ILLUMINATION
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ILLUMINATION

How Hospital Parking Kills Patients, Pt. 1

A parking circular parking garage on-ramp is seen from above, with a single car driving along it.
Photo by Ricardo Esquivel from Pexels

Parking might not strike you as an integral part of modern healthcare infrastructure, but it regularly affects care for countless patients in the United States. This seemingly simple issue routinely wreaked havoc on my operating room schedule. It also starkly highlights the subtle bias that pervades the healthcare system.

Every few weeks my operating staff and I, prepped and ready in the OR, would watch the clock as a scheduled surgery start time came and went, with no idea as to where our patient was. As each person in the room felt their tightly scheduled day crumble, the murmurs of frustration would grow louder.

Late or no-show patients are always a source of frustration, because a postponed surgery can throw an entire day into chaos. Some surgeries are up to six hours long. Crafting the schedule that governs an operating room is nearly as delicate an undertaking as the surgery itself.

And each moment is enormously expensive: Thousands of dollars go to equipment, supplies, medications, and the staff needed to perform the procedure. And if that procedure doesn’t occur, the patient’s insurance provider doesn’t pay for any of it, forcing the hospital and surgeon to eat the cost for everything. Every minute that passed cost $45.

No matter how thoroughly we felt we’d informed and reminded our patients and their caretakers, the problem persisted. More and more, I noticed how some of my especially incensed colleagues would talk about late patients: “Those people are always late!” It was subtle, but their frustration increasingly came with a certain disregard.

It was an othering I recognized.

I came to America during a tumultuous time. My parents left our homeland of Iran so they could pursue their education, and it seemed like as soon as they left home, the country behind them ignited. Suddenly there was a revolution — family members and friends were being imprisoned, persecuted and executed, and my parents and I were stranded an ocean away. We were helpless, powerless, stuck in a foreign land. And then I became desperately ill. My parents, who spoke very little English, rushed me to the hospital.

I spent months as an inpatient with bacterial meningitis. My future was unclear: both the illness and the medications used to treat it have the potential for life-altering effects ranging from hearing loss to permanent brain damage. The language barrier meant my parents had to push for the most basic details, and were still left confused. They had to navigate a massive healthcare institution, with scant experience and means.

We were “those people.”

Decades later I was proud to be a surgeon at that same hospital. Throughout my training and work in other hospitals, I had begun to notice the subtle divisive language within the healthcare system. Now as an attending surgeon, I had learned of an internal study that confirmed what everyone privately already knew — what was meant when doctors said “those people.” Late and no-show patients are almost always on public insurance like MassHealth (CHIP and other Medicare Programs), just as my family had been. I also began to understand that under these programs, hospitals and doctors are paid just half as much for services rendered to these patients as they are when treating patients with private insurance.

A graphic titled “Private Payment Rates Are Higher Than Medicare Rates for Hospital and Physician Services.” the graphic demonstrates that private insurance gives higher payouts to hospitals and doctors than public insurance.
Graphic courtesy of the Kaiser Family Foundation

For the first time I began to understand the friction that exists in our healthcare system between revenue and equity. And as such, even if “those people” were always on time, they aren’t the patients doctors or hospitals prefer to treat. In 2017, Mayo Clinic CEO Dr. John Noseworthy faced criticism for announcing that Mayo would be prioritizing privately insured patients over public ones. I was disgusted by his comments — but also surprised by the backlash. After all, he’d merely said aloud the quiet rule that secretly governs hospital scheduling practices all over the country: double book “high risk, low reward patients,” (“those people”) and don’t take on too many at once.

Data bears this out. Research shows that patients on public insurance face particular stigma and bias in the U.S. healthcare system. This is despite the higher-than-average likelihood that they’ll need to call upon it. Insurance-based discrimination is one of U.S. healthcare’s dirtiest open secrets.

So when publicly insured patients at our hospital showed up late or not at all, it reinforced stereotypes already formed in many minds. They located the patients’ tardiness within a web of other negative associations related to the patient’s class — they were lazy, they were unserious, they had no respect for institutions, and so on. As a result, patients received worse care from doctors biased against them, a combination known to produce worse health outcomes.

But at the same time, I knew the people I worked with were good people. They had dedicated their lives to helping sick and injured children. How could these educated and loving individuals buy into a narrative that was so hurtful and dangerous? I believe this bias has its roots in a lack of curiosity, shared experience and true human connection—the kind that fosters empathy. Without that foundation of empathy, there’s nothing to shore you up against the slow, incremental, unconscious drift toward prejudice that happens each time you face frustration that seems compounded by facts.

It may seem small, but lack of curiosity and empathy for another person leads to dehumanizing that person because of a misunderstanding of an entire population. Otherism is like a tide that rises slowly, surrounding you when you’re distracted by other things. It takes away an individual’s humanity and replaces it with the patterns and behaviors of “those people.”

This kind of passivity when it comes to thought and reflection is common across industries. But it’s especially glaring when it comes to the patterns that emerge at the intersection of financial systems and healthcare, where it can lead to collective thought that breeds bias without further examination. This bias is detrimental to both the people these systems were designed to help and heal, and the helpers and healers themselves.

Logic and experience get us part of the way: when it comes to healthcare for children, it’s hard to argue that anything is more powerful than a parent’s desire to care for their child. That’s how I knew that when my Medicaid patients arrived late or didn’t show up for surgery at all, there had to be more going on than neglect, laziness, or lack of interest in addressing serious health issues. These were caring parents to vulnerable kids. So I got curious: I asked my patients, in a kind, patient, and empathic way, “Why are you late for surgery?”

Almost every family had the same answer: parking.

part 2

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