healthsignals new york

Patient blogs

High Point Regional Health System, in High Point, NC has set up patient blogs! Well this is a dangerous but interesting experiment.

Patients reportedly can write about any negative experiences. We'll see about that won't we. Readers can e-mail comments. So far it's not evident what happens with those comments. Patients may post from home.

Reportedly, a hospital staff person reviews each blog to make sure it is relevant before posting it to the hospital's site.

Here's a staff posting with a bit of (self) back-patting. 

Well, think of it this way. Anybody with a computer and a connection can set up a blog in an afternoon. The way things are going, it's just a matter of time before an unhappy patient sets one up or uses one they already have to rip into a hospital. We've already seen it with a disgruntled Blue Cross employee.

So why not tip-toe into the environment in a very controlled manner?

 

Press coverage of the closure commission ... and us

Jay Gallagher's story in today's Rochester Democrat & Chronicle discussed the hospital/nursing home closure commission. He quoted me a bit, accurately by the way,  and I think I'll expand on what I said to him.

Many use the Federal Commission that targets military installations for closure as a handy metaphor to describe New York's hospital/nursing home closure commission. But there are  a few key differences, some of which I discussed with Jay, some of which I didn't think of until afterwards.

1. The Federal government owns its military installations while the hospitals and nursing homes are merely regulated by the State. Those facilities are owned by private, mostly not-for-profit organizations. There is no prospect of a legal challenge by a base commander to a closure decision. But we can count on a legal challenge from at least some hospitals and/or nursing homes being told to close.
   
2. Because of the ownership difference all the savings from a base closing accrue to the Federal government while only a fraction of the savings from a hospital or nursing home accrue to the State, even when you include the local share of Medicaid costs.
3. The political reaction against military base closings is overwhelmingly about direct jobs and other local economic impact. In addition to the economic issue, closing a hospital also generates an emotional effect among former and potential patients that is quite apart from their economic interests. So the issues take on a different tenor.
4. Not every Congressional District has a military base. Indeed, military installations are concentrated in the South and West. But I'd bet that a very solid majority of NYS Senate districts have a hospital and probably several nursing homes. (There are 61 Senate districts and 150 Assembly districts, fewer than the number of hospitals and and many fewer than the number of nursing homes.)
5. There's a huge difference between telling military personnel that it's time to pick up and move elsewhere and telling a frail 90 year old that they must move out of what has become their home for their waning days or telling their 65 year old child that they must travel further to visit mom. Can't you just imagine the "human interest" stories in the press on that one? It's hard enough to close a residential facility that's providing bad care. The Health Department press person who gets tasked with defending these cases and tagged as cold and heartless has nothing but my sympathy.

Here's how I came up with the "70 of the state's 230 hospitals" analytical estimate which contrasted with my "half a dozen, maybe a dozen" political estimate.

Health Department staff told me at the beginning of this week that New York has 247 hospitals with 62,800 beds and an occupancy rate of 60 percent. That equates to 37,680 patients per day. Optimal average occupancy is probably about 85 percent (allowing for normal fluctuation), but we'll cut them a bit of slack and say 80 percent. Eighty percent occupancy with 37,680 patients equates to 45,216 beds, or 17,584 less than what we have today. Today's average hospital has 254 beds. Divide 17,584 by 254 and you get 178 hospitals down from today's 247, a reduction of 69. So round that to 70. Given that it would be reasonable to assume a continued decline in hospital days and that we assumed 80 rather than 85 percent as optimal occupancy, these may be conservative estimates.

Certainly there are many folks who can come up with a more sophisticated political estimate than I, but here are the reasons for my skepticism. Assume that Senators and Assembly members in districts with a hospital proposed to be closed will tend to vote to overturn a package of Commission proposals. Then in order to protect the package from being overturned, you must have a majority in at least one of the houses which doesn't have a hospital in the package. Otherwise you've got sufficient votes for an override. So you've got to keep the total number small.

Mind you this assessment doesn't even begin to take into account a host of factors. Take for example, the research and education being conducted in teaching hospitals and their all-round political clout. These of course are the most expensive hospitals in the system and their care often doesn't measure up to that provided in community hospitals, but they have tremendous leverage.

