University Medical Center Inc., Ad Hoc Operations Review Committee Meets.

Background of Internal University Review.

Last January, the University of Louisville announced that it was forming its own Internal Review Committee for University Hospital. In large measure, this must have been in reaction to the increasing calls for an audit of the Hospital’s use of the QCCT fund for indigent medical care. Indeed, the Auditor of State Accounts had already announced he would perform such an audit. Surely the University and its Hospital must already know a great deal about its own finances. After all, having a handle on internal finances is part of the job of running a hospital. Furthermore, for several years the University had been preparing for a merger/acquisition for which both internal and external reviews by the potential partners would have been mandatory as part of due diligence. University leadership admits it knows enough about the Hospital’s finances to submit an RFP to take on a new partner. Nonetheless, there is nothing wrong with taking a fresh look at the way any business is being run. Good for them!

This new committee did not emerge in a vacuum however. The University is emerging from a period of intense criticism of the way it interacts with its community– indeed that criticism continues. In my opinion the committee’s formation at this time is also part of an intensive and comprehensive public relations effort to improve or at least paper over its image. I believe this is a major reason why the offer was made that the review committee’s meetings would be open to the public. That is a major reversal of the tactics used by the University when it tried to merge with Catholic Health Initiatives and Jewish Hospital/St. Mary’s. In those proceedings, the University attempted to operate in secrecy until the last minute when it was forced to reveal at least part of its plans. The community did not like those plans. We now have an opportunity to see if the University and its leadership have changed their spots. This jury of one is still out.

Summary of the first meeting continued below. Continue reading “University Medical Center Inc., Ad Hoc Operations Review Committee Meets.”

UofL and UMC File an RFP for a New Hospital Partner

The University of Louisville and University Medical Center Inc. seek a knight in shining armor to bail them out.

“Investing in and delivering healthcare services, education and research in conjunction with the University of Louisville and University Medical Center.”

The University of Louisville and University Medical Center, Inc. have jointly filed an RFP “to seek a business partner that will bring capabilities, experience, and commitment to include but not limited to: Critical Care, Facilities/Operations, Teaching/ Training and Research.

The following represents my initial thoughts as I read through the request for proposal (RFP) and the attached current Affiliation Agreement by which UMC operates University Hospital for the Commonwealth and the University. I apologize for typos and bad grammar. I am trading off timeliness for polish. I will attempt to clean it up in the days ahead. Because the timeline chosen by UMC and the University is deliberately and unduly brief, I would rather have something out there to work from then nothing at all.

Executive Summary
By way of an executive summary of my initial thoughts, shaped as they are by other recent events in our community, I offer the following.

The qualifications and criteria for judging responses to this RFP parallel exactly the justifications and solutions advanced at the time of the recently failed acquisition of University Hospital by Catholic Health Initiatives. I am having the feeling of déjà vu all over again. The extraordinarily short timeframe of action, together with the severely constricted avenues by which an external agency can gather information are not compatible with the due diligence that should be required of any third party not already intimately involved in the operation of the downtown medical center. The criteria for processing applications described in the RFP gives the University and UMC great leeway in whom they might select or refuse to consider. I cannot in my own mind come to any other conclusion than that this RFP was written solely with a single applicant in mind who has already signaled interest in close affiliation with University Hospital and with whom the structure of agreements has already been agreed. I cannot force the word, “sham,” from my thoughts. What a shame. I will be glad to be proven wrong.

The RFP process does not permit any public disclosure until after an agreement is signed. There is no recognition that any acceptance by the Commonwealth of Kentucky is required. The University of Louisville and UMC appear to have ignored any lessons they might have learned from the fiasco of last fall and winter. This community demanded the right to know what decisions were being made about their healthcare and by whom.

The rush to conclusion seems incongruous with the magnitude of the undertaking. I cannot personally ignore the conclusion that the haste is intended to allow documents to be signed before the Kentucky Appeals court has ruled on the issue of whether University Medical Inc. is a private entity free to do as it pleases, or whether it is an arm of the University and of the Commonwealth. What rational corporation would take on the responsibilities of this RFP without such determination made and finalized?

Many numbers are thrown out but fewer definitions and even fewer comparative data. An attempt is being made to compare our situation here in Louisville with other Academic centers around the country. This is justifiable and worthwhile, but cannot alone determine the direction our community should take. The current consultants to UMC have stressed that every medical center is different. We want ours to be different to. We want it to be better.

All the comments in this brief represent my personal opinions but I would like to think they are informed opinions. There is no one in Louisville more committed than I to the long-term survival of University Hospital as an ethical and excellent teaching facility, and for a healthcare support system for the underserved that is characterized by quality, dignity, and justice.

In my mind, the least positive implication of this rush to conclude a deal is that we will memorialize in stone for yet another generation, a segregated and second-class system of healthcare for those who do not qualify for mainstream medical services. The comments below are not mine, but I could not have expressed them better. A respected authority describes the system we have now in Louisville.

“If someone decides there are some hospitals in Louisville whose job it is to take care of the poor black and the marginalized and that it’s okay if they have to be kept waiting for a couple of weeks and it’s okay if the carpet is frayed, it’s okay if the phones don’t get answered, and it’s okay if the doctor is late, but there are other hospitals in Louisville where upper-class white people get taken care of by doctors who answer the phone on the first ring and smile a lot. There’s shag carpeting, and wood wainscoting on the wall. Was there a plebiscite … in Louisville where people voted and said they wanted to have segregated medical care? I don’t think so. But, there is a very strong theme that it’s okay for medical students and interns and residents to learn on poor people, but when you’re done, then you’ll be able to take care of private patients.”

