Nine hospitals in the two-county Rochester area played essential roles in the hospital experimental payment program. The other major institutions on the main stage—businesses, payers, planning entities, hospital associations, and external factors—were described in the previous chapter. Here the focus is on the individual hospitals, their distinctive historical missions, responses to local demographic trends, and services rendered to their patients. Each hospital is profiled from its founding to the 1970s, before the start of HEP in 1980 or its precursor, MAXICAP, in 1976. We begin with a brief history of hospitals in America, a history characterized by Rosemary Stevens as a complicated story of “medicine, money and power—of change and the continuity of conflicting ideals.” These themes are pertinent to the nine Rochester-area hospitals profiled below.

American Hospitals in Brief Historical Context

American hospitals were originally built for the poor. Their origins in the early 1800s were associated “as much with ideas of dependence and class as with the unavoidable incidence of sickness and accident.” As Charles Rosenberg has written: “One of the fundamental motivations in founding America's first hospitals was an unquestioned distinction between the worthy and unworthy poor, between the prudent and industrious objects of a benign stewardship and those less deserving Americans whose own failings justified their almshouse incarceration…. The hospital was something Americans of the better sort did for their less fortunate countrymen; it was hardly a refuge they contemplated entering themselves.

The most vigorous advocates of hospitals a century later “never envisioned the hospital as central to medical care; even for the urban working class, the hospital was seen as a last resort. It was expensive; it was unnatural; it was potentially demoralizing…. Ordinarily a home atmosphere and the nursing of family members provided the ideal conditions for restoring health….