What did they expect?
There was a big fuss in the news yesterday and today. Norton Healthcare and the University of Kentucky (UK) announced an expansion of their clinical and academic interactions to include the pediatric services at Norton Kosair Hospital in downtown Louisville. The new announcement itself seems fairly benign– the only two children’s hospitals in Kentucky agree to share their expertise and quality protocols in service of the children of the Commonwealth. Norton Kosair is by far the larger of the two children’s hospitals in the state and has much to offer UK. Children could receive care closer to home instead of having to travel to Cincinnati, Nashville, or even further. The two hospitals will “remain separate, but will be operated jointly through collaboration.” It is anticipated that it will be easier to recruit pediatric sub-specialists to Kentucky, which is something of a problem now. An increase in clinical volume from retaining Kentucky patients instead of sending them elsewhere will help build experience and quality. Having a good network in place will facilitate the coming state Medicaid expansion.
Details remain to be worked out, but the project seems like more than a simple agreement to cooperate. For example, clinical operations will be coordinated and integrated including “clinical guidelines and patient care protocols, joint opportunities for teaching and research, and even integrating finances.” The new partners hope to further develop a statewide network of perinatal and neonatal care providers for high-risk mothers and babies, and developing more children’s outreach clinics in the state.” The medical staffs of the hospitals will not be consolidated and will have their own medical staff bylaws, rules and regulations. UofL is promised by Norton to continue to receive the academic support that it is due. How can this be a bad thing for the Commonwealth?
Why would Norton consider reaching out for additional partners for its pediatric services? Could it be related to the fact that in its merger and partnership agreements with KentuckyOne Health that UofL promised to give KentuckyOne first option on acquiring its pediatric services when the present contract with Norton expires? Could it be that in the partnership agreements with KentuckyOne Health that UofL agreed not to enter into any academic or programmatic affiliations with other Universities or institutions without permission? Could it be the fact that in the same agreement, UofL promised not to give clinical academic appointments to any physicians except KentuckyOne doctors? Could it be that UofL was willing to promise to try to make its physicians practice only in KentuckyOne Health institutions? These were academic kicks-in-the-teeth. Might Norton have drawn the same conclusion that I did and concluded that UofL and KentuckyOne were keeping open their option to build a separate pediatric hospital to serve their own network? What would you have thought?
Officials at the University of Louisville (UofL) reacted promptly with much indignation and bluster amid complaints that they were given no prior notice and were considering a lawsuit to block the agreement. When UofL joined itself at the hip with one of Norton’s biggest competitors, what did it expect would happen? Did UofL consult Norton over their plans to merge with Catholic Health Initiatives and Jewish Hospital? In fact, did they consult with anyone in the greater community? It took a lawsuit to drag meaningful information out of them during their first failed merger attempt.
UofL is also alleging that Norton’s move is mainly for commercial and financial advantage. In my opinion this is a laughable accusation. How should we then characterize the partnership between UofL and KentuckyOne Health/CHI? Who would object to the states flagship University playing a greater role in the state’s premier children’s hospital? Might fear of financial competition be playing a role?
UofL also alleges that the Norton-UK partnership violates some conditions under which the state allows Kosair to operate. Even if this is true, leases can and should be changed in the interests of the public of the Commonwealth.
I have commented before that when UofL took commercial sides with a single Louisville hospital system, that our medical community would become even more hyperpolarized and less coordinated. We are now seeing additional evidence of that prediction. In my opinion, a state University should not be taking sides in the commercial market, but then again, UofL considers its clinical operations, including those of its hospital, to be private and not to be a state entity.
The current pediatric affiliation is only one of a series of formerly close academic relationships between Norton and UK. However, UofL has been burning its bridges with its major Louisville partner for some time now. It was no surprise when some three years ago, Norton and UK began to interact more closely. Norton controls a major clinical service in the most populated part of the state. Any medical school with teaching and research responsibilities would be interested in collaborating. UK has a statewide mission to which UofL’s outreach into the Commonwealth pales in comparison. What UK is doing is neither new, unexpected, nor inappropriate. Besides, I am told that there are more UK fans in Louisville than UofL fans! UoL’s spin machine is working overtime to cast Norton in a bad light, but that would be far from the truth.
