A new chapter focuses the subject of Medical Ethics. The reader will find a helpful introduction to most of the situations relevant to hospital ministry. Familiarity should enhance the pastor's usefulness. As is true with the other chapters, readings in the form of an annotated bibliography are found at the end.
The Handbook is an effort to add new construction to the bridge connecting the pastor and the hospital. We hope the result will be an easier path for the minister in delivering pastoral care to parishioners. If the book proves useful and fulfills its limited goals, the authors will feel gratified. We made the decision long ago that the effort was worth it, because we believe strongly in the value of spiritual care during illness and its place in the delivery of wholistic health care.
We also hope this book encourages further cooperation between chaplains and pastors. Either of our names could appear first in authorship as the contributions of each have been similar. A small section of this book addresses the appropriate need and probable benefit of more frequent collaboration, particularly in critical life events such as illness.
No single book is adequate, however, to prepare a minister for the specific concerns which might be experienced. This book is directed to those situations most commonly encountered. Even then, it provides a general guide. For more specific information the reader is directed to the annotated bibliography at the end of each chapter as well as the glossary at the end of the book.
1
Today's Hospital
It's Not Like Where You Were Born
A Revolution You Ought to Know About
Hospitals are experiencing radical changes, some occurring even as you read this book. This revolution is of interest to pastors, lay-persons, and the Church for several reasons. A significant portion of your ministry is carried out in relationship to illness events. Understanding the nature and structure of hospitals can aid you toward working effectively within that system. Second, you and your parishioners utilize health care facilities as patients and being aware will assist you toward becoming an informed consumer. Third, it may be that some of these changes call for the Church to become more active, at least educationally, in the health care endeavor.
At the heart of this revolution are two central questions. Is health care a right to be afforded to all persons or is it available to the privileged only? Privileged usually means that you and/or a third party (insurance) will pay the bills. The second question is: Who is going to pay for the services? In our society the prevailing political answer1 to the first question is that Americans should have unlimited access to the best available health services. In order to provide the service, however, health care costs currently consume 10.7% of the gross national product.
This wasn't such a problem as long as the family doctor got in his car and drove to your home when you were ill. S/he usually had everything required for treatment in a black bag, predictably a tongue depressant, a stethoscope to listen to heart and lungs, a light to look in the ears or eyes, and, finally, a penicillin shot. As technology developed, however, a clustering of services resulted. Physicians preferred to locate offices near hospitals, which became the centers for the treatment of illness. You now go to the physician's office for care and, if necessary, can be admitted to the nearby hospital, reducing travel time between office and hospital for the doctor.
It has been theorized that when physician house calls became uncommon,2 the sanctity of the physician-relationship changed forever. In its place emerged a less personal, more technological approach which can save lives, but also can prolong life unnecessarily, always at a high cost. There is the resulting need continuously to refurbish and replace outdated hospital facilities and to have the latest piece of new technology. Physicians’ salaries have skyrocketed, yet patient-physician relationships have grown even more impersonal, which contributes to a litigious climate. This climate results in higher malpractice insurance premiums, the ordering of more tests for defensive purposes, and higher costs for the patient. The spiral of increasing costs has been staggering. Controlling these costs and preserving the availability of health care has become a national concern.
Private For Profit Not-For-Profit
To address these problems, changes are occurring, both within and without the hospital. Externally, a recent change (October 1983) was made by the Federal Government. Previously, Medicare reimbursed hospitals for actual costs based on services delivered when a patient covered by the program was admitted for treatment. Now a complicated reimbursement program has been implemented over a multi-year span which is based on diagnostic categories of illnesses and is referred to as prospective payment.3 What this means is that hospitals will know in advance what Medicare will pay for the treatment of a particular illness. If the hospital can provide service for less than Medicare will pay, it can keep the balance as profit. Should their costs exceed the amount reimbursed, however, the hospital experiences a loss. As was predicted, most insurers have followed a similar fixed reimbursement formula.
In response, as you can imagine, hospitals and medical staffs are having to re-learn much of their way of providing health care. Some of these changes are positive and others will create further problems in the future. For example, tests which are not critical for the patient's treatment will no longer be performed. This should lower costs for everyone. On the other hand, hospitals have at times provided very humane services which will also necessarily be discontinued. The patient ready for discharge but who has nowhere to go will not be cared for in the hospital until other arrangements can be effected. Again, some illnesses may become viewed as desirable admissions due to their proven profitability for the hospital. Others, however, which become known as marginal, may be avoided. Today, many of the “for profit” hospitals will not provide pediatrics, obstetrics-gynecology, psychiatric or emergency services as they are known to be cost-inefficient.
Other outside agencies exist which seek to guide the development of hospitals. Federal and State cost containment and review groups must approve price increases, allocation of beds, and new construction in an effort to avoid an abundance of resources which would lead to ever increasing costs. By the mid-1970s these outside agencies made hospitals one of the most highly regulated enterprises in the United States.4 The response of the health care industry has left the neighborhood hospital where you were born ill-prepared to cope with the new structures which are emerging. The hospital will soon be only a part of the effort to treat and / or prevent illness. The emerging structure is that of the Health Care System, a corporate or holding company model.
The function of the “system” is to capture a significant portion of the health care market in its geographic region. It is a business approach with key notions being “cost containment” and “revenue production” without compromise in quality of care. To achieve these goals, the system must structure itself to accomplish two things. First, it must market health care, including preventive and rehabilitative functions. This means offering a diversification of services, some of which were originally provided by the hospital. This is a reversal in the earlier trend to center activities in the hospital. Second, each division in the system becomes a referral source to the hospital, in order to maximize occupancy rates, and, in turn, the hospital refers back to other parts of the system for its specializations.
The changes in the