More Expensive Medical Services or Products Does Not Equate To Better.

I have been writing articles for this health policy blog since 2009– almost all of the 390 posts since 2011. Of them, the one most frequently accessed by the public is a 2012 article titled “Horse Liniment for Your Arthritis and Healthcare Reform.”  I encourage you to read it also, because it provides my background for this article, and explains why I write a lot about how pharmaceutical companies – with the active consent of our elected government officials – are gouging the public. The earlier article caught my attention because of a tiny advertisement in the Courier-Journal notifying me that an “arthritis pain mystery” had been solved and that the secret was horse liniment. In my studied professional opinion, the claims were vastly overblown and that in any event, the “secret” was not a secret at all. The ingredients in the horse liniment were available in a variety of over-the-counter joint-rub-ons at a fraction of the cost of the “miracle” liniment offered for sale. I lament the fact that the public at large could be motivated to part with their money in such a way, but alas, physicians are equally as vulnerable to bamboozlement by the traditional pharmaceutical industry– think OxyContin. Sadly, the marketing approaches I wrote about in 2012 are still alive and well. Such advertisements in the Courier-Journal are now bigger and more numerous than ever.  A recent such sparked today’s article. Continue reading “More Expensive Medical Services or Products Does Not Equate To Better.”

City Air Makes You Free. A Public Health Case for Sanctuary Cities.

The following is extracted (with permission) from an article first published in hasselbloger.com.


In the printed edition of the Courier-Journal on January 25, a letter-writer contributed the following:

‘Dignity of Labor’ to get healthcare is wrong.
According to your report of Jan/ 13, Gov. Bevin wants to change Medicaid requirements to enable the “able bodied” poor to learn the “dignity of labor.” It was a teaching of the Nazis that “Arbeit macht frei.”  The similarity between these two simplistic positions is too dangerous to ignore.  Stephen Schuster, Louisville.

Based on reflection over the past two years, I do not deem Mr. Schuster’s reaction to be overblown.  I submitted my own letter in response, but it appears that it was not accepted. Having my own “barrel of ink,” I publish it below.


Dear Courier Journal.
A recent correspondent to these letters drew uncomfortable attention to a similarity of phrasing used by Gov. Matthew Bevin and the German Nazis.  To obscure an ultimate goal of decreasing Medicaid enrollment, he and other governors would require “able-bodied” beneficiaries to either work or provide compulsory volunteerism [an oxymoron?] under the dissembling cover of gifting the poor with the ability to learn “the dignity of labor.”  Mr. Schuster and I were both reminded of the phrase Arbeit macht frei (Work sets you free) posted by the Nazis at the entrances to their Arbeitslager (labor camps) which evolved into the death camps of Europe.

A much older German phrase entered my mind as President Trump and his acolytes scold and sue cities like Louisville for protecting their inhabitants born under other suns.  Stadtluft macht frei  (City air makes you free.) expresses a centuries-old common law concept of medieval Europe whereby slaves, serfs, or peasants who entered a self-governing city were protected against involuntary repatriation to the rural countryside or servitude by their owners or landlords.  Remaining in such a city for a defined period ruptured the physical and economic bondage of structural rural poverty. Those so sheltered could become Bürger, or citizens.  Cities were places of opportunity!  The concept of a path to citizenship in a sanctuary city has a long and honorable history.

In the late 19th century, the abstraction of Stadtluft was still being used to summarize the motivation of rural Germans wishing to escape the tyranny of their birthplace, their legitimacy, their institutionalized poverty, or limits imposed on their occupations and ability to make a living.  I am proud of the leadership in Louisville and similar cities which protects those living in their jurisdiction against the unleashing of the most ignoble of nationalistic urges.  Louisville should not reopen its workhouse of the early 20th century.

Peter Hasselbacher
Louisville
29 January 2018

Addendum:
I take the liberty of reposting this larger part of my other article in this health policy blog because I believe it is relevant.  Individuals who in the current climate of immigration stings and deportation may be justifiably afraid to respond to demands of “show me your papers,” will correspondingly  be much less likely to seek medical care when they are sick.  This is not good for anyone!  As a people, we are no healthier than the sickest among us– regardless of place of birth.

KentuckyOne Health Has Already Sold Most of Its Real-estate Assets in Louisville.

