Hospital Handbook. James T. Wagner

in the system and the severe regulations described earlier which govern its functioning. Rate reviews, price structuring, and prospective payment, for example, do not currently apply to outpatient services but only to inpatient hospitalization. Consequently, the system will seek to “unbundle” hospital services and separate out any function which can be independently organized. Some of the more common services which have been unbundled are surgery procedures which can be done on an outpatient basis. “Surgi-Centers” are the result. Emergency clinics are another illustration. Not only can the system charge more for services provided by these facilities, but, should the patient require more serious attention, s/he can be referred to the system's hospital. If the patient has experienced a stroke and is treated at the hospital, upon discharge the patient can be referred to the system's “Wellness Center” or “rehabilitation program” for recuperative care.

      Economic restraints on the hospital have resulted in the necessity to restructure health care delivery. Marketing this health care has fashioned a much broader, more wholistic approach. It is quite different from the single-minded acute care facility which has been the identity of most hospitals. In the system the hospital is only one dimension, although it remains the central one.

      Obviously, other disadvantages await the neighborhood hospital which continues to try and stand alone. Larger systems will either link themselves in cooperative voluntary ventures or be owned/leased outright by corporate structures, as in the case of Hospital Corporation of America. By virtue of size, purchasing and personnel advantages abound. Supplies can be bought at such volume to assure discounts when compared to single unit purchases. It is hoped that these savings can be passed on to the patient. If this is true, then the patient will prefer to select admission to a hospital which is part of a larger system, and not the local, independent, neighborhood hospital. An idea which improves health care can be duplicated throughout similar facilities in a larger system. As well, the system may only have to employ one person with high-tech skills, sharing the costs, and make him available to all parts of the system. These are but a few examples of other advantages when systems are compared to your free-standing, neighborhood hospital.

      The changes which this revolution represent are an industry's efforts to meet the need of providing health care services at a reasonable cost. These changes are in their early stages and their impact is not yet clearly known. They attempt to be more cost efficient for consumers while being businesslike in approach. Clearly, if the system fails in this country, the persons hurt most will be those who have the least ability to gain adequate care: the poor, the disabled, and those on fixed incomes.

Meaning For Ministry, Lay Persons, and the Church

      Unlike the free-standing hospital of the past, which provided crisis intervention when illness or accident occurred, the system will market health care. Persons who wish to participate in maintaining or enhancing their state of health will find organizations such as Wellness Centers available. In this sense, the shape of health care will become more wholistic, which is a positive development. The dimensions of health which systems will find themselves least able to provide, however, have to do with life questions of meaning and purpose.

      These are spiritual concerns which have as much to do with our health as good nutrition, proper exercise, and stress management. Although chaplains and social workers will continue to be employed by hospitals, the need for the Church's ministry during the crisis of illness will probably increase. This will be true because of several factors, all related to illness being a “teachable moment” that invites a re-examination of life values. First, the patient's experience of hospitalization will likely become more brief and intense. Inpatient days will be reduced. There will be less time in the hospital, both before and after the onset of illness or having surgery. Second, opportunities to review life experiences and reframe values and priorities will be minimized. Yet questions like “Why is this happening to me?” “What meaning does it have for my life?” “What have I learned?” remain important in the adjustment and recovery process.

      What is being communicated here is not that pastoral ministry to ill persons is new or that pastors have neglected their parishioners. The message is that the need for the Church's ministry is heightened by the changes going on in hospitals. In his popular book Megatrends,⁵ John Naisbitt talks about the growth of high technology creating a corresponding need for “high-touch.” It is not the intent of hospitals to be less personal as they become more businesslike and as medicine relies increasingly on new technology. It will happen, nevertheless. The patient's need will grow for someone to enter his life who has no form for them to complete, no technology to be explained, no procedure to be done. The pastor is someone who can sit quietly, hear what the patient is feeling, respond with empathy, and relate it to a faith that enhances healing and wholeness.

      This same need for “high-touch” exists for persons who work in hospitals. The new technology saves lives, but it can also prolong and unnecessarily complicate dying. It isn't simply that a respirator frustrates the natural occurrence of death. More critically, a machine that can breathe for you has almost become a part of the natural order. In the case of reversible causes, such as a drug overdose, the respirator breathes for you until life is safe and recovery under way. The emotional problems which lead to the overdose can then be sorted through. In other cases, the respirator provides needed time to evaluate and diagnose, or to give further treatment. But when it is believed, but not yet a certainty, that meaningful life is not possible, no uncomplicated decision-making process exists to discontinue life-sustaining treatment.⁶ Hospital staff need the sustenance of their faith to adequately cope with the stress of being responsible for difficult decision-making.

      Ministers and churches need also to be aware that, as health care systems and participating hospitals become more competitive, they also become more sensitive to public relations and community opinion. The Church can encourage support for chaplaincy as well as the pastoral care of individual ministers by communicating with the administrations or boards of the hospital. There are many services churches can provide to hospitals. For example, almost every hospital has an auxiliary for volunteers. A church which invites the director of that service to speak and encourages participation breeds good will. Parishioners hospitalized can communicate their appreciation for a chaplain's visit or the accessibility to their pastor, even in an intensive care unit. Obviously, any church expressing these interests must represent needs and concerns common to every denomination and not attempt to manipulate personal advantages. At times, a responsible Ministerial Association can assume this role.

      Just as pastors are gaining new understanding regarding the emergence of health care delivery systems, parishioners will benefit from a similar exploration. Perhaps the idea of establishing a Health Care Committee in your church would assist in educating members to these new structures. Other, equally important concerns need exploring also. For example, most major faith groups are increasingly relying upon lay persons to provide ministry during life crises. Although a chapter of this book discusses the topic of lay ministry in depth, a Health Cabinet can provide a portion of that education.

      Moreover, there are several direct ways in which the Church's educational program can speak directly to the national issues of preserving availability of health care and cost containment. First, the Church can remind its membership of stewardship which relates to care of the body. The larger issue is that of preventive health care. It is hoped that research will soon emerge to provide cures for many types of cancer. Even if this happens, most of the dramatic breakthroughs which impacted so positively on health, like the discovery of germ theory, antibiotics, and polio vaccine are past history. Most authorities agree that the major breakthroughs lie in the realm of individuals adjusting their life style, specifically reducing caloric intake, eating better foods, exercising more, and learning to manage stress. The major killers, such as coronary artery disease, strokes, and hypertension, cannot be cured with a vaccine. The Church should take a more active role in spreading the “good news” which relates to an abundant, physically healthy life.

      Second, containing costs of health care is not simply the responsibility of physicians and hospitals. The need is for all persons to become informed consumers. Out of a false sense of fidelity, for example, an individual might decide against seeking a second medical opinion. Checking into a hospital on a