Medicine's Neglected Infrastructure

On Saturday, we rode one of the "L" (elevated) lines of the Chicago Transit Authority. The line was usually closed that day so we transit buffs had the line to ourselves, with a four-car subway train and, fortunately, two experienced engineers.

We took pictures of the subway cars, we split the train and "dragged" up and down the two tracks, we chased teenagers off the closed stations, etc. You really had to be there to enjoy it.

Well, at least I enjoyed it.

But then someone asked one of the locals, "Why was the line closed on the weekends?" The answer was surprising: The supporting structure for the elevated's rails was deteriorating.

It had been there since the late 1800s, and many of the steel girders were sitting on cement foundation that had crumbled away. In fact, some portions of the track were held in place by temporary support beams. New construction would start in the next few months on the weekends when the line was closed.

Those of us from out of town had to look closely to spot the problems. The subway cars were in wonderful shape. Their stainless steel bodies looked fresh from the factory. The rails were straight and smooth. But if you looked closely at the infrastructure below, you could appreciate the problems.

Webster's Dictionary defines infrastructure as "An underlying base or foundation," or "The basic facilities needed for the functioning of a system." There is an analogy here to Sacramento's health care system. Our infrastructure is badly in need of attention. There are many examples:

The last hospital built from scratch in the greater Sacramento area is Kaiser's Roseville Hospital, it opened in 1998. True, there has been much hospital constructions over the years, but usually to add on to an existing, older structure. This explains why so many people tend to get lost walking through a hospital!

In a previous issue of Sierra Sacramento Valley Medicine, I discussed the increase in population in Sacramento from 1995 to 2000. Health care facilities, in my opinion, have not kept up with the population growth.

True, there has been some decrease in utilization of hospital beds, but not enough to meet the ever increasing demand of an ever growing and aging population. Hospitals run higher bed occupancy rates now that in years past. This is more cost-effective for hospitals, but leaves no "wiggle room" when an acute increase in demand occurs.

Our emergency rooms are overcrowded. Even with adequate staffing, there is not enough space in town to meet the demand. The result? The infamous "round robin diversion" to the next ER that can handle the next ambulance in the queue, regardless of where a patient's doctor and records are located. Are hospital systems rushing to build new ER's? Not at all. So far, there is no coordination or cooperation among the various hospital systems to effectively address the issue.

The California Legislature put seismic standards in place that requires many hospitals to be rebuilt by the year 2008. Much of that construction needs to start in the next year or two to be completed by 2008.

How did hospital systems respond? By requesting deferral of state regulations. And those deferrals will probably be granted, for no one has the money to pay for the upgrades - an estimated $10 billion across California.

But, if the upgrades are needed and we don't do them, will our already aging facilities come crashing down in the next earthquake? An Office of Statewide Health Planning and Development (OSHPD) study shows that more than one third of the hospital buildings in California are at risk for collapse.

Medicine has fooled us. The new wonder drugs, the technological advances, the artificial joints and organs, have been our shiny stainless steel subway car. We see the advances and we think all is well with the system as a whole.

But that is obviously not so. Yes, dialysis saves the lives of patients with kidney failure. What happens when there are not enough dialysis centers? Look at your evening news: this issue was discussed on local TV a few weeks ago.

Any answer to the predicament in Sacramento will require a coordinated effort to not duplicate facilities that are not needed while skipping the crucial ones that are needed.

For example, urgent care centers could easily unload much of the ER's business, but there has to be a way for patients to walk into an urgent care center and be treated, regardless of ability to pay. That mechanism now exists only in ER's as a result of the federal EMTALA regulations. But, because of the well-intentioned legislation, patients who need ER care can't receive it because patients who could get care elsewhere flood the ER's.

There is little cooperation between major health care systems. The politics of health care,at least in California, has evolved into health care systems not talking to or trusting one another for the scarce amount of money patients and employers are willing to pay for health care.

As a result, our infrastructure goes begging. The push to reduce the costs of health care has led to a "do for today" mentality. Long-term, costly projects are deferred - awaiting large influxes of capital that simply do not appear.

We need to take notice of and address all of our health care systems' needs, including the most difficult, the most expensive and least noticed: our infrastructure.

The next big earthquake is inevitable - it is just a matter of time. So are the looming deficiencies, if not collapse, of our health care infrastructure.

Be certain neither event will occur at a welcome or convenient time.

robert.midgley@kp.org