Have We Turned the Corner On Kentucky’s Hepatitis-A Epidemic?

The drama surrounding Kentucky’s epidemic of Hepatitis-A continues. Chris Kenning reported today for the Courier-Journal that Dr. John Bennett, current infectious disease branch manager, was dismissed last Friday. No specific reason was offered, but this is the second dismissal from that position in less than a year. His predecessor, Dr. Robert Brawley, was similarly dismissed less than a year ago after he lobbied for a more aggressive approach for what became the worst the Hep-A epidemic in the country. No doubt Governor Bevin’s administration will continue to deny that there was any connection between Dr. Brawley’s recommendation and his dismissal.

Dr. Bennett inherited a mess. A reasonable person might speculate that he is taking the fall for criticism that has been directed toward higher-ups in the administration. We may never know.  However, turmoil as we deal with a new outbreak of serious, food-born E. Coli infection is not what we need now.  Hep-A and E. coli pathogens are both transmitted by feces of infected individuals– basic sanitation stuff.  There are other threats of serious infections on the horizon that we may need to deal with including a drug-resistant fungus, Candida auris.

Above is an updated graph from Frankfort showing new cases of Hep-A up to the week through March 23. It appears to show a sharp drop  for the most recent week, but I assert that it is premature to conclude that the epidemic is ending. The report from which the figure is extracted warns that all cases in the current period have not yet been incorporated into the totals. Indeed, charts from earlier weeks that initially showed apparent trends downward before all the cases were counted ended up hovering around 40 new Non-Jefferson County cases per week. Over the last 4 reporting weeks, the number of counties having new cases decreased only from 21 to 19. The number of counties having at least one case during the epidemic continues to increase, now up to 105 counties. We are not yet home-free.  I do not have access to updated data for Kentucky’s ongoing Hepatitis-B, Hepatitis-C, and HIV epidemics which remain endemic threats.  We deserve some stability and are owed more confidence than we  now enjoy.

Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
April 8, 2019

Our Vanishing Right to Patient Privacy.

On March 20, I submitted the following letter to the Courier-Journal. Others have offered similar views and I gather that my contribution was not accepted. Since I buy my ink by the gigabyte, I have the opportunity to publish the letter anyway! Here it is.

Bullying not allowed in school.
Kentucky education Commissioner Wayne Lewis has demanded that 10 different school districts in the eastern half of the state send him records and documents for teachers who did not show up to work this legislative session. Enough teachers did so, that at least some schools had to close. The demand specifically includes doctor’s notes confirming illness. The first thought of the physician in me is that federal patient privacy law (HIPAA) prohibits the sharing of patient information except to other health professionals or entities sharing in medical care of a given patient. These protections are quite strict. Specific permission from a patient is
required to discuss matters even with a family member, or to even to disclose whether an individual is a patient or not. A note from a doctor– even without a diagnosis– conveys information simply by virtue of the physician’s practice. A note from an obstetrician might suggest a pregnancy. An individual may not wish to disclose that they are seeing a cardiologist, psychiatrist, or any other specialty that might announce a pre-existing condition. Even if Kentucky law or regulation allows Frankfort or a school district to demand a doctor’s note, it is not clear to me why federal law would not supersede state law. I will leave that to legal experts.

Given the obvious animus of the Bevin administration towards Jefferson County and its public-school system in general, and towards teachers and the teacher’s union specifically; a reasonable person might conclude that Commissioner Lewis’s demands represent an attempt to intimidate teachers for standing up for what they believe is right for their schools. The Commissioner’s more recent promise not to punish anybody if there are no further work stoppages converts a veiled threat into an operative one. Commissioner Lewis reasonably suggests that students can ill-afford to miss even one day of school when avoidable. How can one disagree? I would ask, however, what would be the response of the public if Commissioner Lewis asked for the names and the medical records of students who skipped school in order to protest for the need of gun control following the aftermath of school shootings here in Kentucky and elsewhere? I am confident that our public would be outraged! We should be outraged today. Teachers did not make the decision to travel to Frankfurt lightly. They deserve public support– indeed public protection against what is in my opinion, and that of others, an attempt to bully teachers into submission.

