The House of Hope and Fear: Life in a Big City Hospital

Cynthia Rekdal January 6, 2010 Comments Off on The House of Hope and Fear: Life in a Big City Hospital

Neither indigent nor uninsured, Harborview was the hospital of choice for former Washington State Governor Albert Rossellini, after breaking his hip in a recent fall. For native Seattle-ites and those who have lived any length of time in the region, Harborview Medical Center, opened in 1931, is synonymous with charity, trauma, and a newscaster’s voice pronouncing another person “rushed to Harborview” for emergency service.

“The House of Hope And Fear” is a timely book, given the current level of acrimonious debate and mind numbing carrot-stick attempts to create a national health care plan. It is the second book for local author Audrey Young, a recent first-time mother, who now practices medicine at Evergreen Hospital in Kirkland. The book is based on her experiences working at Harborview, a public hospital in the Pill Hill neighborhood, and a poster-perfect example of medical urban sprawl on steroids.

In 1996, Young, a Seattle native, entered Harborview as a third year medical student in trauma surgery. She stayed for six years, becoming a staff physician there.

“I fell in love with a story,” she wrote in the book’s introduction, “It is the story of a tough and unique group of human beings who are committed to a vision of equality for the most vulnerable people in our society, a group who believes that everyone should be treated equally and well, regardless of who they are.”

The book is focused on a collection of haunting vignettes of charity patients cared for during her residency: street people, alcoholics, drug addicts, the mentally ill – societal rejects and family outcasts who seek emergency care and treatment from a medical oasis in the center of the city whose mission is based on the guiding principals: “work hard, be polite, and treat patients graciously, regardless of their ability to pay, even if he (or she) is not the president of the United States.”

In her tale of the push-pull constant of high occupancy needs vs. unpredictable discharge rates at Harborview, one comes to understand the often overwhelming dilemma and tricky dance-of-life moves involved in administering to the sick, maintaining resources, and balancing finances required for institutional survival.

Although it covers somewhat dark subject matter, often using unfamiliar medical terms, Young’s reader-friendly book also includes an informative short history of U.S. public charity hospitals. Originating in the 18th century as “urban alms houses constructed and run by the wealthy elite,” and serviced by volunteer doctors and nurses, public hospitals offered free medical care for the destitute. In time, as they sought to offset the cost of caring for the indigent while simultaneously infusing additional revenue to enhance insufficient government subsidies, they grew into hospitals that also offered private rooms and facilities to those who could afford to pay. Unfortunately, for some, the added focus was not enough. Between 1996 and 2002, one-sixth of the nation’s urban public hospitals closed; in remote areas, the rate was even higher. In the 70s, six hospitals served Seattle’s indigent. By 2006, only Harborview remained. Young details the reasons.

She provides a portrait of Harborview’s business model, one whose charity care, during her tenure there, tripled in 5 years from $112 million to over $550 million per year in revenue, while continuing to run in the black despite limited government support and the overwhelming growth in indigent services. The hospital implemented a business plan, striving to “become the hospital of choice and necessity”. It addressed its inefficiencies, planned new cutting edge, state-of-the-art centers with rehabilitation, neurosciences, trauma, burn, critical care, sleep and HIV/AIDS programs. It overhauled its product lines, began brand imaging to lure well-heeled patients through its doors, and became known for physician expertise and the recruitment of excellent administrators.

Today, Young states, “Harborview is not a classic public institution, or a business enterprise, but a mix of charity and commerce — a blend of ‘margin and mission’ providing high quality care to all, including the most needy.” In a recent interview with Young, she added, “Harborview thrives not just because of its dedicated staff, but because the hospital is forced to compete for business with other hospitals in the community. . . . We should pay attention to the Harborview story for the reasons I describe in the book, because competition among various hospitals and providers can raise the quality of health services, essentially without increasing the cost to the taxpayer.”

Asked if the author had any opinion regarding the current health care debate, Young noted, “It’s important that we’re talking about providing health insurance for everybody. Something many people don’t realize is that we already pay for health care for all, but we’re doing it in the most expensive and least rational way possible – through our emergency rooms. . . . We pay for invasive procedures, but not for preventive health care, and not surprisingly, that’s led to huge growth in complex care while the basics have been neglected. This imbalance needs to be reigned in.” Another problem with the current system, according to Young, is the “total lack of financial transparency in the system, and the role that this plays in ever-rising costs. . . . We spend more than double what any other country does for health care . . . (and yet) we rank near the bottom . . . in most health basic measures, like life expectancy. . . . The current system is inadequate. It provides acute and superficial solutions at some of the steepest prices in the world.”

Perhaps, Young’s book on Harborview — the house of hope and fear — can provide the hope needed as an example of how to run a health care system that works for rich and poor, supports itself, and “increases efficiency and quality care” putting an end to the current toxic debates raging in Congress. Perhaps, someone should send copies of her book to the other Washington.

Comments are closed.