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.
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
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
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
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.
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
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
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.
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:
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.
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.
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?
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.
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?
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.
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.
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.
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).
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 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).
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.)
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 ...