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?”
On the way to my gym on Shelbyville Rd., I noticed a billboard advertising Baptist Health’s cardiology service. It advises me that “some of the best cardiologists around don’t practice downtown.” This, of course, is true. The ad is an obvious riposte to some of the advertisements of downtown hospitals, one of which advised that for your best chance of surviving a heart attack, you should take the next exit. If corporations are people, it is now getting personal!
It’s hard not to notice that our area hospitals advertise their cardiac services heavily. Each one is said be the better for you, and amazingly, many can produce reports from external review organizations appearing to back up their assertions. What is distinctly lacking, in my opinion, is objective evidence in the promotional material to support claims of excellence. For most of the Fall and Spring of 2008-09, I drove several times a week past the sign (and the exit) on Interstate 65 that promised my best chance of surviving a heart attack. I wondered on what basis the hospital could make such a claim. When I learned that Medicare’s Hospital Compare was then calculating risk-adjusted mortality following heart attack, I had to check it out. In fact, not only did the advertising hospital not have the best survival rate in the city, it had the lowest. Nevertheless, the sign stayed up for many months. Today the mortality rates have evened out, but is all such advertising so much puffery? How are we to know?
Why are cardiology patients fought over?
It is not a state secret why cardiology, cancer, orthopedics, or neurosurgery are advertised so heavily by hospitals. These are among hospitals’ most profitable services. My former hospital lobbyist colleagues were quite open in admitting that cardiology services are overpaid by Medicare and other insurance companies. According to the bank robber Willie Sutton’s law of medicine, that’s where the money is. I will say more about this in another post because an absence of profitable services is relevant to the financial difficulties of Louisville’s University Hospital. In my opinion, the other downtown hospitals have helped to keep University Hospital in its place.
The Baptist billboard is clever, and reminds me of the series of billboard ads for hotdogs and whiskey also containing witty one-liners that we all chuckle at. I would not be surprised if the same advertising agency was responsible for some of the medical ads as well. That is, a very depressing thought however. At a time when food and dietary supplements are marketed as though they were medicines, medicine is marketed as though it was soap powder. Are we really that gullible or so easy to manipulate? I have already told you how I feel about the quality and ethics of some of these advertising campaigns. If you believe everything you see and hear, you will be badly served. Continue reading “The Cardiac Gloves Come Off!”
No one who has corresponded with me believes that the University has given up its quest to be acquired by Catholic Health Initiatives. The Chairman of the Hospital’s Board of Trustees pointedly refused to answer a direct question on the matter. One correspondent at Jewish Hospital believes the institution is treading water until the University can jump in the pool. I have already commented on what I believe is the University’s strategy to present the governor with an offer he cannot refuse. Indeed, I am hearing secondhand that President Ramsey is telling supporters he will push this thing through. It certainly seems as though that is true. (If you have first-hand knowledge, I would love to hear from you.)
Today, reporters Chris Kenning and Patrick Howington tell us about yesterday’s closed session of the Trustees of the University of Louisville giving its medical center permission to issue a request for proposals to seek a new partner. (I thought closed sessions weren’t allowed for this sort of thing? So much for transparency.) Recall that failure to follow state procurement rules was one of many criticisms of the Attorney General’s Office supporting the rejection of the first merger effort. The University appears to be doing some backfill work. I have not yet seen this RFP, but University officials are quoted as saying they are seeking a “health care entity with a statewide network and capital resources to help maintain the hospital teaching and indigent care missions.” It seems to me this will be very short list. I will not be surprised that the RFP is written so narrowly that there is only one entity on earth that will fit the bill. (That is what some unethical employers do when they want to hire a particular person but yet be seen as following the procedures of affirmative action employment.) No doubt I will be proven wrong and will apologize for expressing an erroneous opinion. In fact, it just occurred to me that I am dead wrong. The University of Kentucky with its statewide presence and deep well of state support could easily be an eligible entity. The more I think of it, the better the idea seems! Brilliant!! (Of course there are also the Baptist and Norton systems.)
KentuckyOne Health told its physicians today that it has been aware (was anyone else?) of the process and believes that a “close working relationship with the University of Louisville School of Medicine and University Medical Center is important to our vision as an organization.” In fact they seem downright eager to respond to an RFP.
Shame on the University of Louisville for dragging its community through this monkey business all over again. Arrogance is a descriptor that comes to mind. Of course, if you know you will ultimately get your way, how you appear is of less consequence. There are many in our community who want to help the University and to protect our public hospital. The University is making it difficult for us to do so.