Peter Hasselbacher, MD
Louisville, KY
March 25, 2019

Kentucky’s Hepatitis-A Epidemic: Could We Have Done Better?

A society is only as healthy as the sickest individual within it.

Summary:
Kentucky is in the middle of, and hopefully emerging from a major epidemic of Viral Hepatitis-A (Hep-A).  Hepatitis-B and Hepatitis-C, are caused by different viruses and commonly result in more serious chronic liver disease.  Classically, the spread of Hep-A is attributed to contamination and ingestion of food or water by the feces of infected persons or related poor hygiene practices.  Nonetheless, illicit drug use appears to be the major risk factor  in Kentucky’s current outbreak.  Hep-A is rarely fatal to otherwise healthy people but can cause debilitating symptoms. It can be fatal however, especially to individuals with preexisting liver disease such as alcoholic hepatitis or other forms of viral hepatitis. It is not clear when the first cases of the current outbreak began to emerge, but in the 21 months between Aug 1, 2017 and Feb 23, 2019; some 4229 presumed or suspected cases of Hep-A have been reported, including 2036 hospitalizations and 43 deaths. This can be compared to only 9 reported cases in all of 2016! Our current outbreak is the most severe in the nation. Concern has been expressed that, compared to the aggressive and successful response by the Board of Health of Jefferson County, that the best advice from experienced state public health experts within Kentucky’s Public Health Department in Frankfort was ignored allowing the statewide epidemic to expand and be prolonged. My independent analysis of available data supports this criticism. In my opinion, the appointment of an inexperienced public health commissioner by the Bevin administration– probably for political and ideological reasons– likely played a significant role in what occurred. Kentucky remains in the middle of upsurges of Hepatitis B and C. All three varieties of viral hepatitis have roots in poverty, substance abuse, exclusion from healthcare systems, despair, and other non-medical fellow-travelers that will be difficult to fix. It is therefore important that the current responses to the Hepatitis-A epidemic be independently reviewed so that we may be better prepared for the next time– which will surely come. Continue reading “Kentucky’s Hepatitis-A Epidemic: Could We Have Done Better?”

Mandatory Posting of Hospital Charges: Rest In Peace.

I thought that before I signed the death certificate of the Posting Standard Charges Project, that I would place a mirror beneath its nostrils just to make sure it was ready to put in the ground. I was planning to add this confirmatory step as an addendum or comment to my first article, but it was clear that additional details and discussion would be necessary. My first pronouncement was based on a bedside-look at the several chargemaster databases. What did the local hospitals choose to disclose; what must they have intentionally omitted; how easy was it to find anything; and was the information useful to compare different hospitals? I did not even have to feel for a pulse to know the answers. Out of fairness and a desire not to bury the patient alive (but with certainty that my initial diagnosis was correct) I applied a more definitive diagnostic test that might been a valid real-world trial for me had these posted standard charges been available last Fall.

As I pulled away from my cardiac pit stop at Rhode Island Hospital, it was suggested I schedule a cardiac echo stress test back home to evaluate the size and function of my heart. Using all of my wisdom and experience as a physician and Professor, I did what everybody else does– find a cardiologist who would see me as a new patient and do what they suggest! The stress test was normal. I could not have hoped for a better result nor more competent and attentive care. The question for our present exercise is: If posted standard charges were available– and I had time to look at them– what I have found? [Spoiler alert! The effort would have been a waste of time, if not misleading.] Continue reading “Mandatory Posting of Hospital Charges: Rest In Peace.”

Federally Mandated Postings of Standard Charges by Louisville Hospitals Are Unusable for Their Intended Purpose.

