is. Pretending it magically appears when you backdoor make other people pay for it and that those costs aren’t “real” is just trickery.

    Actually pay for things and you can do cost/benefit analysis, rather than pretending you can wave hands and make costless goods appear.

    Apply also to environmental protection – the Endangered Species Act gives people lots of incentive to destroy habitat quietly before someone notices, because having it found on your property is suddenly super expensive to you.

    If the Feds bought out your interest in critical habitat, the incentive would be reversed.

    But that costs money, and it’s so much easier to just pass a law saying “Thou Shalt Not” and depend on people mostly following it and sucking up all those costs for The Greater Good, isn’t it?

    If we had to pay for it, people could push back and make arguments for better uses of the resources, and we can’t have THAT, can we?)

  9. This is perhaps the classic example for why the laissez-fairw approach that maximizes quarterly profits is not the approach the maximizes the chabces of the overall society’s survival.

    The hospital system has to operate at a loss most of the time to cover the relatively rare evwnts that enable society to survive.

    And the idea that “efficiency” (in the sense of eliminating “redundant” beds and siphoning off the profitable specialty stuff from general care) is better for society is bullshit.

    Nor is it better for the shareholders. Dead shareholders can’t take their money to their graves. It’s just paper.

    1. Sounds like commie talk. Don’t you know the market never fails and is the ultimate saving grace for society?

  10. He makes it sound like CON aren’t really a problem and it’s all markets but my understanding is that in the Great Lakes CON aren’t given so freely. In New York they have the parallel Jewish ambulances and another group wanted to set up their own due to religious issues related to women not calling a service staffed by men (pretty sure it was mentioned here a while ago), but they were denied with no reference to the market.

  11. I had a client whose facility was slated to become one of the emergency hospitals they were planning back in the early months of the pandemic. A bevy of high ranking officials from the CDC, army corps of engineers, and other military came through and made plans. Kind of cool, but it never came to fruition as they never ended up needing it.

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