One doesn’t ask of one who suffers: What is your country and what is your religion? One merely says, you suffer, That is enough for me. You belong to me and I shall help you. Attributed to Louis Pasteur.
The Commonwealth of Kentucky once required hospitals and doctor’s offices to post the prices of their top 20 services. This was fair– hospitals were asking their patients how they expected to pay. The policy concept of disclosure was and is reasonable, but the results were embarrassing, unused, and perhaps not even helpful. Under pressure, the Commonwealth repealed the law after two years.
I suggest we would all feel better (and probably even be better) if we would post the above thesis instead. Why don’t we? Most or all of the doctors with whom I went to medical school would have echoed Pasteur at the time. I suspect most hospital administrators and their corporate boards also wish they could post Pasteur’s profession on their front doors. After all, the earliest hospitals were established almost entirely to serve the poor. The non-profit status of today’s hospitals stems from those charitable roots. The sad fact is that in our system, no single physician or hospital could stay in business if they actually tried to serve all who showed up on their doorstep. It takes a community effort. In Louisville, talk of indigent care usually focusses on University Hospital. Why is that, and should it?
Fitness of University Hospital to serve the poor.
Earlier this month, and under the sword of an examination by the State Auditor’s Office, the University of Louisville announced that it would review its hospital operations to address questions of the strengths and vulnerabilities that were raised during the debate over their proposed merger/acquisition by Catholic Health Initiatives. They will retain an outside consultant of their choosing and have named a 9 person review committee. We are told that the review will consider how University Hospital compares to other academic hospitals financially and in the amount of “indigent care” provided. The University obviously still has a partnership on its mind, but declined to answer a direct question of whether it had resumed discussions with the new KentuckyOne Health entity. [Of course it has!]
I credit the University folks for opening the planned meetings to the public, but it looks to me that they want to control what is discussed just as tightly as they did when they rolled out their campaign for last Fall’s failed merger. Faced with a truly independent outside audit, and still embroiled in the courts over their withholding of court-ordered documents, some damage control might be judged imperative. It is axiomatic in matters such as these, that if you can select the issues and define the vocabulary of the debate, you have won before you even start. The University wants this discussion to be about how many medically indigent patients they serve, and to convince us that all that is needed is more money from the state or elsewhere. One strategy that I see evolving, seeks to give the Governor and Attorney General’s offices the political cover needed to reverse their previous rejection of the CHI acquisition. The University leadership has (1.) already demanded more money than they know the Commonwealth can provide, (2.) will claim that only more money will solve the problem, and then (3.) present once again a deal they still hope to make with Jewish Hospital and CHI, (now KentuckyHealth One). This would be an incomplete victory. Continue reading “University of Louisville’s Review of Its Hospital Operations.”
While looking in today’s paper for inspiration for something to write about, I saw an advertisement claiming that the “Arthritis Pain Mystery” had been solved, and that the secret was “Horse Liniment.” Naturally there was something you can buy. The only corporate identification or images in the ad were the prominent trademarks of both Walgreens and RiteAid. I know something about arthritis, and I initially assumed that these two giant drugstore competitors had joined forces to bring this breakthrough to the public. At first it looked to me like the drugstores had placed the ad themselves.
Actually, the truth is that this advertisement caught my eye because is was one of a long series by many companies that make what is in my professional opinion overly sensational, misleading, and unsupported claims to be effective treatments for arthritis and other musculoskeletal ailments. I have always had to look hard and usually unsuccessfully for the grain of truth in these kinds of ads that might make them legal. No doubt the promoters of ARTH ARREST, “considered a medical miracle by some” had their ad reviewed by lawyers. It may well have passed such muster, but in my professional opinion, it fails the sniff test of ethical medical promotion. Any ad with the word “miracle” or which relys on anecdotal testimonials should wave a red flag. Even the big pharmaceutical companies do not make such claims, and they are not my ethical champions. When I read closer, I saw that the drugs were simply available at Walgreens and RiteAid. Both companies were apparently merely lending their good names to the promotion. Continue reading “Horse Liniment for Your Arthritis and Healthcare Reform.”