(But will reveal the the unacceptable and unjust absurdity of how we pay for medical services.)

Reporter Gilbert Corsey of WDRB was, to my knowledge, first on the block locally to take public look at the implementation of a newly enforced federal law requiring hospitals to publish their Standard Charges online. Originally part of the Affordable Care Act (a.k.a. Obamacared) as turned into regulation last year,, the stated purpose was to allow the public to compare the cost of services and choose wisely among hospitals before they incur responsibility for payment. An overlying expectation (?dream) was to improve quality and decrease costs. Hospitals bitterly protested implementation of this law.

Mr. Corsey’s reporting verified the expectation that charges amoung neighboring hospitals can vary greatly. For example, an uncomplicated birth at one Louisville hospital was priced twice as high as another, and an injection of a drug used for prostatic cancer varied threefold. Corsey’s report also concluded that the published lists are confusing and difficult to decipher. I agree. I will go further and argue these lists are essentially worthless for their intended consumer purpose – surely knowingly so. Their value however for unintentionally making the policy point that, like pricing for pharmaceuticals, hospital pricing and billing exists in a logic-free, Alice-in Wonderland zone to the detriment of the public. Allow me to explain. Continue reading “Federally Mandated Postings of Standard Charges by Louisville Hospitals Are Unusable for Their Intended Purpose.”

UofL and KentuckyOne Agree to Extend Their Academic Affiliation Agreement Another Four Months.

Barely within the statutory requirement for a response to an open records request, I received two critical pieces of the new contractual agreements between the University of Louisville and KentuckyOne Health that extend the current terms of their Academic Affiliation Agreement (AAA) and Master Support and Services Agreement (MSSA). These documents define the conditions and financial arrangements between the institutions for another four months with an option for automatic renewals. The extensions give some breathing room to the organizations currently working behind the scenes to determine the future of KentuckyOne’s operations in Louisville and simultaneously protect the ability of UofL to place students and trainees at Jewish Hospital and Fraser Rehabilitation Institute while simultaneously allowing Jewish Hospital (and Sts. Mary & Elizabeth) to maintain their status as a teaching hospital for Medicare purposes.

The AAA extends the financial obligations of KentuckyOne to the University until April 30, 2019 at the existing prorated monthly amount of $1.98 million for a total of an additional $7.92 million. This is a blessing for financially strapped UofL. The attachments to the agreements that I requested were not provided leaving me to assume that the intended ultimate beneficiaries of the continuing financial support remain unchanged. (Previous versions of Attachment-C contain a lot of personnel details so I will not to post a copy here.)

The two agreements referenced above are interlocking and these second amendments reinforce their connection.  Specifically, item 3 of the AAA notes that its Exhibit C is amended by adding the “Second Amendment to Master Support and Services Agreement.”  Linking the documents together makes sense, but I am not exactly sure what that looks like in final print, and I do not understand the reasons for changes in term-lengths of the Agreements.  The major clause in the new MSSA allows the agreements to automatically renew for periods of 10 months (up from the previous 6 months of potential auto-renewal) further deferring any last-minute anxiety for the concerned!  (There are several versions of earlier AAAs in circulation. The new language appears to amend Section 8.1 of the previous first amendment to the AAA by deleting and replacing its second sentence. In the original version of the AAA available to me, Section 8.1 contains only a single sentence! Any confusion is probably only mine and I will clarify later for this record if I can.)

Final Comment.
The extension of the agreements was, as I argue previously, critically important for the integrity of the two institutions. Obligations to students, trainees, and patients alone are manifestly inviolable. I commend KentuckyOne for shouldering its responsibility which will certainly present challenges. Its parent organization, Catholic Health Initiatives (CHI), has been under financial stress for some time and which I suspect has complicated its intended merger with Dignity Health anticipated at the end of this month. The long-sought goal of CHI to sell QualChoise, its poorly performing health insurance division, was recently announced and which may give the corporation some temporary room to maneuver financially.

