A significant loss to the community or not?
On Aug 1, the Courier-Journal’s hard-working Laura Ungar reported that the University of Louisville was cutting some services available to its hospital patients. The digital version of the report was quickly picked up by national media. Ashok Selvam, a reporter for the industry news magazine, Modern Healthcare, could not elicit comment from the Hospital itself. His story gave the impression that the cuts were a consequence of last December’s failed merger with Catholic Health Initiatives. It seems to me that such an interpretation is exactly the story line that UofL has been using as it maneuvers to finally consummate such a marriage. Additionally, UofL has been forecasting reduced services to the indigent for many months as it argues before the Louisville Metro Council for additional public funding. Without some actual cuts in evidence, such promises might appear hollow. Given its claims of poverty and need for more tax dollars, I am not surprised that UofL might want to provide some kind of evidence that the sky really might be falling in.
Fortunately for Louisville, Ms. Ungar was very successful in eliciting more information. Despite the fact that UofL President Ramsey recently went out of his way to say that he makes it a point not to read the Courier-Journal, the Hospital would have lost much local credibility if it had stonewalled. So, what were the actual services that are said to be cut, and how might they be related to a failure of the merger or to the provision of indigent care? I must say that I agree with the comment from the Louisville Mayor’s office that “it appears these services are not critical.” Lets take a look ourselves.
Open-Heart Surgery.
The UofL Hospital is going to close its open-heart surgery program. This was a surprise to me, because I was not aware that the Hospital even had an open heart program. In the early 1990s, UofL sold gave its cardiac programs to Jewish Hospital in exchange for research space and money. In fact, in the late 1990s, one of my first federal lobbying tasks for UofL was to try to find a way for University Hospital to maintain its accreditation to perform cardiac angioplasty because it did not have the required backup cardiac surgical support on site to handle the inevitable complications. I do not know what happened since, but I can be excused for not knowing of a surgery program that was doing barely more than one surgery a month! As I commented to Ms. Ungar, closing this program is probably a good thing for the community. It must have been expensive for the Hospital, and I suspect that there may still have been accreditation concerns. (Without accreditation, hospitals cannot offer certain services.) With small-volume programs such as this, quality also becomes an issue.
Back in the earliest 1990’s when UofL gave away its burgeoning cardiology programs, the then-Chairman of Medicine announced to the medical staff that from thenceforth all private (read “insured”) cardiology patient referrals should be sent to doctors (faculty or otherwise) at Jewish Hospital, and that calls on behalf of indigent patients should be shunted to trainees on the cardiology service of University Hospital. In my opinion, more than any single event, this clear segregation of the rich from the poor cast in stone University Hospital’s image as an undesirable place to go and epitomized the willingness of the University of Louisville to offer dual standards of care to its patients.
Of course, even poor people sometimes need open-heart surgery. What are they to do? I would argue that as long as Jewish Hospital or any other Louisville Hospital is willing to host the paying patients of University faculty, they can darn well take care of their fair share of uninsured patents too. Does anyone disagree? After all, isn’t that what nonprofit hospitals are expected to do? Perhaps, some of the QCCT indigent care money can be used to contract with another hospital to do such cases, just as the Louisville Veterans Hospital contracts with Norton Hospital to do its cardiac surgery. [Isn’t that fact amazing?] Of course, another option would have been for UofL to recall its entire cardiac program from Jewish Hospital back to University Hospital. I would really like to hear the the University’s reasons for not doing so, wouldn’t you? We would then have the real issues out on the table! What are the alternatives to closing this tiny University program? Continue to operate on patients in a marginalized facility in which quality has become a major concern and which perpetuates de facto the segregated second-class system of the last century? Good enough for poor people, but not good enough for everybody else? I hope for better.
Sleep Center Closure.