A week ago I was pretty tough on a possibly hypothetical physician who was said at a Frankfort hearing to have abandoned two child patients because one of the three new Kentucky Medicaid Managed care vendors had not paid him for three months. What is not hypothetical is that the Medicaid system is now in shambles. There are now four independent Medicaid managed care systems in Kentucky plus original Medicaid itself to deal with. Each of these has its own bureaucracy and unique systems. Thats a lot of different hoops for physicians and other healthcare providers to jump through. I have no doubt all are pulling their hair out. By all accounts, all three new vendors are in the pay-slow, pay-low mode. Cynics will point out that this is an easy way for an insurer to make a profit. After all, even Kentucky government uses the gimmick of paying healthcare providers late as a way to balance the books and make it look like they have actually been doing their jobs.
It is easy to assume that the three new managed care companies are to blame. That does not easily explain why all three seem to have failed at the same time, or why they appear successful in other states in which they work. When I worked in Kentucky Medicaid in the 1990s during my first-ever sabbatical and later as a faculty fellow, it was clear to me that there were major inadequacies in the state’s Medicaid computer systems and their ability to transfer and analyze information. I hope things have improved since then. Remember that all information about eligible beneficiaries, hospitals, and other providers has to be transferred to the managed care companies and continually updated so they know who to pay and for what. The three vendors have been silent publicly, but I will bet a martini in your favorite Louisville bar that internally they are struggling to interface with the state’s system. When you consider that each hospital and doctor’s office may also have their own computer system, it is no surprise that Kentucky Medicaid is staggering under its own weight and complexity. I hope we can pull out of this death spiral of cost and confusion. I still expect the state and providers to hold patients harmless, but that cannot continue infinitely. What a mess! Continue reading “Kentucky Medicaid is a Mess.”
A few weeks ago, following the collapse of the attempted merger/acquisition of University of Louisville Hospital by private interests, a respected member or the community asked me how we had arrived at a point where the advocates of the takeover failed so miserably to understand the critical issues of concern to the public. I attempted an explanation, but there is no simple answer to this complex issue. Here is the reply I offered. Continue reading “Is the University of Louisville Moving in the Right Direction or Not?”
Yesterday, Phil Galewitz reported for Kaiser Health News (reprinted in USA Today) on a practice that is one of my biggest disappointments in our health care system, the sale of our personal health information for the benefit of someone else. I do not mean the use of de-identified medical information to improve public health, medical quality, enhancement our ability to treat disease, or even for law enforcement. I am talking about the use of your individual health information to try to sell you something else that you may or not need. Did you ever wonder why all of a sudden you started getting ads for diabetes supplies? Or why ads for erectile dysfunction started arriving in your mailbox as well as your email? It is because your personally identifiable medical information is being shared to improve the bottom lines of those who have access to your medical records. The story highlighted the practices of hospitals that use information from their medical records to peddle other services to their current or former patients Partnering with mass marketing companies, your hospital knows a lot more about you than is present in their records. For example, if you smoke, you get a directed ad for lung cancer screening. Believe me, when you come in for a “screening,” something can almost always be found that ”needs” to be done. Screening can be a hospital’s or doctor’s best friend. It all depends on how ethical or financially strapped the provider is that determines how far evidence-based scientific medical practice will be stretched. Examples of abuse are easy to find. Continue reading “Loss of Medical Privacy? Is that OK?”
I have been trying to find the time to branch out to other topics on this policy blog, but material related to issues of the recently failed merger/acquisition of University of Louisville Hospital by Catholic Health Initiatives keeps rolling in. Yesterday it was reporting by Peter Smith in the Courier-Journal on local Catholic Archbishop Joseph Kurtz’s tough talk about the new federal law requiring employers offering health insurance to cover birth control pills, morning-after pills, and certain other basic necessary health services related to reproductive and womens’ health. The Catholic Church equates contraception to murder, although even the large majority of American Catholics and most of the rest of us do not agree.
The coverage requirements do not apply to churches or other purely religious communities such as convents, although presumably some (but not all) of the covered services would not be missed in such institutions. The new law only extends to entities such as hospitals and universities in the public marketplace that would hire non-Catholic employees.
Bishop Kurtz complains that, “People of faith cannot be made second-class citizens,” and that his religious ancestors did not come to these shores “only to have their posterity stripped of their God-given rights.” He complains further that the new law “has cast aside the first amendment … denying to Catholics our nation’s first and most fundamental freedom, that of religious liberty.” The Bishop apparently fails to see any irony that by forcing employees or patients in hospitals like University Hospital to follow his religious dogma, that he is guilty of violating the freedoms of others, god-given or otherwise! Reverend Simmons, a minister and teacher of medical ethics in of Louisville says it better, “that the only freedom being cast aside is the “liberty to enforce their opinions on others.” Continue reading “Archbishop Fights Health Plan Policy.”