Edward C. Halperin, MD
From: “Slave Medicine and the Banality of Evil.”
Gheens Foundation Lectureship,
University of Louisville School of Medicine, Feb 2, 2012

To participate in the above system of contemporary segregation is to participate in an evil.  I think it is time for a plebiscite in Louisville, and I trust that our citizens to favor a different set of priorities. Those decisions must not be made behind closed doors by a self-selected privileged few. The leadership of our University and our health care systems need to hear from all of us.

Peter Hasselbacher, MD

Analysis of RFP continued below. Continue reading “UofL and UMC File an RFP for a New Hospital Partner”

Kentucky Medicaid Still a Mess: Month 4

Primum non noccre.  First do no harm.

Attributed to Hippocrates, the above aphorism is often cited in discussions of medical ethics.  The fact is that it is impossible to practice medicine without causing some harm.  Nothing from taking a medical history to administering chemotherapy and everything in between is free of potential harm.  As in life, few things are simple and a ballance of risk and benefit is always made.  The aphorism should be rewritten as:

Primum minimus noccre.  First do the least harm.

I no longer see patients and have no first-hand experience with the new state-wide Medicaid Managed Care systems.  I can however still read, and it is clear that things are not going very well, at least if the testimony at Frankfort hearings is generalizable.  Some of the reports sound just plain awful.  I cannot conceive that a stable epileptic would have medicines dolled out two weeks at a time.  Is there a copay involved that would also double?

Managed care companies are charged with weeding out the unnecessary or poor quality medical care that physicians and other providers are unable or unwilling to tackle themselves.  I acknowledge and even applaud those efforts. Active managed care however is very difficult to do and requires cooperation from both patients and providers– cooperation that has never been in abundance.  As a result, managed care companies have evolved to depend more on things like preauthorizations, copays, formularies, and restricted payments.  Cynics will call this rationing by inconvenience.  Modern insurers are certainly practicing medicine in the sense that they are determining treatments or withholding them.  (Sometime they practice better than free-range doctors.)  All this micromanagement might trim medical expenditures, but it also increases overhead costs to both the insurer and the providers.  Where is the balance point?   If needed services are delayed, then the cost will be more than just in dollars.  I honestly do not know how much is really saved by managed care as it currently is practiced.  Perhaps not much at all.  It has never been shown to me that Passport (which provided good care) ever saved the state money.

What to do now?

I do not believe things will be sorted out quickly.  Not only are the systems all new to the state and providers, but also to patients who do not know what to expect.  An attempt to apply the full bore of managed care protocols that might have worked elsewhere to a new population was probably doomed to failure here, at least I think so.  What the state needs to do now is to signal the three new Medicaid companies to back off a little and apply their controls in a more gradual manner.  This will require that some money be allowed to flow into the system.  Don’t waste time trying to adjudicate bills from last November or you will never catch up.   The overbearing principal here is that sick people should be protected.  This will hurt the bottom lines of doctors, hospitals, pharmacies, insurance companies, and the state treasury.  This was never going to be easy or cheap. Real reforms are not going to me made by requiring long phone calls between doctor’s offices and drugstores to authorize prescriptions.  Effective reforms must be made in the entire medical marketplace, and not just in the market of the most vulnerable.  Bite the bullet and make a nationwide medical system that is a coherent whole, not one in which some benefit at the expense of others.   Any Medicaid problem will then melt away.  This will take more political courage and true professionalism than we have been able to manage up to now.  I am not optimistic.  In the meantime, do less harm.

Medicus quidem faciendum malum.

Peter Hasselbacher
Feb 24, 2012

How does UofL hospital compare to other hospitals?

Let’s look at some numbers.

The University of Louisville is going to try and make a case that it has unique requirements that will require additional non-patient revenue to fix. Specifically, they are asking for more state money, or alternatively, permission to partner with an outside business entity that is willing to give them more money. The claim will be made they are caring for a disproportionate share of nonpaying patients, and do not have enough profitable patients to subsidize the losses the way other hospitals do. This is a reasonable argument to make but it is an incomplete one. The University’s problem will not be fixed by money alone. There are a host of other issues that must be addressed simultaneously. I have begun to discuss these elsewhere.

There are 3502 acute care hospitals that participate in the Medicare program. Of these, 1047 are teaching hospitals, and 601 are large urban teaching hospitals like the University of Louisville Hospital. It would be easy for the University or its consultants to pick and choose hospitals to compare with that would bolster its case. Picking your own benchmarks is one way to make yourself look good, or in this case bad. Much of the University’s credibility will hinge on the choice of comparable institutions. Fortunately, there is an ocean of comparative data available that I believe helps put things in perspective and can provide a starting point for a broad-based study of our medical school and its principal teaching hospital. I will try to present such information on the Institute’s website. Such analysis often challenges popular wisdom.

For example, teaching hospitals get billions of dollars of special funding from Medicare (and Medicaid) solely because they have medical residents on their wards. These Direct and Indirect payments for Graduate Medical Education (interns and residents) increased substantially over the years as a result of effective lobbying. It was argued from the start that teaching hospitals deserve more money because they have extra expenses related to faculty salary, inefficiencies of care, and for other reasons that may or may not be relevant today. Federal analysts estimate that Medicare pays teaching hospitals twice as much for graduate medical education than the actual cost of those programs to the hospitals. Not to be denied, the teaching hospital lobby continues to argue that they are entitled to the extra money because of their disproportionate service to the poor. Is it in fact true that teaching hospitals take care of more of the poor than non-teaching hospitals? I was frankly surprised when my first attempt to find out showed that in fact, the proposition does not appear to be true. Continue reading “How does UofL hospital compare to other hospitals?”