KentuckyOne’s two acute care hospitals and its business operations in Louisville still remain on the sales block.

Soon after I clicked the button to publish last week’s update on the status of the sale of Catholic Health Initiative’s assets in Louisville, I was told by an anonymous reader that a group of capital investors was the last of potential buyers still in the game. Perhaps naively I have been assuming that only other hospital systems would be interested in acquiring the clinical operations of  Catholic Health Initiatives (CHI)/ KentuckyOne Health in Louisville. I was aware that at least parts of one of the doctors office buildings next to downtown Jewish Hospital had been transferred to a new landlord.  A quick look at the Jefferson County Property Valuation Administrator’s (PVA) website and a bit of Internet research revealed much more.  Beginning in 2015 and finishing in the spring of 2016, CHI sold all of its local medical office buildings and outpatient medical centers (of which I am aware) to a single, investor-owned, national real-estate investment trust (REIT) – Physicians Realty Trust and Physicians Realty L. P.  (Nasdaq- DOC).  I must be the last person in Louisville who knew the extent of these real-estate sales.   This third-party owner is now necessarily a major player in planning the future of not only the downtown medical Center, but the healthcare infrastructure of the Jefferson County region. The rents must flow! Continue reading “KentuckyOne Health Has Already Sold Most of Its Real-estate Assets in Louisville.”

The Search For A New President of UofL Must Be More Open.

The University of Louisville is trying hard to recover from what can arguably be considered its darkest hours.  It has, and is still weathering challenges to its accreditation at several levels.  It has been turned upside down by a string of scandals that may yet lead to criminal charges.  All of this has been well-reported publicly resulting in a community consensus that a lack of transparency and accountability at the highest administrative and governance levels allowed corrupt and abusive practices to fester for years.  Where there should have been openness, there was deliberate obfuscation.  It is against this background that the UofL’s Board of Trustees seeks to appoint a new President of the University using a process that could not be more opaque.  Faculty members, some administrators, and students who have the most skin in the game are openly critical.  I am too.

The descriptors ‘open’ or ‘closed’ in reference to such a search are by themselves poorly defined. However, the recruitment process selected by the Trustees would deliver us as Deus ex machina, a new president to solve our problems, but one who would not be named until after they were appointed.  Such a process meets my definition of ‘secret.’  More of the same is the last thing we need.  The Board is increasingly being criticized for its retreat into opaqueness generally.  Its meetings are carefully scripted and I have yet personally to hear a substantive discussion publicly.  I must conclude, as I have in the past, that all major discussions or decisions occur behind closed doors.  Perversely, even those Trustee representatives of faculty, staff, and students are prohibited from sharing information with their own respective constituencies – or for that matter even sharing their own opinions publically. The assumption of this posture by the Board beggars the concept of shared governance. Continue reading “The Search For A New President of UofL Must Be More Open.”

How Close Really Is KentuckyOne Health To Selling Its Louisville Assets?

Catholic Health Initiatives (CHI) just published its financial report for the first quarter of Fiscal Year 2018– the three months ending Sept 31, 2017.  One initial media report led with what CHI would no doubt wish to emphasize, that the company has cut its “quarterly operating loss by more than half.”  The actual reported system-wide loss from operations in Q1-FY2018 was $77.9 million compared to a loss of $180.7 million in Q1-FY2017. This change is being attributed chiefly to more efficient purchasing and to decreased labor costs.  Indeed, CHI reported a decrease of 2,667 full-time-equivalent employees over the quarter.  Whether such cuts are healthy for the company in the long run remains to be seen.  I await more expert financial analysis than I am able to offer and to see how the financial markets or potential new partners or asset-purchasers react.  It appears these latter are not being hasty.  As I plow through the numbers, I see many other measures going in what appear to me to be the wrong directions.