Or take for example, communities with two hospitals whose total capacity is well recognized as more than necessary, but one of the hospitals is secular and the other is Catholic. Now which one do you choose?

Perhaps the Commission and Legislators will be gutsier than that, but find me the evidence in the past decade of that discipline and willingness to face the public having made those sorts of decisions.

For a future post, let's consider what the Commission would have to do to really impress us. (Feel free to send me private e-mails on this rather than comment. I'll keep your name out of it.) Here's a "just thinkin' out loud" start as to what the the Commission's package should include in order for us to be at least mildly surprised and impressed with their fortitude. The package has to:

• Include a proportionate number of teaching hospitals and at least two in any case.
• Target hospitals that are less efficient and/or provide care of lesser quality than their competitors. There are lots of quite sophisticated methods for measuring efficiency. And let's not count reputation as a quality measure. Show us some hard data.
• Compare more than the hospitals and their patients. First compare the use of hospital services within hospital service areas. It's a subtle but quite important difference. Look first at the per capita hospitalization rates of the populations in each hospital market or service area. Calculate which areas have high hospitalization rates and figure out why and the degree to which it may be unnecessary or avoidable. Then look to see where those patients are being hospitalized.
• Offer up a workable plan for retiring outstanding capital debt that doesn't take systems off the hook for their hospitals that are proposed for closure, but which also spreads some of the burden for retiring that debt on the surviving competitors.
• Detail how the savings will be generated from each closure and who will accrue the hard dollar benefit. (Remember, when some of a hospital's would-have-been patients go to another hospital, the surviving hospital gains, but neither Medicaid nor other payers get any savings. And if the surviving hospital has higher prices than the closed hospital, the savings can get real small real fast.)
• Close a sufficient number to make a real dent, but leave a sufficient number for each market to remain competitive.

I'm not sure that this is really supposed to happen. It's great rhetoric, but I continue to wonder whether it's a feint by some of the players in the hospital industry who expect to survive. Perhaps it's a way to get the State to pay off the capital debt for facilities that systems wanted to close anyway. Perhaps what I'm doing here is daring the Commission to generate proposals with the scope necessary to make a real difference. I'd be amazed, but glad to be wrong.

The overly congratulatory Daily News

Here's today's New York Daily News editorial on the hospital/nursing home closure commission.

... buried in the hundreds of pages that lawmakers ratified sight-unseen was a real gem of an idea: putting the state's overweight health care system on a diet.

Cute. And we know how effective most diets are.

No one knows what this excess capacity costs in higher bills for Medicaid, Medicare and private health coverage, but it's likely to be in the billions. Carrying this weight is a large reason that New York spends more than any other state on health care, yet its hospitals and nursing homes constantly teeter on the brink of bankruptcy. Often they've been rescued with taxpayer-financed bailouts.

But we could know at least approximately what that excess capacity costs. Who's game for doing that calculation? Or better yet, (crass commercial here) paying us to do it.

The commission - Pataki's brainchild -

Or put another way, Pataki's way of sucking everyone else into what he (through the Commissioner of Health) had the power to do all along.

Pataki deserves credit for conceiving the idea, and industry officials and legislators deserve credit for going along.

Well, I suppose we could give the Governor some credit for at least bringing the underlying issue (gross overcapacity) to the forefront. But the question remains what took so long. It's not as if nobody's known about this the past ten years. As we noted yesterday, New York partially de-regulated in 1996, but it didn't de-politicize the hospital market. Being charitable, we might observe that this Commission which has emerged from and will be immersed in a political process is to offset the politics of the past decade which prevented the market from doing exactly what the Commission is supposed to do, namely reduce the size of the hospital and nursing home systems.

And credit for the industry officials? Puhleeze! First, this is a way for them to play out their political games promising protection from the Commission for their allies and punishment for all others. It's a way for them to take political advantage of what the market would probably have done anyway.

