Hospital (14 page)

It wasn’t clear if Mr. Zen—illegal alien, undocumented worker, very sick man—was counted among the 47 million uninsured people in the United States, since he officially did not exist. But he was definitely part of the daily census at Maimonides, a crucial figure in the numbers game that obsessed the managers on the second floor of Eisenstadt, where the Maimonides executives were clustered. The “executive suite” was a humble row of little offices, many of them windowless, on either side of the hallways that intersected in the reception area, where the undistinguished portraits of former hospital presidents were hung at uneven angles. No feng shui there. Brier and McDougle had larger offices than the rest, but nothing fancy. Budget-conscious was the operating motif.

Maimonides managed to stay in the black—barely—without major benefactors because it almost always had an occupancy rate of 99 percent and because in the previous decade it had reduced the average length of stay from 8.24 days to 6.24 days. That was the magic equation: full house and not too many people allowed to overstay their welcome—not past the billing guidelines of the twenty-one insurers the hospital dealt with (compared with five or six in the days before the idea of managed care through competition took hold in the 1990s). The equation worked only if most of the patients kept moving through.

As Joseph Cunningham, chief of surgery, said, “You take any two hospitals, if I can do a coronary bypass and get a patient out into a secondary location—home, rehab, family—a day shorter than Lutheran, I’ve put another ten thousand dollars in my pocket. Every discharge across the board is at least ten thousand dollars to a hospital.

“It’s all about turnover,” he told me. “The more you can get in and out, the more times that cash register clicks. It sounds like business, and it is business, but the caveat is, you can’t get them out if they’re not ready. We’re not kicking them out. But if you get them out two days later, for every discharge you lose, you’re losing ten thousand bucks.”

Everyone felt the pressure to build volume. “All these people crunch numbersevery day,” said Amit Schwartz, the young neurosurgeon who often showed up at the cancer center’s interdisciplinary meetings. “You know when you’re being looked at by Mark McDougle or Lillian, or Naldi [the chief financial officer], there’s a number on your head of how many cases you did in the last month. They look at that number all the time. I can walk in the hallway and the president of the hospital will say, ‘Okay, you did ten operations last week.’ They know everybody—who they did, how much they did.”

Pam Brier acknowledged that this was true. “I look at the volume every damn day,” she said. “I wake up every morning, I come to work, I read admissions and discharges. I read about patient discharges by service and by doctor on every single service. You sort of live and die by it.”

Surgery numbers had been down over the summer, especially in cardiac; newer technology—stents, angioplasties—had steadily taken over. Waiting outside Pam Brier’s office one day, I heard her yelling on the phone to Fraidkin, “These fucking surgery numbers are keeping me awake at night!”

When I walked in, Brier was sitting at her desk, very ladylike, straightening one of the already-very-neat piles of paper on her desk. “I love the synergism of my job,” she said with a stagy smile as I pulled out my tape recorder. “Is the recorder on?”

Chris Kam wasn’t joking when he said that his real assignment had been, as he put it, “to kick Zen out.” Before Kam was assigned to the case, not long after Mr. Zen came to the hospital, Janice Yang, director of outreach to the Asian community, got a call from a social worker at the Brooklyn Chinese-American Association. Yang, a slender, pretty thirty-seven-year-old woman with straight black hair and an almost constant look of worry, had moved to New York from Canton (Guangzhou) when she was fifteen years old. She still had a heavy Chinese accent. When Yang learned that a friend of Zen’s had complained that the hospital was trying to kick him out, she contacted the friend. Yang explained that the hospital wasn’t meant for long-term care and that it was usual procedure to send patients home or to rehab or hospice or a nursing home. Yang tried to talk to Mr. Zen without success and then sent a series of interpreters, who got nowhere trying to convince Mr. Zen to move.

“He hesitated to talk to Asian faces,” Yang told me. “Everyone is afraid they’ll get a bill or we might ask them for money, so they try to protect themselves, they don’t want to release information. It happens to a lot of the cancer patients, especially the Chinese patients. Either they are illegal here or have no insurance. Even people with insurance, not a lot of them do preventive care, so they end up in the emergency rooms. They’ve never been checked up, so once things happen, they go to the emergency room and find out it’s too late.”

She sympathized. She didn’t speak English when she arrived in the United States. She and her brother and sister worked after school until eleven at night, because the family had no money. Her father had been a doctor in China but in the United States worked in an antique store staining and painting furniture. She remembered what it was like eating on the floor of an empty apartment because they couldn’t afford furniture.

“I know it’s not easy to be a new immigrant to this country,” she told me. “We can’t speak, we can’t hear, we can’t read. I want to help the community, because I went through the pain.”

Patients like Zen clogged the system, curtailed patient flow. But Chris Kam seemed unconcerned about consequences for failing in his assignment to “kick Zen out,” and Gregory Todd, the physician, said he never felt any specific pressure to discharge a patient before he believed it was time. Nevertheless, he said, “We all have the general pressure of shorter length of stay, which every hospital wrestles with every day. We always comment when we do it well—we don’t know how we did it and how to reproduce it.”

The tender care of Mr. Zen, spread over a period of months, was an anachronism. Old medicine. Social workers like Kam and Keen were replaced by nurse case managers, who had no leisure to spend time at bedside, because they were occupied with moving patients through the system. New medicine demanded cultural competency, clinical excellence, and psychological awareness, but not at the expense of efficiency, coordination, and speed (none of which conformed to the vagaries of illness, insurance compensation, and the availability of aftercare for the elderly and the infirm).

Every day, it seemed, a new study or book was published discussing the failures of the system, the pressures placed on health delivery by the domination of pharmaceutical and insurance behemoths—“How health care in America became big business—and bad medicine,” to quote the subtitle of one of them (
Critical Condition
by Bartlett and Steele). But at Maimonides most people were too busy to ponder the larger forces that were making their lives difficult. Thinking about the big picture could crush you: Health-care expenses in the United States rose from $1,106 per person in 1980 ($255 billion overall) to $6,280 per person in 2004 ($1.9
trillion
overall). Yet in 2005, 44.8 million in the United States, an appalling 15.3 percent of the population, had no health insurance.

“I don’t spend a lot of time thinking about global issues,” Robert Naldi, the chief financial officer, told me. He had curly graying hair and a rat-a-tat way of talking that seemed just right for a numbers guy. “When I hear Medicare is being cut six billion dollars over the next ten years, Medicaid cut four billion dollars the next, that ten billion dollars doesn’t change what I do on a Thursday morning. I just don’t get into that trap. I worry about our little hospital in Borough Park. . . . I have a luxury. . . . We have a very strong core business. People in the community like us a lot. It has its ups and downs, ebbs and flows. Me, I don’t even read about it, to be honest. I don’t spend any energy forecasting the next three or four years, because I don’t think anyone can do that. We’re lucky if we forecast the next six months, things change so rapidly. I just don’t waste time on it.”

Mr. Zen was part of “the bed-management problem,” the bureaucratic way of referring to the fact it could take twenty-four hours and sometimes more for patients admitted through the ER to make it into a bed. Almost every day the scene that shocked Chuck and Carolyn Gregorius, Davey’s parents, was reenacted in the emergency room that was Zen’s entry into Maimonides. In the hallway leading to the ER, it was routine to find patients backed up like airplanes on a runway in lousy weather. Just in case any of the administrators up on the second floor of Eisenstadt forgot about the situation, Carl Ramsay, medical director of the ER, periodically held his cell phone aloft and snapped a picture, which he then transmitted to them by computer.