healthsignals new york

Taking a couple days off

Happy New Year!

I may get a post or two in between now and then, but I doubt it. We'll probably be back here on January 6.

Best to you and Happy New Year

I used to write a monthly column, "Health Matters," for the local business paper. Like this blog, it was mostly about the business and organizational aspects of healthcare. Each year as the holiday season approached I found myself mostly uninterested in writing about sucy topics. So in 1998, I wrote this (registration required). As it turns out, it was one of the more remarked upon columns I wrote (at least to my face). It's below, slightly re-written. It still applies. The best to you and yours.

As we enter the holiday season, it's worth reminding ourselves how the health care "business" is not just commerce. So here are a couple of stories. As usual, some names have been changed.

Health care professionals

Joe Doolittle tells a story of four nurses in the continuing-care department of a health maintenance organization receiving a bouquet of roses from a 61-year-old patient. The patient had died two weeks earlier.

But the card was addressed to each of them, signed in the patient's own hand and read, "Thank you for all that you did for me."

These nurses will tell you that they didn't do all that much for her. Well, yes, they had known her since her initial diagnosis two years prior, and had been with her through her surgery and chemotherapy. Since the patient lived alone, they had made sure there were rides for her, and people to be there with her.

As time passed, they saw a lot of her at home and in and out of the hospital. Despite the fact that these nurses didn't think they had done much, the patient obviously thought differently; they had done a lot for her. She'd planned ahead to say thank you to people who had become an important part of her life.

For these professionals, it may have seemed all in a day's work. But to the patient, it was far from routine. It was valuable enough to be recognized at the end.

Health care organizations

Jane is a 47-year-old grandmother. Because her daughter has a drug problem, Jane has taken in her grandchild, who is about 8 years old. Painfully, this is a pretty common story these days.

What makes Jane's story even more wrenching is that she herself has multiple sclerosis.

Each day, staff from a visiting nurse organization help Jane get up and into her wheelchair, take her medications and take care of her catheter. Under new federal rules, this agency's payments for Jane's care are based on an average number of visits far below what's required for Jane's care and far below what's necessary for her to live independently.

This agency is going to lose money on Jane, and it had resigned itself to that fact.

However, when Jane was hospitalized a few months ago, she was discharged from the agency's care. Of course, when Jane was ready to leave the hospital, she wanted to return home. Under both federal and state rules, nothing required the agency to take her back. It did anyway.

Knowing it was going to lose money (and probably a lot), this agency promised to continue the services that allow Jane to continue living at home and caring for her grandchild. Absent those services, Jane likely would have spent the rest of her life in a nursing home, and her grandchild would have spent the rest of his youth in foster care.

A neighbor

Pat was in her late 20s when she died of cancer. After 15 months of trying just about everything, her physicians finally told her there was nothing left they could do, and she went home.

Her last few weeks were just what you would expect: painful for her and her family. Pat lived in a rural community with no hospice. She had gotten extraordinary hospital care during her illness (despite being uninsured), but during her last few weeks, the organizational supports pretty much disappeared.

Mary was a nurse who lived down the road. She knew Pat, but really only enough to say hello when they passed on the road. When Pat went home for the last time, Mary simply arrived, having heard about Pat's plight.

During those last weeks, Mary went to see Pat every morning before she went to work, every afternoon after she returned, and every night before bed. She often left work during her lunch hour to drop by.

Mary was the one who gave Pat her pain medication, who called the doctor when it was time to increase the dosage, and who remained a steady presence during those last weeks. She never asked for anything.

After Pat's death, her family offered to pay Mary, but she shrugged it off. "Yes, it's my profession, but I'm a neighbor," she said. "My profession simply enables me to do things that I couldn't otherwise."

Every day, thousands of professionals, family members, friends, neighbors, volunteers and just folks share in the joys of a healthy newborn and the relief of a recovery from illness or injury. Every day, these same folks struggle with the issues that arise in the most intimate, vulnerable and painful moments of our lives.

At the end of the year, it's worth remembering them and reminding ourselves that every day, they do it with skill, energy, generosity and grace.

So for the moment, we'll ignore business strategy, the economics of health insurance, government regulation and whatever the latest aggravation is. Instead, we'll salute and thank all of those folks and remind ourselves that the real core of the health care enterprise is both human and humanitarian.

Mission matters?

Are we making money to provide care or are we providing care to make money? In few minds is the trade-off that stark. And it's probably also true that in few board rooms of non-profit healthcare organizations that the trade-off is that stark. But it's easy enough to lose ones way. And it's particularly easy to lose ones way when operating in an environment that routinely pressures us to move in a particular direction.