And, perhaps even more important. Isn't the implication of an institution's not being on the closure list the Commission comes up with that it should be saved at all costs? Emphasis on costs. Say the market would eventually reduce the size of the hospital system by 70 hospitals (to get to 80 percent occupancy systemwide). Then say the Commission only proposes to close 20 because it makes a political calculation that any more than that would lead to a Legislative override or because of the pressure and horsetrading. (Perhaps I should explain the rules in another post.) In the following legislative year, don't the survivors have the perfect argument for lots of "save me" money in the State budget? I sure think so.

 

After eight years of waiting?

In the fall of 1996, the Wall Street Journal published a story by Lucette Lagnado that opened with the line, "All hell is about to break loose in the once sedate and antiquated world of New York hospitals." She, like many of us, was anticipating the effects of New York's Health Care Reform Act of 1996 which ended a twenty-five year-old policy of regulating hospital prices for private payers.

Lucette called a couple years later and asked, well why didn't it happen? And in January of 1999, she wrote a story that began "New York's hospitals tallied record financial surpluses for their first year operating under deregulation, according to an unreleased study by health authorities."

Perhaps the moment has finally arrived, but not in the way we expected.

I couldn't help but recall Lucette's stories when reading Richard Perez Pena's recent lengthy story in the New York Times, Hospital Business in New York Braces for a Crisis.

The "crisis" is partly the result of market changes and partly the result of politics, including all the budget debate about a hospital (and nursing home) closure commission modeled on the Federal military base closing process. Let's discuss the market first.

The other legislative bill

We linked to the New York Legislature's health and mental hygiene appropriations bill here (S.554C or A.554C).

We neglected to note another bill, with the substance of the legal changes. Go to the same links for the Senate or Assembly and read, if you dare: S.3668 or A.6842.

It's a couple hundred pages, so it may take a while to connect.

By the way, if you've never looked at something like this, you might want to take a glance just to get a sense of what it's like. Go through and pick a section at random and actually read it. Never mind the politics and the negotiating, the shear logistics of  putting something like this together are often daunting. And it usually happens when the staff who do the drafting are already exhausted.

NY's Legislative budget bill for health

Want to plow through a couple hundred pages of legislation?

Determined to finish on time for a change, New York's State Legislature has an agreed upon a Budget Bill ... agreed between the houses that is. The Governor is still not pleased and retains the option to item veto whatever the Legislature adds.

Go here  and look for A554C or here and look for S554C. If you're at this site, you're probably looking for the Health and Mental Hygiene bill. But if civic duty or curiosity compels, look at some of the others too. If it's your first time, it'll probably come across as dry, as in arid. But there's real stuff in there.

When I just checked the "C" version wasn't up yet. But it should be fairly soon.

OK, Tim

Well, the queue of drafted, but incomplete posts is way too long and the (much appreciated) complaints about the absence of posts are getting to me. So we're starting up again today.

I've been working on a series of fairly lengthy posts about healthcare budget politics in New York and the feud over how we should get to a smaller sized hospital and nursing home system. Note that it's no longer whether; it's how. I'm betting that this is a very significant change in the public debate.

For decades, it's been the dirty little secret among professionals that New York is way over-bedded. But the hospital and nursing home associations couldn't really admit that in public. The first to break was NYAHSA when they began to talk about "rightsizing" a couple of years ago. But now they're all in on the action. But that also means that the issues which were repressed are bubbling to the surface:

• To what degree can, should, and will unionized facilities get favored treatment in this colossal game of Survivor? Can't we just imagine the "tribal councils" to vote hospitals off the island?
• What are the implications of the upstate/downstate differences in hospital organizational structures? (Downstate, most are part of multi-hospital systems. Upstate, they are not.)
• From a programmatic and economic perspective, which is the better approach, market or regulatory? This isn't just a question of ideology. Would the actual results from the two approaches really differ?
• Which will cause more political damage in the districts that lose facilities, an active regulatory role (you, Mr. Legislator gave the Governor and this commission the authority to close my hospital) or (you, Mr. Legislator stood by while my hospital was forced to close because the market squeezed the life out it)?

