The Hospital

The hospital is a unique place within a community.  Originally contrived as a common location to collect and care for ailing people, now along with schools, libraries, and parks, hospitals have come to be seen as an important and necessary part of a thriving community with each community or county supporting its local hospital. 

However, the healthcare landscape has changed in profound ways over the past several decades.  Post the 2009 legislative healthcare overhaul, this tectonic movement has resulted in the consolidation of independent healthcare practices under the banners of large, corporate healthcare organizations.  While this change brings efficiencies of scale, it also tends to corporatize the medical encounter and view the patient/physician interaction (along with all the things that go along with healthcare delivery) as merely the engine of corporate revenue – a thing to be optimized.

In this book, Brian Alexander tells the story of the local hospital in Bryan, Ohio.  With history dating back to the early decades of the 1900s the hospital became a fixture in Williams County.  For those who have worked there, it is a place of community.  And for the county, it is a place of healing on the front lines of medical care in a remote part of the country.

At the time of writing, Bryan Hospital was situated between the medical territories of Fort Wayne based Parkview Health and Toledo based ProMedica.  Throughout the book, Alexander highlights the regional, political and even fiscal challenges faced by Bryan Hospital as they attempted to stay independent from both large healthcare organizations.  This story is told through the eyes of the senior executives at the hospital, physicians practicing in Bryan and various members of the Williams County community.

As a physician in an urban emergency department, I found this book fascinating.  While the book is set in rural northwest Ohio, my experience in an urban environment just a few counties away shares many similarities.  It illustrates the idea that pathology is no respecter of persons.  And whether you are in the city or rural areas, the social struggles are the same.  This book shows to a broader audience what each of us in emergency departments across the country see every day.

I thought that this book did a good job telling the stories of the working poor in rural America and the struggles they encounter as they interface with their health and the health care industry.  I see this on a routine basis in the Emergency Department.  It is easy to view a patient’s medical condition from a perspective of knowledge and resources and wonder why people just don’t take care of themselves.  And while I have my issues with many of the applications of the “social determinants of health,” I see each and every day that the environment you find yourself in does create its own set of unique challenges for patients.

I also enjoyed the unique look at the business side of medicine.  For physicians and patients alike, third-party payment keeps much of the economics of medicine veiled behind premiums and deductibles.  The book provides a good look at the challenges of incentivizing medical talent to practice in underserved areas as well as the convoluted web that is the system of medical finance.  It shows how, unfortunately, many of the incentives in healthcare finance are misaligned.

There were several areas that I found disappointing about the book.  Specifically, the book took a politically left leaning approach to healthcare policy.  While I will be the first to admit that there are many areas where our healthcare system in the United States is broken at a very fundamental level, the book approached this topic from a very one-sided view with regard to the nature of the healthcare industry and the surrounding economic environment.

The implied conclusion of the book is that we need to have a publicly funded health care system.  At a surface level this idea has a lot of appeal.  The argument is that healthcare (I mean honest-to-goodness appointments with doctors, medical tests and procedures, not just a paper certificate of coverage) has become so expensive that is unaffordable for all but a small few who are wealthy enough to be able to pay for their care out of pocket, have employer-sponsored insurance, or who can afford the premiums and deductibles of private insurance.  The whole healthcare market that overlays the doctor/patient interaction is built on the idea of using that interaction as the basis to try to extract as much money as possible. So, it’s no wonder that some form of taxpayer-funded group healthcare payment model seems attractive to many.  But the experience of countries with national health services illustrates the inefficiencies imposed by these models.  And as we look at our own experience with Medicare and Medicaid, we see low reimbursements functionally price patients out of the healthcare market as many providers don’t take these patients.  Additionally, the government subsidy and reimbursements create perverse incentives that ripple through the public and private insurance marketplace.  In the end, healthcare becomes less affordable and innovation is stifled.

So final thoughts… I thought this was an interesting book.  In many ways it pulled the curtain back on a number of aspects of healthcare that are not well known to many people.  It showed the struggles of running a small-town, community hospital, and it showed the healthcare related struggles that many Americans face and how those ailments can have a profound effect on everyday life.  In the end, though, I was disappointed at the political bias and how the author used specific examples to craft an argument.

Title: The Hospital: Life Death, and Dollars in a Small American Town

Author: Brian Alexander

Rating: ★★★★☆

Find it on Amazon: https://amzn.to/4vDgBg8

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