As desirable as the extensions to the current Agreements are, the can is only being kicked further down the road. I have no information or prediction of what is yet to come. It is not clear that Blue Mountain Capital is currently the only party negotiating with KentuckyOne to buy its Louisville hospitals, or to what extent UofL will succeed in finding the money or a partner to take over (and at what non-financial cost).  We are still wandering in the dark woods without even a trail of breadcrumbs to follow. Not all fairytales end well for their protagonists.

Peter Hasselbacher, MD
Emeritus Professor of Medicine
President, KHPI
January 8, 2019

What Will Louisville’s Medical Landscape Look Like in 2019?

Isn’t it about time that the curtain is raised a little?

As we enter the new year, many anxious folks in Louisville are waiting to learn about the status of a proposed sale of KentuckyOne Health’s Louisville assets, and what that will mean to the University of Louisville and its Health Sciences Center. The University and KentuckyOne had an existing, multiply-extended, Academic Affiliation Agreement that would have expired December 31, 2018. This critically important document and related agreements defined the financial, administrative, educational, and clinical relationships between Jewish Hospital and the University. A valid Affiliation Agreement is essential for Jewish Hospital for Jewish and Sts. Mary & Elizabeth Hospitals to claim the financial bonuses and other advantages of a Medicare teaching hospital. An Academic Affiliation Agreement is equally important for the accreditation of the Medical School if it wishes to continue to train students and residents in Jewish Hospital or document that it has adequate clinical teaching facilities for its family practice and all its specialty programs. These are no small details. Continue reading “What Will Louisville’s Medical Landscape Look Like in 2019?”

University of Kentucky Dental Professor Forced Off Faculty for Criticizing Gov. Bevin’s Medicaid Cuts Gets $620,000 in Court Settlement.

Yes.  But, behind them I suspect is the Emperor.
                                            Paul Atreides, in “Dune.”

More than a year ago I wrote about the capture of the academic process by the Kentucky Governor’s Office where some unnamed individual with clout became “pissed-off” when Dental Professor Dr. Raynor Mullins exercised both his faculty and first-amendment rights to suggest that cutting back on dental and vision services to Medicaid beneficiaries was a bad idea. Everyone involved seemed to know who in Frankfort held the power to intimidate the leadership of our “Flagship University,” but the Governor’s office denied any involvement in the matter.  (We have encountered that scenario before, right here in River City!)  The University rolled over and dismissed Dr. Mullins.

In response, and to both hold the University accountable and presumably to shine a bright light on what actually appended, Dr. Mullins filed a lawsuit against the persons of the Vice President for Administrative and External Affairs and the Dean of the University of Kentucky College of Dentistry.  In my earlier commentary, I opined that perhaps under oath that the truthfulness of the allegations would come out– or not!  It is not clear to me that any such disclosure happened. The University requested of Federal Judge Robert Wier a summary judgement (dismissal) of the case against it which was denied.  As I understand it, before the case was to go to a jury trial, a private settlement was reached without any admission of guilt.  I do not know how much pre-trial discovery was done. Today’s reports in the Lexington Herald and Courier-Journal do not refer to any information from depositions taken under oath.  Often such settlements include clauses of confidentiality that hide embarrassing findings from public view. Is it conceivable that court records might be sealed?  Is it possible that we may never know to whom the UK officials caved?

What is just as disturbing as not ever knowing the identity of the bully is the claim that communication within the University and with the Governor’s office in this matter was conducted using personal e-mails.  The use of personal electronic devises and emails to skirt open-meeting and open-record laws is an emerging threat to the ability of the public to hold its government accountable.

The University of Kentucky does not come off looking good in this matter.  It seemingly admits no guilt at all, but some UK entity now has a 6-figure settlement to pay with legal fees to boot. Dr. Mullins is taken back in to the faculty. Transparency disappears. No one is held accountable. Dr. Mullins may not have achieved all his goals, but in my view, he stood up to the state agency that is the University of Kentucky and won!