But in the meantime, there have been some Medicaid developments I'm mixed up in that are all at the same time, amusing, amazing, promising, and troubling. More on that tomorrow. Not to be a tease, but it appears that a Medicaid paper I wrote a couple years ago is now in the middle of a political brawl between State and County officials. I'm meeting this afternoon with a Senator who sent the paper to county officials all over the State. (What was that old quote about the honor of facing a firing squad?)

I've actually got most of the next post written, but probably shouldn't finish it and certainly shouldn't post it until after I've met with the Senator.

Also on the docket for tomorrow (though it may be very late tomorrow) ...

Part of the reason for my absence the past couple of weeks (yes, it's an excuse and a pretty lame one at that) has been work on a new website. Here you get to read my yammering. But except for a few bold souls, I don't get to read yours. So we've been working on something that I think will be distinctive in the the healthcare environment.  Stay tuned.

And thanks for your patience.

 

Which year?

With Ken Raske's "bare as the moon statement" yesterday, we thought it would be fun to test your ability to discern differences on the fraught meter. So ...

Match the year to the statement. Yes, there are some years missing in the middle, but only because it was pre-web and I'm not going to that much trouble.

1. 1990
2. 1991
3. 1991
4. 1993
5. 1995
6. 2001
7. 2001
8. 2002
9. 2002
10. 2003
11. 2003
12. 2004

1. "We recognize that the State of New York faces fiscal challenges, but New York's health care providers are already on the financial brink and some have fallen over. We simply cannot tolerate any more cuts or taxes," said Healthcare Association of New York State (HANYS) President Daniel Sisto.
2. Newsday quoted Raske, commenting on new proposals for Medicaid reform: "There's no question in my mind people will die because of these proposals."
3. “Health care providers cannot afford sick taxes or Medicaid cuts,” said HANYS President Daniel Sisto. “Proposals such as these threaten the very programs and services our communities depend upon to keep them healthy.More cuts made to an already weakened health system could result in another round of layoffs and diminished access to care.”
4. "We will try to stave off the death blows," Raske told The New York Times, in relation to cost reductions ... "But if we don't succeed, we are going to see a vast destruction of the health-care system in New York."
5. "Nursing Home Finances in Jeopardy," NYAHSA Says
6. Speaking of Medicaid reductions ..., Raske told Crain's New York Business: "If these cuts were to be made, it would deal a devastating blow to many New York hospitals, especially those caring for the poor and elderly." Four days later, he told Newsday, "This is a nightmare scenario."
7. "... a substantial number of voluntary nursing homes are at risk of bankruptcy or insolvency."
8. "NYAHSA's new report shows the bad news in not-for-profit and public nursing home finances - and these survey answers were given even before the state proposed any additional Medicaid cuts, said Carl S. Young, president of the New York Association of Homes & Services for the Aging (NYAHSA). 'Our report shows that any additional further budget cuts will simply spell financial disaster for nursing homes in the state."
9. "Medicaid reductions ... "have the potential to wreck the health care system in New York," Raske told Newsday.
10. "Greater New York Hospital Association (GNYHA) today assessed the impact of several of the major proposed hospital cuts and new taxes contained in the New York State Executive Budget and found that the impact could devastate New York's health care system, with the burden falling hardest on the State's teaching hospitals and 'safety net' hospitals, which care for New York's poorest communities." "These cuts will hit hardest where we can least afford: teaching hospitals, which are our first line of defense against future terrorist attacks, and the safety net hospitals that are relied upon by the poor," said GNYHA President Kenneth E. Raske. "A real threat is posed to public security and to the health care of our most vulnerable citizens.
11. Because of proposed changes in state funding, "There will be some significant service cutbacks," Raske told American Health Line. "The anxiety has never been greater."
12. "We have before us a budget proposal that not only does not make new investments in our health care system, but calls for damaging cuts to not-for-profit and public continuing care providers, including nursing homes and home health care agencies." Ken Raske

Hint: if you're a regular reader and you follow the links, you already have seen some of the answers.

Answers tomorrow at 4 PM.

Two prize winners for posting in the comments section (e-mail entries excluded):

1. The first to post the correct answers (yes, of course before the answers are posted);
2. The person to add the most over-the-top new and verifiable quotation on the healthcare plagues to ensue after budget cuts.