This new pediatric partnership is only the latest in a series of body blows to UofL’s academic and research image. Its high-priority and long-standing quest for a National Cancer Institute Designated Cancer Center continues to falter while UK joins the ranks of the nation’s best with its recent NCI designation. We can write more about that later. Not that Norton is a potted plant as far as cancer goes. Norton has its own NCI Community Cancer Center designation. It has more cancer doctors, serves more patients, and from what I understand, does more clinical research than the James Graham Brown Cancer Center of UofL. When your former partner in the same town thumbs its academic nose at you, why would you not accept overtures from the Commonwealth’s flagship university? The four leading UofL Cancer doctors who left UofL for UK last month made their own decisions about where they could best do their work. UK didn’t have to steal them, they went of their own accord. UK’s pediatric service will gain tremendously from closer integration with Kosair. Isn’t that what coordination of care is supposed to mean?
Enough for now. No doubt over the next few days we will hear more impassioned outpourings from UofL. In comparison, the statements of UK and Norton are considerably more reasonable, and businesslike.
As is the tradition of this policy blog, if I have made any errors of fact or interpretation, I invite clarifying comments below. If one of our readers has information they can share publically or privately that will inform the public, I welcome hearing from you.
[Addendum, Aug 27, 2013]
Lots going on in the media and doubtless behind the scenes. The Courier-Journal printed an excerpt of a letter Steve Williams of Norton sent to David Dunn of UofL when Dr. Dunn would not meet with him. I had an opportunity to read the entire letter and I think the public deserves to see it as well. In fact, it looks like it was written for the public! [Here it is.]
University officials are making this look like Norton is reneging on its obligations to UofL but my reading is very different. According to the letter, the two parties were at the end of negotiating their continuing affiliation agreement when UofL presented a very different set of conditions in a take-it-or-leave-it manner. Norton apparently called their bluff. Now the University seems to want “reimbursement” for spending money it didn’t have for new faculty members and other uses. Since when is it Norton’s responsibility to write blank checks to pay for the University’s adventures? (UofL may be short of funds since it is no longer able to use Medicaid money from Passport as it did in the past and for other reasons including decreased state appropriations. I suggest dipping into the ocean of money in UofL’s athletic department that the New York Times is writing about this week! Or how about using some of the promised KentuckyOne money that no one I know has seen yet?)
One of biggest holes in the new University of Louisville/KentuckyOne medical structure is the lack of a pediatric medical facility that it can control completely. A conspiracy-minded individual might even speculate that UofL, knowing of language contained in the lease of the land on which Hospital sits, engineered this matter in order to wrest control of Norton-Kosair Hospital from Norton Healthcare! This is nonsense of course, but might explain the unexplainable to me of why UofL agreed not to give faculty appointments to non-KentuckyOne physicians perhaps including those hired by Norton to work in Kosair! I never personally doubted that the prohibition against joint programs with other Universities contained in the merger/partnership documents was intended to block interactions with the University of Kentucky. Talk about a long game! What does it say about the health of Louisville’s hospital and educational system that such thoughts should even enter my head?
I would very much like to see the full text of the lease. If anyone can send it to me I would love to share it with the public. UofL seems to believe it can block Norton’s relationship with UK with the terms of lease. Do UfoL officials think they can use the lease to boot Norton out of the hospital Norton built and with which Norton, with the partnership of UofL, used to serve the public faithfully for over 30 years. Much has changed since. The conditions and definitions used back then may no longer be relevant today. For example, now that the University of Louisville no longer considers its clinical operations to be public entities, and that their faculty practices are private, why should the Commonwealth or Norton have any obligation to finance those aspects? In their initial merger attempt with Catholic Health Initiatives, the University of Louisville tried to use changing circumstances to put the community asset of University Hospital into private hands. It failed. UofL cannot be permitted to attempt the same thing now with our children’s hospital.
I am sure there will be more to come! Please tell me what you know.
Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
24 August 2013