HHS Announces Additional Protections for Patient Privacy

The Department of Health and Human Services (HHS) issued today its intended regulations to modify the Privacy Rules under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The new standards relate to how these Privacy Rules account for disclosures of protected health information (PHI). HHS would like to require covered entities and business associates to account for disclosures of protected health information as it relates to treatment, payment, or even health care operations in general, provided such disclosures occur in connection with the patient’s electronic record.

An extension of the Health Information Technology for Economic and Clinical Health Act (HITECH) and HIPAA, these proposed regulations would entitle individuals to an access report identifying exactly who accessed the electronic protected health information in the particular context.   Present requirements under the Privacy Rule (45 C.F.R. § 164.528) require covered entities to make available (at an individual’s request) certain disclosures of health information.  A disclosure is defined at Section 160.103 as “the release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information.”

For each disclosure, the accounting must include:

  • The date of the disclosure
  • The name (and address, if known) of the entity or person who received the protected health information
  • A brief description of the information disclosed
  • A brief statement of the purpose of the disclosure

Existing law, however, provides for a number of exceptions from the disclosure requirements, including:

  • To carry out treatment, payment and health care operations
  • Pursuant to an authorization
  • For the facility’s directory or to persons involved in the individual’s care

Section 13405(c) of the Health Information Technology for Economic and Clinical Health (HITECH) Act, Title XIII of Division A and Title IV of Division B of the American Recovery and Reinvestment Act of 2009 (ARRA) provides that the exemption of the Privacy Rule for disclosures to carry out treatment, payment, and health care operations no longer applies to disclosures “through an electronic health record.” Section 13400 of the HITECH Act defines an electronic health record (“EHR”) as “an electronic record of health-related information on an individual that is created, gathered, managed, and consulted by authorized health care clinicians and staff.”

If enacted without further modifications, an individual will have a right to receive an accounting of such disclosures made during the three years prior to the request.  HHS has proposed that these new requirements take effect January 1, 2013 (for EHR systems acquired after January 1, 2009) and January 1, 2014 (for EHR systems acquired before January 1, 2009).

Additional information about these changes in patient privacy rights can be found at the Federal Register Website.

The Nation’s Health Care Hierarchy and Cost in 2011

In a country of more than 311,000,000, the burdens placed on the health care system are both enormous and complex as Americans expect a fundamental right to first rate health care without much regard for its cost. The Federal Government, however, is mindful of this expense, and since 1964 the United States Department of Health and Human Services (HHS) has published an annual series of data presenting total health expenditures in the United States.

Health Care Spending

Identified as National Health Expenditure Accounts (NHEA), these estimates attempt to measure the total annual dollar amount of our nation’s health care consumption. The information also tries to identify the amount invested in the future of health care (such as medical structures, equipment, research, etc.). Some of the more significant expense categories monitored by the NHEA include:

  • Hospital Care: This includes all services provided by hospitals to patients (room and board, ancillary charges, resident physicians, pharmacy, etc.), measured by total net revenue.
  • Physician and Clinical Services: This includes services provided by Doctors of Medicine (M.D.) and Doctors of Osteopathy (D.O.), outpatient care, and some laboratory expenses. It also includes the professional component of hospital charges if these charges are usually billed separately.
  • Other Professional Services: This includes professional services by private nurses, chiropractors, podiatrists, optometrists, and physical/occupational/speech therapists.
  • Dental Services: This includes Doctors of Dental Medicine (D.M.D.), Doctors of Dental Surgery (D.D.S.), or Doctors of Dental Science (D.D.Sc.).
  • Other Health, Residential, and Personal Care: This includes care provided in residential care facilities, ambulance services, and workplace health care services, among others.
  • Home Health Care: This includes health care provided in freestanding home health agencies (HHAs).
  • Nursing Care Facilities: This includes freestanding nursing home facilities that provide both nursing and rehabilitative services.
  • Prescription Drugs: This includes the retail side of medication.
  • Durable Medical Equipment: This includes in part the retail side of certain items such as surgical and orthopedic products, wheelchairs, eyeglasses, and hearing aids.
  • Other Non-Durable Medical Products: This includes the retail side of non-prescription drugs and medical supplies.
  • Population: The NHEA uses a modification of U.S. Census figures.
  • Out-of-Pocket Payments: This includes direct spending by consumers for all health care goods and services, including any amounts not covered by insurance (such as co-payments and deductibles, but not insurance premiums).
  • Health Insurance: This includes private health insurance, Medicare, Medicaid, and other such public payers.
  • Private Health Insurance: This includes premiums paid to insurance companies, as well as the costs for advertising, sales commissions, rate credits, taxes, profits, etc.

