University of Louisville’s Review of Its Hospital Operations.

And Who Will Take Care of the Poor?

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 Under pressure, the Commonwealth repealed the law after two years.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.

Narrow review not enough.

What we need is a game changer, a discussion much broader than counting indigent heads and state dollars. That is not likely to happen in the University’s review because the University will probably want to define this problem simply as not enough state money. The public deserves to hear about what it has done with the mega-millions the University has already received and how it was spent.  Why should hard-to-come-by clinical money be going to the University for research, for rent, and for who knows what else? Where does the $180 million clinical dollars going to the University’s Research Foundation come from and how is it used? Surely there is a simple answer that has eluded me, but that and the hidden income of the faculty make it appear that the University is awash in clinical money.  Surely some of this can be used for indigent care, or perhaps it is already and is insufficient. Only the University knows for sure.

Under the theory that you can’t fix something unless you know how it got broken, here are some questions I would ask and issues I would like to see explored. These are off the top of my head, not exhaustive, and not in any particular order. Please suggest others in the comments section below.

Questions and Issues I would like to see explored.

• Does University Hospital shoulder the load of uncompensated medical care alone? Should it have to?  There are not-for-profit hospitals in Louisville that serve very few Medicaid, let alone indigent patients? A designated indigent care hospital will always be separate and unequal. Why should University Hospital alone get special funding for indigent care? Why should not the obligation and support be spread in proportion to the care provided?

• Why is the quality of care at University Hospital  lower as measured by Medicare’s Hospital Compare?  Is this the reason why the hospital is not a preferred one for so many insured patients? Is that good enough for the uninsured? Why is University Hospital not part of Humana’s preferred network? Cost? Quality?

• Why did the University burn its bridges with Norton? The partnership was fruitful for both parties, including in obstetrics and pediatrics. Norton provides the second-highest amount of indigent care in town. There were authentic teaching services on the wards of Norton’s hospitals when there were none at Jewish or Baptist. Substantial research money was given to the University by Norton. Surely the Medical school is under pressure for clinical training services. Might the University regain its formerly beneficial relationship with Norton Hospital?  Would new leadership be required for this to happen?   Or instead will the University begin a new children’s hospital so as to be able to sever its last major bond with Norton? That would be a travesty of the highest order, but I see that already playing out.  The community should insist that this not happen.

• University Hospital gets many $millions for both operations and capital from Medicare and Medicaid specifically to subsidize uncompensated care of the disadvantaged. Additionally, the hospital receives many $millions from Medicare and Medicaid for graduate medical education. These latter amounts are larger than required for teaching and are justified in part because of the extra share of indigent care teaching hospitals claim to provide. What are the total sums received by University Hospital from federal and state government, and how is the money shared? What other sources of indigent care funding does the hospital receive? How much from the University, the Medical School, or the clinical faculty practices goes towards indigent care?

• University Hospital will never get as much money as it wants. What else does it plan to do?

• How do you calculate “indigent care” at University Hospital?  How does every other hospital?  If the methods are not the same, how do we determine how to distribute public support?

• Why has University Hospital charged its patients so much? In 1995, University Hospital charged its patients $17,400 for an extended simple mastectomy, more than double the state average and more than triple what Baptist charged. Some claim this was to exhaust the QCCT fund more quickly. How is the QCCT billed today? Throwing more money into a flawed system is no solution. Is this why University Hospital is not on Humana’s preferred list for Medicare Advantage?  Is the QCCT still the best way to funnel money into care of the disadvantaged in Louisville?  In exchange for QCCT funding, Humana promised to cover all other indigent care itself.  Is this still a feasible demand for University Hospital?

• Should the Medical School merge with the University of Kentucky? That will give it a true statewide presence and reduce expensive duplication of state resources. Talk about a network!

• Is the relationship of the University with the private practices of its faculty a healthy one?  Faculty historically had not supported University Hospital with their private practices.  The community is having trouble seeing faculty accepting 7-figure salaries at the same time the University is demanding more money from the state to care for the poor. What happens to the clinical dollars that these full-time faculty make? Do all faculty participate equally in the care of the disadvantaged?

• What are the concerns of the organizations that accredit the Medical School and its many components? Those reports and surveys should be released and are likely to be very useful in helping the community understand and support the needs of the University.

• What does the hospital and University plan to do with any new money? We were told that none of the new money from CHI that the University hopes to replace was going to be used for indigent care. How did the University plan to proceed?  What was the University going to do with the new money.  I have never seen or heard an answer to this question.  It appeared to me the money was going to go to research and academic activities, not patient care facilities.

• What are the long term plans of the hospital. How can the University ask for more money with out disclosing such plans?

• If things have become so bad, are changes in leadership or organization needed anywhere along the line?

• Why does the University continue to fight against the release of documents requested under the open records act and demanded by the courts? Is the University still trying to hold out for private corporate status for its hospital and multiple boards and foundations? Why are we not waiting for that resolution before anything else is done? The University needs to declare itself before it asks for more public money.

University’s review panel is non-representative of the community.

I do not think University will not want to do such a review. I suspect it will  want to get it over quickly with a minimum of controversy. To my eye it has selected its review panel to facilitate that process. The members of the committee include current board members who presumably are already in favor of a merger with CHI, individuals strongly linked to the economic development of the city, and a Metro Council Member who has been an apologist for the University’s QCCT board. I see no names of traditional advocates for the disadvantaged, and certainly no one who has expressed any concerns during the previous debate over the ill-fated acquisition.   A one-sided review will discredit its findings even before the process begins.

I fear that what the University wants to do, and quickly, is to apply financial pressure to force the Governor to overlook all the other issues and to approve their original merger deal or a similar one.  That would be a travesty. These issues are not going to be resolved by April, nor should they be. Nor will they be resolved by money alone.  This is a once-in-a-generation opportunity for all of us to help the University of Louisville, its School of Medicine, and its Hospital to fulfill their traditional aspirations of service to their students, their community, and the to sick who come to their doors. Our community review must to be executed to serve this end to the satisfaction of all.

What do you think?

Peter Hasselbacher, MD
Feb 15, 2012