“Do No Harm”…Lessons from the history of one of the nation’s most important institutions, Bellevue Hospital in New York City

bellevue_psychiatric_hospital_old_building

I urge everyone to read the article on the history of Bellevue Hospital of New York City in a recent issue of the New York Review of Books.  Here is the link to the article:

http://www.nybooks.com/articles/2017/01/19/take-me-to-bellevue/?sub_key=586e56a49da22


If you don’t know the history of the nation’s oldest health care facility, dating back to the mid-17th century, it is time to learn it.  In so doing, we can all become re-grounded  in the collective responsibility that we have to all of our people as part of our history.

I don’t know about you, but I actually wake up every day trying to understand the reasons why our nation does not provide affordable, accessible and high quality healthcare to all.  Really!

I remind myself of the seminal article by Stephie Woolander and David Himmelstein, written more than a decade ago:  “We Pay for National Healthcare, but We Don’t Get It”, updated in the last couple of  weeks:  “The current and projected taxpayer shares of U.S. health costs.” David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H. American Journal of Public Health, online ahead of print, Jan. 21, 2016. doi: 10.2105/AJPH.2015.302997)

In these articles these doctors/researchers/writers added up the simple truths that when you count Medicare, Medicaid. VA expenditures, and the Federal Employee Insurance Program, we are spending enough federal dollars to pay for healthcare for all people living in this country.  But when we realize that we waste nearly $1 trillion annually on lack of preventative care, missed opportunities for prevention of disease and injury,  errors and unnecessary harm, fraud and abuse, uncontrolled prices, and perhaps most importantly, a disaggregated non-system of care delivery, it is no wonder that we have such poor population health, such deep disparities in health outcomes based on race and nationality and class,  and the deep anxiety that exists. Sadly, in the wealthiest nation in history,   individuals and businesses worry themselves sick over affordability and  access to care itself.

Then there is the story of Bellevue…to drive home just how far off the mark we are…

It is documented that Bellevue, in its 280 years of service has never turned away a patient. Who are these patients?

In the contemporary moment especially, we should re-learn our history through the experience of what this great public institution has accomplished:  all early waves of immigrant people to New York City, Irish, Germans, Jews, Italians, Hispanics, Haitians, Africans,  and so many, many others right up to this moment have sought care at Bellevue.  In this frame, we also recall that each of these peoples, as they came in waves,  were vilified through ugly attribution of race and ethnicity to disease:  the “troublesome Irish”; the “tailors disease” (tuberculosis) of Jews, to the AIDS epidemic of more recent decades attributed to so many.  It  was at Bellevue where all these peoples have been treated successfully.

Today, 3 million of the 8.5 million New Yorkers are foreign-born…that’s more people than live in Chicago!  They speak 800 languages.  They seek care at Bellevue and at  the other NYC Health and Hospitals system, the largest public hospital system in the nation. At Bellevue alone in 2015, there were 670,000 non-emergency admissions.  80% of the payments were from Medicaid or there were no payments at all from the 20% uninsured.

At the same time, Bellevue has a long, long history of being the sought after place for medical training.  Many medical students from the city’s most prestigious universities, including, NYU, Columbia, and Cornell send their students to Bellevue.  Why?  Because it is there that they will see “everything”.

As I write this, New York City Health and Hospitals is facing its most challenging financial crisis ever:  all agree that by the year 2020, the system will have a deficit of at least $2 billion.  Most also agree that the system, like most systems, need substantial rebalancing of services and deployment of resources, both human  and   capital.

New Yorkers, and to some degree, people outside of New York know about Bellevue…but they don’t know enough.  Somehow, the notion of PUBLIC has gotten a bad name, when in truth, as in the case of Bellevue, the performance and contribution of the institution is nothing short of extraordinary.  Those dedicated caregivers who walk through those doors every day commit to care for the poor and the uninsured, watching over their shoulder hoping the institution will remain open!

The Hippocratic Oath mandates caregivers to “do no harm”.  However, we should remind ourselves that public health advocates with plenty of allies in the private sector have told us for many decades that if the caregiver is only treating  the individual patient with the intent  to do no harm,  unless the  caregiver is simultaneously looking at the health of the.  population as a whole,  we will do harm.  The resources dedicated to the health of our people must have stewardship, an economic system of health that will enable doing no harm to the population’s health.

Bellevue stands as a kind of “ground-zero” for our thinking as we must create the moral authority and the ethical responsibility to reform health care in ways that does no harm to the population. I,  like many of you study healthcare system change.  We are not making progress fast enough, and one of the victims of the slow pace of reform is the original American form of population health:  our public hospitals and Bellevue.

Jonas Salk, among others trained at Bellevue.  In the article you can read the long list of famous physicians who trained there as well.  What all learn at Bellevue is that medicine is a social art.  Scientific knowledge and expertise are essential for great medical practice…but economics is at the heart of care and outcomes.  And economics is a social matter, an ethical matter, a matter of choice of how wealth is utilized and  distributed.

The economics of healthcare does harm.  We cannot build great institutions like Bellevue and then let them suffer because they have been given an impossible task.  There is no balance to Bellevue’s mission with its financial model.

 

 

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