As a trainee at a large private health system (residency) followed by a NCI-designed comprehensive cancer (fellowship) in two large metropolitan areas in the United States, I was not prepared to face the challenges of working at a university setting affiliated with a county (public) hospital in more rural west-Texas. After one and a half years of experience as a practicing urologic oncologist, these are the five challenges I have encountered:
1. Access to the latest technology. County (public) hospitals are typically more cash-conscious without access to large amounts of research money, wealthy donors, high-profile fundraisers, or patients with a reliable payer mix (i.e., commercial/Medicare). This is even more pronounced in non-metropolitan settings. As a result, getting access to the latest technology is difficult due to the tighter financial circumstances of a county hospital, which often relies on taxpayers to subsidize losses. With the Affordable Care Act and expansion of Medicaid in certain states, these subsidies from the federal and state government are disappearing, making the situation worse. As a result, hospital administration is more reserved in spending money on new, sometimes multi-million dollar machines to keep up with medical technology development.
2. Access to the latest clinical trials. While there is quality care provided by radiation, medical, and surgical oncology, access to the latest clinical trials is still limited (although getting better) for patients that are non-responsive or progressing on standard therapies. Given the long travel time (via motor vehicle) to the nearest major cancer center, it possesses a significant time and financial commitment by patients, not to mention the inconvenience.
3. Unreliable payer mix/unreliable reimbursement. A county (public) hospital is tasked with taking care of the majority of the uninsured and Medicaid population in the area. This patient population typically has unreliable payments and sometimes days of expensive medical care is written off. While this mission is admirable, the financial consequences can disseminate throughout the health care system and impact the bottom line.
4. Overuse of the emergency room. Due to #3 and a lack of consequences for the uninsured, there is no deterrent or significant penalty for patients to keep coming back to the ER and receive expensive medical treatment they cannot pay for. Lack of access to primary care physicians for preventative care further precipitates this problem.
5. Lower reported patient satisfaction. There are clinical studies to support that patients who are less invested in their own health and who have poor medical expensive coverage are likely to rate their own care worse in both inpatient and outpatient settings compared to similarly-treated patients with better insurance. Due to shift in reimbursements to value-based care (paying providers based on the quality, rather than the quantity), this may further impact the revenue generated in a county (public) hospital setting.
While some of these challenges do reflect systemic problems in the current health care landscape in the United States, the burden can sometimes be unfairly shouldered by a few.
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