Growth in U.S. National Health Expenditures (NHE)  over the next ten years is expected to be slightly higher due to the Patient Protection and Affordable Care Act (PPACA), as well as other issues. Average annual growth in NHE for 2009 through 2019 is expected to be 6.3 percent (0.2 percentage point faster than pre-reform estimates).  NHE as a portion of the nation’s Gross Domestic Product (GDP) is expected to be 19.6 percent by 2019 (or 0.3 percentage point higher than projected before reform). Incidentally, PPACA is expected to result in a lower average annual Medicare spending growth rate for 2012 through 2019 (6.2 percent). This is 1.3 percentage points lower than pre-reform estimates.

For comparison purposes, the following information was compiled for 2009:

  • NHE grew 4.0% to $2.5 trillion, or $8,086 per person, and accounted for 17.6% of GDP.
  • Medicare spending grew 7.9% to $502.3 billion, or 20 percent of total NHE.
  • Medicaid spending grew 9.0% to $373.9 billion, or 15 percent of total NHE.
  • Private health insurance spending grew 1.3% to $801.2 billion, or 32 percent of total NHE.
  • Out of pocket spending grew 0.4% to $299.3 billion, or 12 percent of total NHE.
  • Hospital expenditures grew 5.1% in 2009.
  • Physician and clinical services expenditures grew 4.0%.
  • Prescription drug spending increased 5.3%.

Health Care Oversight

To understand the scope of issues health care must face on any given day, it is important to become familiar with the building blocks that make up today’s health care hierarchy.Who is responsible for oversight?  At the top of the health care pyramid is the nation’s President, Barack Obama.  Underneath the President lies a complex organization of individuals and agencies at both the federal and state level, who make up the gargantuan structure commonly referred to as health care.  The President directly oversees the Office of the Secretary, HHS.  HHS has multiple operating divisions, including:

HHS staff divisions include:

The Food and Drug Administration is another important agency under HHS. Protecting and promoting public health, the FDA consists of nine centers/offices, including:

Accreditation and Certification

Due to the sensitive nature of their services, hospitals must exist in a heavily regulated industry, and the Federal government is only part of the overall health care regulatory equation.  Accreditation, certification and periodic review come from a variety of both public and private sources, though the goal is generally consistent:  develop uniform standards to ensure that hospitals in the United States all operate at an acceptable safety level and deliver quality patient care in an appropriate and effective manner.

Any one healthcare institution can be subject to accreditation review at any time from entities such as the Joint CommissionHealthcare Facilities Accreditation Program (HFAP), Community Health Accreditation ProgramAccreditation Commission for Health CareThe Compliance Team, or Healthcare Quality Association on Accreditation (HQAA). In October 2008, CMS approved DNV Healthcare as a third national accreditation program for hospitals seeking to participate in the Medicare program. Recently, hospitals accredited through DNV Healthcare have been added to the American Hospital Association (AHA) Guide, listing these facilities as well as those accredited by the Joint Commission and HFAP.

Each program or department is governed by its own set of rules.  For example, Joint Commission surveys hospitals by following more than 276 standards, reviewing 1,612 elements of performance.  HFAP does largely the same thing, pursuant to its 1,100 or more individual standards.  Focusing on durable medical equipment (DME), HQAA has developed its own review process, and “vows to continuously strive to set standards of the highest quality on behalf of the DME industry and business owners.”  Indeed, HQAA “listen[s] . . . act[s] . . . [and] stand[s] together and in unison to bring the whole of DME service and provision to the next level.”