The report gives special attention to what has been going on here in Kentucky.  [I extracted all mentions of Louisville or Kentucky from the 61-page report into a separate document available here.]  The percent of operating revenues contributed from the Kentucky Region was 7.5% this last quarter compared with 16.2% in 2013. This represents a drop from 2d place to 5th place among the 11 or 12 regions or operational segments.  Perhaps the most newsworthy item is the first notice of which I am aware that the anticipated (hoped for?) date for a closing on the sale of CHI’s KentuckyOne Health facilities in Louisville has been put off six months to June 30, 2018.  A reasonable person might conclude that KentuckyOne is having a difficult time finding a motivated buyer for its hospitals, outpatient medical centers, and physician practices here in Louisville.  I am not surprised. The return of control of University of Louisville Hospital to the University has not improved the financial performance of Jewish/Sts Mary & Elizabeth Hospitals.  With respect to apparently continuing discussions between CHI and Dignity Health to align their activities, the report uses the same language it did at the beginning of this year.  No substantive indication is given as to how things are going.  Although some media reports use the word “merger” to describe the process, that word seems to be carefully omitted in accounts by CHI itself. Continue reading “How Close Really Is KentuckyOne Health To Selling Its Louisville Assets?”

University of Louisville Hospital Pledges To Do Better.

I was both pleased and proud to read yesterday’s letter in the Courier-Journal by Ken Marshall, President of University of Louisville Hospital, recommitting to a higher quality of medical care for our community, including its most vulnerable citizens. Alas, under the clinical and management captivity by Catholic Health Initiatives and KentuckyOne Health, the hospital has performed unfavorably in virtually every quality-comparison with other hospitals, including other teaching and safety-net hospitals. Indeed, major layoffs of clinical and support staff by KentuckyOne, and concerns about quality of care by some staff physicians drew Federal attention that threatened the Hospital’s accreditation.

Various of the many items measured and methodologies used by the numerous evaluating entities have been criticized, and in my opinion sometimes rightly so. After all, what constitutes quality? One major criticism of current federal and proprietary hospital quality assments is that they do not adequately take into consideration the socio-economic status or severity of illness in the patient populations served. With all the valid current emphasis on the nonmedical determinants of health care status and outcomes, how can we not take these into consideration? Nevertheless, for University Hospital there is nowhere to go but up. Continue reading “University of Louisville Hospital Pledges To Do Better.”

VA Declares Brownsboro Site The Final Choice For New Hospital.

Is this the last word?

The Record of Decision dated May 30, 2017 and signed by the Secretary of the U.S. Department of Veterans Affairs on October 12 makes it sound like an easy decision. The 23-page document contains only three words or phrases in the text highlighted by the VA to draw attention to the central logic of the decision.

Page 1. “The purpose of the proposed project is to provide Louisville area Veterans with facilities of sufficient capability (functional) and capacity to meet their current and projected future health care needs.”

“The proposed project is needed because the current hospital and CBOCs [outpatient clinics] are operating at maximum capacity and are unable to accommodate the projected increase in the regional Veteran population. The configuration and condition of the existing 63•year-old Louisville VAMC facility offers limited options to expand to meet these needs, and parking at the Zorn Avenue VAMC is insufficient.”

Page 7. “For these reasons, VA does not view the general locations or sites suggested in public comments as reasonable alternatives warranting additional investigation and detailed evaluation in the EIS [Environmental Impact Statement]. Chapter 2 of the Final EIS includes a detailed description of the site selection process, as well as the reasons for eliminating the Fegenbush and Downtown sites, and for not reconfiguring the existing VAMC on Zorn Avenue.”

It has not been a straight path! Continue reading “VA Declares Brownsboro Site The Final Choice For New Hospital.”

Catholic Health Initiatives Releases Annual Financial Report.

Catholic Health Initiatives (CHI) released its Annual Report for Fiscal Year 2017 last week. Given that the company is in the middle of discussions with Dignity Health about a possible merger or alignment, and the attempted sale of half of its hospital beds in Kentucky, the report is of considerable interest. I cannot pretend to understand the arcane rules of accounting underlying the numbers and discussion in the report. Others in a position to do so emphasize the increasing $585 million loss in operational income from the company’s core healthcare business, and the considerable outstanding debt of $8.7 billion. There is a reason that bond rating agencies have been downgrading CHI’s rating and assigning a negative outlook. What I intend to do below is to highlight material from the report that is specific to Kentucky, to offer a few general comments, and to ask my readers to help us interpret what is at stake for Kentucky.