Peter Hasselbacher, MD
Emeritus Professor of Medicine,
University of Louisville
Dec 10, 2018

[If anyone has public court documents or other information that might shed light on this sad affair– or for that matter correct any misunderstanding of mine– I hope they will communicate with me confidentially or with the email link found in the side-bar of this website.]

Here is a copy of Judge Wier’s opinion of 9-28-18

Another St. Joseph- London Cardiologist Is Sentenced to Prison.

Could this have been averted early on before this unfortunate result?

Last week, following his conviction last April for medical billing-fraud related to medically unnecessary placement of cardiac pacemakers, Dr. Anis Chalhoub was sentenced to 42 months in prison; required to pay $257,515 restitution to Medicare, Medicaid, and private insurers; and fined an additional $50,000.  Dr. Chaloub’s attorneys had requested a shorter time in prison and perhaps it is possible they will appeal the sentence.

According to the press release from the U.S. Attorney’s Office, an additional term in the sentence was that following release from prison he will remain on probation for a three-year period during which the “court has prohibited him from practicing cardiology during that time.”  I am puzzled about whether a federal court has superior jurisdiction over Kentucky’s Medical Licensure Board for such a restriction on licensure.  If I were the Kentucky Board, I would be embarrassed or angry, or both.  Out of curiosity, I looked today at the Kentucky Board’s website which informs me and potential patients that Dr. Chalhoub still has an active Kentucky medical license with “no actions” or restrictions mentioned. (I confirmed this with a call to the Board.)  Although several physician-referral & rating websites have him affiliated with hospitals in Lousiville and Indiana, I do not know if he is still practicing medicine. Continue reading “Another St. Joseph- London Cardiologist Is Sentenced to Prison.”

Can Jewish Hospital in Louisville be Saved? Perhaps Not.

If not, what then?

Surely the end-game of the years-long efforts of Catholic Health Initiatives and KentuckyOne Health to sell some or all of their hospitals in Louisville must be coming to a climax. Transferring management of University of Louisville Hospital to KentuckyOne– a move that turned out badly for both institutions– was always as much or more about saving Jewish than ULH.  Many outside entities came to kick the tires of what KentuckyOne wanted to sell but walked off the lot.  The last acknowledged potential buyer whose keys KentuckyOne was holding was the tag-team of the private equity firm Blue Mountain and its spinoff for-profit hospital management company, Integrity Healthcare– now majority-owned by for-profit Nantworks Companies and Nantworks owner Dr. Patrick Soon-Shiong.  Sound complicated?  It is!  Casting a very dark curtain over this potential transaction in Louisville is last week’s announcement that Blue Mountain & Co.’s first and only attempt to take over a failing non-profit Catholic hospital chain in California has failed– the hospital system has filed for bankruptcy. These six Verity Hospitals (formerly the Daughters of Charity) might be bought by their communities, taken over by others, liquidated for their assets, or otherwise close.  I cannot avoid concluding that the same result would occur in Louisville and for much the same reasons.

CHI has played this one very close to its corporate chest. Fanned by anxiety about the future, rumors have been flying in increasingly disparate and desperate directions ranging from “Blue Mountain” has taken a second look and will sign on soon; or Blue Mountain has walked away for good; or that Nantworks and Dr. Soon-Shiong will move forward with the deal without Blue Mountain; or that CHI will give Jewish to the University for a song; and even that one or both of the sister Jewish & Sts. Mary Hospitals will soon shut its doors.  None of the potential players is in a strong place right now as I will outline below.  The one thing I am sure of is that the ground under the downtown hospital complex is going to quake hard, and that secondary seismic activity will be felt out in the county and beyond.  The Louisville Community is going to have to make some public health decisions that are both difficult and expensive. Continue reading “Can Jewish Hospital in Louisville be Saved? Perhaps Not.”