Winners will be treated to a cheap lunch in Albany. Decision of the judge (me) will be entirely arbitrary and final. But feel free to try to influence the results in the comments section.

Pataki's Budget, Part 3: Making decisions

The Governor's Budget differs from past ones in a subtle, but very important way. Rather than spreading the pain, he clearly made some decisions that favor one approach over another.

Prime example:

The big Medicaid cuts were targeted at hospitals and nursing homes. With a couple of minor exceptions, home health care was mostly left alone.

It comes down to this: people would rather be at home. Medicine and healthcare have advanced so that more can be. It's that simple, but that important. The Governor recognized that and acted on it. Kudos!

Full disclosure: I've mentioned this before, but some of you may be new here. My wife is President of the Home Care Association of New York State. We share many (but God knows not all) of the same biases.

Pataki's Budget, Part 2: Hospital closure commission

One of the proposals related to the Medicaid savings is the establishment of a commission to recommend the closing of specific hospitals and nursing homes (though I assume the focus would be on hospitals). Reactions?

1. The Executive Branch already has statutory authority to, not only recommend, but act. Chapters 76 of the Laws of 1976 and 77 of the Laws of 1977 provide the Commissioner of Health with the authority to close hospitals and nursing homes because he or she finds there is no longer public need for the facilities. They also provide for downgrading the type or status of a facility or part of a facility. For example, the Commissioner can recertify a portion of a hospitals acute care beds to skilled nursing facility beds.
2. Because the Commissioner already has the legal authority to force closure or conversion, we can presume that the notion of a commission is solely for political cover.
3. Regardless of where the idea came from, it is interesting that the Governor has put it on the table and it will be interesting to see if he moves ahead with it. He does not need the Legislature's permission to go ahead though I suppose he could use the threat in negotiating with individual legislators.
4. Despite the fact that the legal authority has been in place for almost 30 years, it has been used only rarely. There was one forced closure of an inconsequential hospital (about 25 or 30 beds) of poor quality in Central New York fairly early during the Cuomo Administration. The legislators from the area were probably Republicans and had no leverage ... even if they wanted to prevent the action. There were two forced conversions of acute to skilled nursing beds in Buffalo (Erie County Medical Center and the old Buffalo General) around 1980 (give or take a year). Each of the conversions accounted for about 100 beds. In one case for reasons too arcane to go into here, the action actually generated increased income for the facility.
5. Virtually all health professionals who pay attention to these issues have agreed for decades that New York has excessive hospital capacity, hospitalizes people and keeps them hospitalized more than would be necessary if the system were configured differently. So why are is the Governor proposing doing this now?
6. To save real money by this means, you can't take small chunks out of several hospitals. You have to close entire hospitals.
7. In the New York City area, to save real money by this means, you should really be closing one of the Academic Medical Centers. Good luck on that one. At least you've got to go further than targeting a couple of rinky-dinks.
8. Isn't this an ironic approach for a Republican Administration? Bad enough to use regulation to prevent market entry, but using regulation to force market exit? Many folks think that the Certificate-of-Need (CON) system has become increasingly politicized during the Pataki Administration. If so market entry is more politicized. Controlling market exit would be much more so.
9. The proposal is based on the Berger Report. As we pointed out here, one of the ironies is that the Berger Committee was driven largely by folks who had been part of the Carey Administration. They had the authority, but never used it. Worse, it was the Carey Administration that began, formalized, institutionalized, and then repeatedly used all the opportunities it could to bail out failing hospitals. Not only did they not force closure of excess capacity, the established the policy of preserving excess capacity. They didn't allow failing hospitals to fail.

It's much easier to let failing hospitals to fail (and we haven't done that) than to deliberately force closure. Politically, the latter is an extremely steep push. After watching the past 30 years of failing at the easier task, permit me some skepicism about whether we'll even try, much less succeed at the more difficult.

If they do try, the politics will be extremely ugly. That's one thing you can count on. So we can credit the Governor for acknowledging that excess hospital and nursing home capacity is real and it has real costs. But we have to wait to see whether he'll do something with the power he already has, whether the process will be entirely politicized, and whether he'll do enough to make it worth the pain that will result.