Between a stubborn recession and a still-uncertain course for health reform, running a healthcare organization these days calls for nerve, patience and perhaps a little therapy.

The Post-Gazette's annual listing of revenue figures for major local healthcare organizations -- 10 of the top 13 are in the hospital business, with insurer Highmark and its nearly 3 million Western Pennsylvania subscribers at the top -- shows that most of them reported revenue numbers that are holding steady or doing slightly better than a year ago.

But those improving fortunes could change depending on what the economy does and what a reformed U.S. health care system looks like.

A.J. Harper, president of the Hospital Council of Western Pennsylvania, noted that a bad economy means more lost jobs, which means more people seeking treatment without traditional employer-based health insurance coverage.

As a result, hospitals are seeing patients who are on medical assistance or are self-insured, which means lower reimbursements. With average operating margins of less than 3 percent in Southwest Pennsylvania in 2008 (2009 figures won't be available for a few more weeks), a significant swing from seeing paying customers to providing uncompensated care could spell trouble.

That, in turn, makes the outcome of the health care debate in Washington, D.C., all the more crucial, and not everyone is excited about the possibilities.

The pending House and Senate bills "barely pay lip service to improving the safety of health care and improving the quality of the outcomes of health care. They're all about health insurance reform," said health care consultant Jan Jennings, president and CEO of American Healthcare Solutions, Downtown.

But, for hospitals, health insurance reform directly impacts the bottom line. Any cuts in Medicare reimbursements -- "the largest payor in Western Pennsylvania," Mr. Jennings noted -- could disproportionately hurt our region, with its high percentage of Medicare eligible residents.

He also wonders about assumptions that it is possible to lower costs associated with Medicare and, to a lesser degree, Medicaid, by eliminating waste and fraud.

"I do not think it is true that there is extensive waste and fraud in Medicare."

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