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Tuesday, September 25th 2012

When More Is Not Better

San Antonio is no longer the largest city without a freestanding children’s hospital. It will soon be the proud owner of two freestanding hospitals dedicated solely to pediatrics and a third substantial pediatric operation within a larger hospital campus. For the effort that went into establishing a children’s hospital in San Antonio the city now looks to have three.

The editorial board of the San Antonio Express News has described this development as “exciting.”

Competing health systems working to provide the best pediatric care possible will benefit the community, the children in need of the services and the students receiving their training here.

A more realistic view is that of John Hornbeak, the former CEO of Methodist Healthcare in San Antonio, who said in his own editorial,

[T]here are more than enough egos and resources to put on quite a show and produce a children’s medical arms race on steroids. All three plan to be No. 1. This promises to be a war of attrition, long and tortuous.


But the worst of it all is that, for all the added expense, the health status of children will only be marginally better. All three combatants will have to battle for the best paying patients, the highest margin services and give short shrift to the low or no pay kids and money losing services. There will be many protestations to the contrary, but splitting the business three ways requires this. That’s what competition looks like in health care.

The idea that competition amongst so many pediatric hospital beds will drive quality is a hopeful one but naive. It is hardly borne out in data where no evidence exists for children’s hospitals and the studies of competition of hospitals in general shows a mixed bag.

Not to deny the full flesh of arguments for children’s hospitals but the measurable clinical benefits are a little bit difficult to tease out in the literature. That said, if there is one place where a single freestanding children’s hospital would have indisputably improved the care of the children of south Texas it would’ve been in the tertiarization of complex cases. In this I disagree with Mr. Hornbeak who has concluded that the enormous costs going into these three children’s hospitals would’ve been better spent on community and primary care instead of on “the one little Jimmy out of a million getting his surgery.”

The brain tumors and the congenital heart defects and the solid organ failures make an exceedingly compelling case for bringing inpatient pediatric care in San Antonio and south Texas under one roof. These complex diseases, and so many more, have incredibly strong evidence that higher volumes within a system, within a hospital, lead to better outcomes.

And yet, the various health systems of San Antonio now promise great expense to keep pediatric care competitive and disparate. A promise to keep all of their complex programs adequate but none of them great. It’s bad for San Antonio.