Some issues are complicated. In fact, lots of issues involving government are complicated. It’s not like there are two sides to some of these issues, it’s more like there are fifty.
Let’s talk about this birthing center. This was an attempt by some folks to open a birthing center in Elizabethtown, Kentucky. They went to the state government to get something called a “certificate of need,” which is required in Kentucky to open or expand health care facilities.
They were denied that CON. So they appealed and the ruling was reversed, but then that was appealed and the CON denied again.
So what’s the deal? Is it really just “big hospitals” flexing their muscles and denying a place for the little guy?
A brief look at the proposed birthing center’s page shows me that these are some midwives who are proponents of home birth who decided to open this birthing center. Since it’s absolutely certain that Nicole would never have utilized their services, I’m not sure why she’s upset about this. Their delivery fee was scheduled to be in range of about $7K.
But no matter. We’ll talk about certificates of need anyway.
I wondered what they were way in my day, when I first heard about them in relation to CAT scan services.
The reasoning was like this.
Let’s assume that you’re running a hospital in Russell County, Kentucky, near me, and you have a CAT scan machine. You have a population of X people and out of those folks, Y percentage will have a CAT scan in any given year.
People, of course, can go anywhere they like for their medical services, so perhaps some of those people go to doctors who prefer to use the CAT scanner at the hospital in Pulaski County, KY, which is the next county over.
This actually happens quite a bit in reality.
In order to pay for that CAT scanner in Russell County, they have to figure out how much the thing costs per year and divide that by the number of people likely to use it, and from there get the cost per patient. The fewer patients who have a CAT scan, the more money it costs per patient.
And guess what happens when it costs more? Somebody has to pay for it, and those somebodies are the bodies being scanned.
This is very simple economics.
The more dogs a groomer grooms, the less it costs her per dog on a monthly basis to maintain things like clippers and the water bill and the rent.
But see, nobody has to have their dog groomed.
People absolutely have to sometimes have a CAT scan. And sometimes they have to have an MRI that they never expected to need. Or deliver a baby in the ICU on a moment’s notice. When stuff like that happens, there is no such thing as deciding to forego the help and just wing it. Or rather, you can decide to do that, and then your family can bury you and your baby.
So that’s pretty much the basis for the idea of certificates of need. Most states that require them do so for health care facilities on the grounds that it keeps health care costs lower if one facility’s equipment is being used at near-full capacity, instead of having five that are barely touched.
This, of course, makes libertarian types crazy because they think that it’s just great to have lots and lots of little competing hospitals all operated on a damn shoe-string.
Reading court cases can be just fascinating and this is no exception. The proposed birthing center was basically a joke.
They said they were gonna get all these home birth mothers to flock to their facility in ETown from Louisville (!!!!), even though there aren’t very many of them in the first place. They also insisted they’d get a bazillion patients but then said they weren’t going to accept Medicaid, thus reducing their potential client pool by about 50%.
Their numbers were ridiculous and completely impossible.
But a birthing center isn’t an MRI machine.
So what if these ill-informed and very silly women wanted to open a birthing center only to go belly-up in six months? Who cares?
What are the costs associated with a birthing center, whether you’re talking about a little start-up in ETown or the birthing center of a large hospital?
A major cost would be staffing. Having redundant birthing centers with few patients will drive up the cost per patient.
Let me compare it to something I know about, and that’s recovery rooms.
I used to work weekend nights, 12-hour-shifts, in a city hospital (Greenville Memorial, Greenville, SC). I was the only nurse in the recovery room most nights.
I had to be there no matter what. Didn’t matter if I had a patient or didn’t have a patient. I had to be there. I was well paid to just be there. My favorite kind of night was to get a patient in at about 2 a.m., something nice and easy like an appendectomy on a 25-year-old, get him awake and up to his room in an hour and then sit back and relax until the day shift started to arrive at about 6:30 a.m.
The rule was that I could never be in the recovery room with a patient alone. I had to have another nurse there (or a resident, but try getting one of them to hang out with you). So, usually, the OR circulating nurse would come in and sit with me. She didn’t have to do anything. She was just there. If it got really busy, there was always a recovery room nurse on call and I could call her in. We tried to avoid that.
But look at the economics of this.
On my favorite kind of night, I took care of one patient for one hour, and was paid for twelve. Some nights, I took care of zero patients and was paid for the whole shift.
This was offset, of course, during the day when the OR hummed with the sound of scapels being wielded and blood being sucked and stitches being placed and bandages being applied, and one patient after another was wheeled into a fully-staffed recovery room, where it was easy for one nurse to take care of about six patients daily, maybe more.
Each little station where those beds were wheeled had built-in oxygen, built-in blood pressure and other vital sign monitors, and stuff like that. It all cost lots of money.
What if the state hadn’t bothered with those pesky certificates of need and there were five other little hospitals that sprang up all over town, each with six operating rooms and an eight-bed recovery room? What would have happened to our patient load?
If our patient load went down, how were they going to pay my salary so I could come in and take care of that one appendectomy in the middle of the night?
There’s another side to this, of course. In looking at it via the Google machine, it appears that the people who just don’t like the whole idea of CONs are libertarian, or libertarian/conservatives. That’s almost all I needed to quit reading, frankly.
But I tried. I really did. These folks all believe that access to health care should be handled exactly the same way that we handle access to goods like new shoes, or access to services like dog grooming.
Let the free market handle it all. The ghost of Adam Smith will just float about and make it all work out nicely.
But health care is not something that works well as a free market commodity.
The problem is that we always have people like Joe and Nicole Naugler. People who ignore their own health care, refuse to see what is right in front of their faces, refuse to insure themselves and end up running madly into the nearest hospital demanding the absolute best in service and then refusing to pay one single cent for what they got.
And then those same people complain bitterly about the fact that the state made that care available to them.
The birthing center, had it existed, would have refused Nicole service. She had no money and they wanted $7K to even consider her.
In a real free market situation, Nicole would have been allowed to simply die.