As survival has become more challenging, as competition has become more fierce, the pressures to favor the money-making side of the equation increase.

And regulatory systems are part of the environment, part of the system structure that conspire to make things worse as well as better. EMTALA and state regulations push toward providing care. New York has long had a law requiring that hospitals provide care to those in need.  But in return for sharing funds from its Indigent Care Pool, New York  requires hospitals to pursue payment.

The stories started with a string of articles in the Wall Street Journal and a story about Yale-New Haven's lawsuit that left an elderly widower broke as a result of his wife's hospital care. The issue's been bubbling since. (Click here, here, and here.) For example, Lucette Lagnado, who's written many of these stories, wrote this article in June (subscription required)  about Provena Covenant Medical Center in Urbana, IL that lost its local property tax-exemption due to its profit making entities, its debt collection tactics and the amount of charity care it provides. (Provena has reportedly changed policies since then and is attempting to regain its tax exempt status.)

The AHA (PDF) and HANYS moved quickly to stem the damage.

Now the Times has picked up the issue with a lengthy article its magazine, Uncharitable, by Jonathan Cohn.

When a faith-based hospital sues a grieving widow over medical debt, plunging her family deeper into poverty, some part of the health care system has clearly failed. But which part, exactly?

While the press coverage is relatively new, the issue isn't and perhaps its time to give up the pretense. As a current and former Board member of non-profit healthcare organizations, I have decidedly mixed feelings about this idea but it may be time to reexamine what we expect. Let's pose some questions:

1. Are social expectations of hospitals are generally greater than those for other non-profit healthcare organizations? Should they be? Should there be a standard? For example in New York, certified home health agencies are required to provide a fixed percentage of charity care. Nursing homes are not.
2. What is the best means of defining those social expectations? Is tax exempt status an optimal means of rewarding performance of  socially desirable behavior? Tax exempt status is binary. Organizations either have it or they don't. But organizational behaviors fall across a very wide spectrum. Thus, the "rewards" (different tax savings for different organizations) for socially desirable organizational behaviors probably doesn't match up well with actual behaviors.
3. Do social expectation and legal requirements to provide uncompensated care provide a ready-made excuse for hospital managers to offer to their boards and to public policy makers when they don't perform well financially? How can we effectively differentiate between genuine charity and sloppy administration?
4. Isn't the real issue here that while society expects providers, particularly hospitals, to provide care, our society is unwilling to face up to the challenge of universal coverage? We don't want people "dying in the streets." Press coverage of hospitals pursuing payment from low income people for care provided is per se bad press. And press coverage of lack of care is even worse. But we won't face our own responsibilities nor our role in creating and maintaining a system where such contradictions are inevitable.
5. Don't we really have a system here that wants a form of socialized care, but wants to pay for it with a market system?
6. Considering the imbalance of power between institutions and patients, which is better: attaching money to institutions and expecting patients to chase care, or attaching money to individuals and families and expecting institutions to chase patients?

Enough. The real issue is not aggressive billing and collection practices. The real issue is the lack of coverage by 15 percent of the nation's population in an economic system that is coverage based.

This is politically the worst time imaginable to try to re-start a debate on universal coverage, but the pendulum always swings. How does that tie to a debate on the obligations of non-profit, tax-exempt institutions? Cover everyone and drop the awkward, unexacting and hard-to-enforce regulatory requirements.

After the holidays, we'll get into it.

Our favorite charities

If you like reading what we post here or if you're just in the holiday spirit, here are four of our favorite charitable organizations

Parsons Child and Family Center in Albany, New York. Solid organization running solid programs with good people.

Rubin Dialysis Center in Troy, Clifton Park, and Saratoga Springs, New York. We've talked about their innovative daily home hemodialysis program before. They have an enthusiastic staff and great medical and nursing leadership.

The Heifer Project. Donate livestock to poor agricultural communities.

The Harris Center in Hancock, NH is devoted to environmental and outdoor education, land protection and wildlife preservation. Great place to take a day-hike too.

Thanks and have a great holiday season.

Home visits are a financial challenge

Though the number of physician housecalls is growing, it's still tough to make it work financially. A local group, Homedical sees about 500 patients with four MDs and one NP. All of its patients are homebound.

But Homedical is having a tough time financially. Last week, they sent out an e-mail asking for donations and they followed it up with this story in the Albany Times-Union. They're looking for $300,000 ($600 per average patient) which I suspect is going to be tough unless they find an angel. 