We are told that UofL will close its Sleep Center. This is a suite of rooms in which outpatients sleep for a night while they are hooked up to various monitors to look for disorders such as obstructive sleep apnea. Since this University service was actually provided in a nearby hotel, it is not clear to me whether this was a true hospital service, or part of the private practice of faculty members. In either case, only 4% of the patients served were reported to be uninsured! I must draw two conclusions from this. Even with 96% insured patients, the sleep center was, for some reason, not competitive with the several other centers in town and was likely failing financially. (Why else close it down?) Was the hospital paying too much to its doctors to be “Medical Directors?” I suspect that UofL’s new consulting hospital management team advised them to cut their losses. I think we are owed a fuller explanation from UofL of why they really closed down this service. It certainly wasn’t a lack of public funding for indigent care! Unless sleep studies are no longer profitable for any center, I suspect the problem was one of management.
My second reaction to the closing of the sleep center is to ask the question, “Given the Hospital’s frequently claimed heavy caseload of medically indigent patients, why were so few uninsured patients served in its sleep center?” Is this evidence that the sleep center was in fact principally a facility for faculty private practices? A more troublesome alternative intrudes involuntarily into my mind, that some medically indigent patients for whom a sleep study was medically indicated may have not been receiving evaluations because of their inability to pay. Given the high incidence of obesity and cardio-pulmonary disease in the Hospital’s service population, surely more than 21 patients in all of 2011 (less than 2 a month) would have benefited from a sleep study. In any event, it cannot be claimed that UofL closed its sleep center because of inadequate public funding for indigent care! We might also reasonably ask if the sleep center is going to be relocated to some other “partner’s” facility.
Decrease in Selected Outpatient Services.
The third alleged cutback is more general and has more troublesome implications. A spokesperson for the Hospital stated that it will cut back on the number of some outpatient services from 320 uninsured patients per week to 238, a reduction of 26%. This is an amazingly specific number which I suspect refers to decreases in services offered to out-of-county patients announced many months ago. The services so rationed are said to include imaging studies such as CAT and MRI scans, and some outpatient rehabilitation. Nonetheless, we are told that such services will be provided anyway if they are judged medically necessary by a physician. This stunning and presumably integrity-saving promise allows that many such services now being performed are in fact not medically necessary! Because medical over-treatment is just as bad as under-treatment, such cuts might even be a good thing!
This rationing represents the mother of all indigent care fears. Will some citizens of Louisville not receive medically indicated services because of insufficient access to the healthcare system at University Hospital (or anywhere for that matter)? In my heart I do not believe that our community will allow that to happen, but it may well mean doing things very differently than we do now. In my head lies an opinion that we cannot accept at face value what the University of Louisville says it can or cannot do without full disclosure of its financial affairs and of the interrelatedness of its programs. The time for stonewalling and spin is over. The University of Louisville Hospital should not be permitted to refuse care to even one patient until it is very clear that not a single dime is being shifted to research or departmental slush funds!
Final Comments.
It is my opinion that UofL has starved its hospital of both money and professional manpower for years to serve its other priorities. I have written about these issues at length. I have reported in these pages on several major external audits that were critical of the hospital and of the University’s inappropriate stewardship of its public funding for indigent medical care. It is time for the community to take the University of Louisville and its leadership to task. [Click on some of the ‘Categories’ for details and supporting documents.]
The University of Louisville has been threatening indicating for many months that unless it is free to do whatever it wants, as it sees fit, and with more public money to boot, that it will not be able to shoulder its share of indigent medical care, and that in fact, patients will die. Therefore, the cuts described above are not unexpected, but neither are they obviously relevant. Ms. Ungar’s report disclosed something else that was, in my mind, even more important: the Louisville Metro Council has extended its indigent care to the hospital for only an additional 3 months and expects to re-negotiate the entire QCCT funding arrangement. This tells me that the Council is no longer buying the University’s unsupported arguments. Good for them! Let me demand further that no more political deals should be hammered out in some back room, and that no deal involving such large amounts of public money be made at all unless UofL abandons its foolish claim to be a private hospital. The community must have an opportunity to review and comment on any new agreement that we are collectively responsible for. While the University and our state and local governments may have tacitly accepted some changes to the funding pact over the years, it is clear to me that the QCCT is no longer either relevant or workable. If the University chooses not to, or is unable to care for any or all medically indigent patients from Jefferson County as it has agreed to, the QCCT is void anyway. It is a new medical world out there, and a new plan is needed.
Peter Hasselbacher, MD
President, KHPI.
Emeritus Professor of Medicine, UofL
August 8, 2012