problem with other local counties, where the prevailing sentiment seems to be: “Why buy a cow when you can get the milk for free?” He noted that “we are surrounded by counties that don’t have public hospitals any longer; they have sold them. The market really rules in Texas, and that’s a big problem at times.” His county commissioners often express interest in closing down the county’s borders.

Parkland spends $125 million a year to fund a faculty, pay doctors, take on the high volume of low-income patients on a regional basis, as well as the low volume of high-cost patients (e.g., HIV and cancer), and absorb the cost of medical education and clinical research and development. Parkland’s expense budget exceeds $1 billion. Anderson said it has been able to stay afloat because of volume—it has about 4,000 Level I activations per year. He noted they were recently named the best hospital in a cohort of 24 academic hospitals for trauma, based on severity-adjusted mortality rates.

“Planning” became a bad word in Texas years ago, he observed, when there was an effort to ration computerized axial tomography (CAT) scans and other health resources through a certificate of need process. Planning is now viewed as akin to socialism. But, Anderson argued, “We need to plan like we’ve never planned before to deal with border issues” (including county, state, and national borders). He said the local politicians don’t realize that H1N1 flu won’t read any stop signs or abide by any borders, nor will F5 tornadoes, or cases of major trauma. But, he said, the potential to work together and find better ways to organize is out there. “We could easily sew the state together in a quilt … and have regionalization fairly easily, if we had the desire to do so and the funding to do so, and if we weren’t so dependent upon local taxation.”

But, Anderson said, a real funding strategy is lacking. The counties have talked about establishing regional taxation at tiered levels to be able to handle stand-ready costs. Anderson said these costs are “very, very burdensome for us to deal with,” because it means you have to be ready for whatever comes in the door, 24/7, whether you get patients or not.” However, Parkland has now reduced its excess capacity to the point that it cannot take care of heavy surges in demand.

Anderson reported that there is also a lack of providers. Parkland is short on primary care doctors, trauma surgeons, orthopedic surgeons, and others. This is partly due to “huge holes” that exist in current Emergency Medical Treatment and Active Labor Act (EMTALA) rules, which allows providers not to take call in their subspecialty (although they can decide to come in for paying patients).

Letting the market decide is a “big pitfall,” Anderson said. “If the market decides, folks, we are really in deep trouble.” You may not trust your government, he said, but if you trust the market, or insurance companies, or other self-interested parties, “you are in worse trouble than you even know.”

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