One of Homedical's physicians, Dr. Roberta Miller, ran what I'm told was a quite innovative home care program through the Albany VA hospital. But she left the VA after an internal struggle that I still don't completely understand.

Going mainstream?

Imagine that. Front page on Sunday. Top left.

The Albany Times-Union carries a 1,600 plus word story, New era awaits in paperless medicine. It included a Q&A as well. (Registration and payment required for both).

The real story is that the paper's editors thought it worth the effort for the general public. The story's text itself covers the usual suspects:

• What we might refer to as use-cases, "imagine that you ..."
• It references the IOM's estimates of lives lost due to medical error
• Using the data for public health research

It also notes that rather than the private sector embracing innovation, in this case, "the federal government leads the way." It particularly mentions the VA.

Locally, the story describes the efforts at Northeast Health and the necessity of moving information between their hospitals, nursing homes, rehab center, clinics, etc.

Other effort in the region are the Taconic Health Information Network and that undertaken by Glens Falls Hospital and its efforts.

The Q&A was mostly about HIPAA, but the article actually covered the increased security offered by electronic systems. That should be helpful.

Progress comes first in the mind of one, then in the minds of many.

Call transcript available

As discussed here, the Office of the National Coordinator for Health Information Technology (ONCHIT) released a Request for Information (RFI) seeking public comment regarding how widespread interoperability of health information technologies and health information exchange can be achieved through a National Health Information Network (NHIN). Earlier this month, they conducted a conference call on the RFI.

The transcript of the conference call call be found here (PDF).

This is trouble

New York, with the country's most expensive Medicaid program, and one of the hothouses in which many have made their careers with creative means of drawing Federal Medicaid reimbursement should be nervous about this story.

Federal health officials said the nomination of Michael O. Leavitt as secretary of health and human services signaled the administration's desire to make big changes in Medicaid, like those Mr. Leavitt made as governor of Utah.

The moves come as the administration is considering a wide range of other new initiatives to curb the growth of Medicaid spending, crack down on improper payments and help states save money by restricting eligibility and benefits.

Federal investigators said Medicaid wasted hundreds of millions of dollars a year by overpaying for prescription drugs. Many states pay on the basis of inflated, fictitious list prices reported by drug companies. One of the initiatives would link payments to actual market prices, which are often much lower.

Given how the Feds define the market for pharmaceuticals in Medicare (it doesn't allow itself to negotiate prices), that one's ironic.

Under one proposal, states would be allowed to make many changes like increasing co-payments and limiting eligibility without having to get federal waivers. Local officials would also be allowed to provide different benefits in different parts of a state.

These are mostly tired old ideas, few of them aimed at real improvement.

A rare event

A hospital in New York is actually closing. United Hospital in Port Chester and part of the New York-Presbryterian Healthcare system, has filed for bankruptcy.

Reported by the Journal News, quoting a former volunteer and nurse at the hospital the :

... she would visit other hospitals because service at United had declined. It seemed there weren't enough nurses to take care of the patients, she said.

As the hospital battled financial problems, many of the staff left, including nurses who sought jobs with more stability and better pay. The 224-bed facility cut services and saw fewer patients over the years, as it accrued $70 million in debt.

Other hospitals in the region are in White Plains (six miles), New Rochelle (nine miles), and Greenwich, CT (four miles).

Open source biology

I'll admit up front that I don't know much about all the issues and trade-offs, but I've always been bothered by the idea of granting patents for biological knowledge. Patents are other methods of asserting control of scientific knowledge damages the foundation of science and in some cases, proprietary control of scientific knowledge may undermine its basic integrity. (It's particularly bothersome that much of the knowledge was gained with the support of public funding.)

By way of Howard Rheingold at Smart Mobs we find David Brolier reporting on open source biology. Think Linux and other software development

Imagine if Microsoft dominated the study of molecular biology because it owned the foundational knowledge of genetics and agriculture. Nobody could do research or innovate without first getting a license from the company. The field could be designed to maximize profits and thwart competitors, just as Microsoft's Office suite has stymied innovation in word-processing programs ...

... a handful of biologists are now launching the equivalent of an open source movement for molecular biology! Richard Jefferson, the American-born chairman of the Center for the Application of Molecular Biology to International Agriculture (CAMBIA), based in Canberra, Australia, recently started the Biological Innovation for Open Society (BIOS) initiative with a $1 million grant from the Rockefeller Foundation.

Good for science and good for society.