Earnings Before Interest, Depreciation, and Amortization (EBIDA).
CHI uses this method of accounting to present much of its financial numbers. EBITDA is (according to Wikipedia) “not recognized in generally accepted accounting principles” but intended to allow comparison of profitability between different or heavily leveraged companies. [The ‘T’ in EBITDA is for taxes, which are less relevant for a non-profit.]  It has been suggested that “EBITDA doesn’t give a complete picture of a company’s performance.” and that because it is not defined in GAAP, “companies can report EBITDA as they wish.” Furthermore, CHI lists its EBIDAs “before restructuring, impairment, and other losses.” In short, I have no confidence in my ability to interpret the financial health of CHI from this report. Can anyone help us?

Items Specific to Louisville.
From the 127-page document, I extracted all paragraphs in which Louisville (or Kentucky) is mentioned, along with the page number from the original document. A lot is stuff we already knew here in Louisville. There is a good bit of repetition, boiler-plate, and business-speak language that seemed not very specific or informative to me. Maybe that is the nature of annual reports. Allow me to highlight (in sequence) some of the mentions. Continue reading “Catholic Health Initiatives Releases Annual Financial Report.”

Who Should Control the Curriculums at Kentucky Universities?

Lest anyone doubt Gov. Bevin’s inclination, indeed intention to intervene in the academic decisions of Kentucky’s state universities, I draw your attention to his recent speech to the Kentucky Council on Postsecondary Education (which sets Kentucky’s higher education policy and which he largely appoints) in which he “suggests” to our university Boards and administrations that they should shed whole academic programs that do not contribute to employment and economic development as he envisions it. This should not come as a surprise to anyone, because he made the same statement early in his term shortly after he celebrated his intention to open the separation of church and state more widely. Others have already noted how a broad-based general education has not done badly for the Governor personally. I will add that the Governor’s initial public spokesperson in Kentucky did not do very badly with her history major from a Kentucky college. She moved from working for a governor to working for the president of the United States.

It is my impression that a “suggestion” from Gov. Bevin forebodes a more aggressive intervention on his part. I point to the “pressure” brought to the University of Kentucky to fire a professor who was critical of one of the Governor’s healthcare policies, and his “pressure” brought on the University of Louisville Hospital and KentuckyOne Health to sever and not renew its transfer agreement to accept the rare patient from Planned Parenthood or other abortion provides who has a serious complication from surgery. (This latter matter is now in Federal Court.)

Although the Governor’s office denies any intervention on his part, in my opinion, and that of the parties being leaned on, the pressure could only have come from the Governor himself directly or indirectly through proxies. The Governor has not been shy about stating his intention to achieve his economic and religious agendas. Why should be not believe him? In my opinion, such tactics do not deserve the banal description of “pressure,” but meet the definition of bullying. We all know what happens when a bully is not confronted – the result is more of the same. University accreditors at SACS, are you watching? Kentucky elected officials and our general public, are you?  Our Universities cannot fight this battle by themselves.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
September 14, 2017

Alice In Wonderland in a Louisville Federal Courtroom.

“Contrariwise,’ continued Tweedledee, ‘if it was so, it might be; and if it were so, it would be; but as it isn’t, it ain’t. That’s logic.”
Lewis Carroll

I began my day yesterday morning attending Medical Grand Rounds at University of Louisville Hospital.  These weekly sessions teach the principles of evidence-based, scientific medicine to the physicians of tomorrow.  They simultaneously emphasize the ethical and patient-centered ideals that underly and legitimize the practice of medicine.  For the physicians of today (and of yesterday like me) they provide a way to refresh and celebrate the ever-expanding knowledge of the science of medicine, and to reaffirm and share together our commitment to the highest standards of our profession.

Because I was already nearby and interested in the proceedings, I drove across town to observe the second day of trial in the courtroom of Judge Greg N. Stivers in the United States District Court for the Western District of Kentucky to hear the constitutional challenge to new Kentucky abortion restrictions which was brought by EMW  Women’s Surgical Center (joined by Planned Parenthood) against Gov. Matthew Bevin and Health Secretary Vicky Glisson.  Judge Stivers will pass judgement on whether the language, intent, or implementation of laws controlling transfers and transport of women with complications of abortion from an outpatient clinic to a hospital unduly burden the right to terminate a pregnancy. Continue reading “Alice In Wonderland in a Louisville Federal Courtroom.”