There are numerous other entities participating in the certification/accreditation process, and virtually every facet of the health care system is governed and reviewed by multiple organizations.  Take the American Hospital Association, which designs and administers Certification Programs to recognize mastery of well-defined bodies of knowledge within health care management disciplines.  The Certification Commission for Healthcare Information Technology is a recognized certification body for electronic health records and their networks.  Even educational programs, general education or specialty education (such as podiatric medicine) must receive proper accreditation in a hospital setting.


In addition to the list above, every hospital is subject to special regulations from its own state.  Health care facilities in California are licensed, regulated, inspected, and/or certified by a number of public and private agencies at both the state and federal level, including the California Department of Public Health (CDPH).

State and federal agencies have separate jurisdictions, but there is overlap.  For example, CDPH’s License and Certification Division (“L&C”) is responsible for ensuring that hospitals comply with state law, but it also cooperates with CMS to verify that facilities accepting Medicare and Medi-Cal (Medi-Cal is California’s version of Medicaid) payments meet federal requirements.  California’s Office of Statewide Health Planning and Development (OSHPD) regulates hospital construction and administers programs which endeavor to implement the vision of “Equitable Healthcare Accessibility for California.”

These two examples serve to emphasize as well as outline the complexities of state regulations that often accompany their federal counterparts.  CDPH is divided into eight separate programs, including:

  • Office of the Director, or State Public Health Officer;
  • External Affairs;
  • Policy and Programs;
  • Center for Chronic Disease and Health Promotion;
  • Center for Environmental Health;
  • Center for Family Health;
  • Center for Health Care Quality; and
  • Center for Infectious Disease.

Like CDPH, OSHPD is one of 13 departments within California’s Health and Human Services Agency.  Made up of six separate boards and commissions, OSHPD’s mission is “to promote healthcare accessibility through leadership in analyzing California’s healthcare infrastructure, promoting a diverse and competent healthcare workforce, providing information about healthcare outcomes, assuring the safety of buildings used in providing healthcare, insuring loans to encourage the development of healthcare facilities, and facilitating development of sustained capacity for communities to address local healthcare issues.”

In the present climate of health care reform, things do change fast. The foundation that makes up the nation’s health care hierarchy, however, may take some time to understand.


CMS Tries to Encourage Accountable Care Organizations in Rural Communities

The Patient Protection and Affordable Care Act (PPACA) intends to implement a system to monitor the quality and efficiency of health care providers. Last March, the Centers for Medicare & Medicaid Services (CMS) released proposed regulations to guide doctors, hospitals, and other health care providers as they attempt to form accountable care organizations (ACOs) under health care reform. These rules included certain provisions designed to encourage rural participation, and CMS recently provided clarification for these rural providers.

Under the general regulations, for ACOs to receive shared savings, they are required to meet a minimum savings rate (MSR). The MSR is the required percentage that ACO expenditures fall below certain standards. In the one-sided model, the MSR ranges from 2.0 percent to 3.9 percent, with variations due to the number of beneficiaries the ACO has assigned. Once the ACO meets the MSR threshold, it is eligible to share in the savings above the MSR amount. Therefore, the ACO is not eligible for “first dollar”savings. Under the one-sided model, ACOs can receive no more than 52.5 percent of their savings (50% for quality performance and up to 2.5% for including a federally qualified health center (FQHC) or rural health clinic (RHC) as a participant in the ACO).

Recognizing the need to encourage the formation of smaller ACOs in underserved rural populations, the Medicare Shared Savings Program proposed an exemption  under the one-sided model from the two percent (2%) savings threshold for ACOs with less than 10,000 beneficiaries. These ACOs would be eligible to share in the first dollar savings provided they comport with the performance standards, generate savings, and meet one of the following criteria:

  • Be comprised of ACO professionals in group practice arrangements or networks of individual practices;
  • 75% or more of the ACO’s beneficiaries reside in counties outside a Metropolitan Statistical Area (a geographical region with a relatively high population density at its core and close economic ties throughout the area) for the most recent year for which data is available;
  • 50% or more of the ACO’s beneficiaries were assigned to the ACO because a critical access hospital (CAH) provided primary care services while billing under the optional method (Method II); or
  • 50% or more of the ACO’s beneficiaries had at least one encounter with an ACO participant FQHC and/or RHC in the most recent year for which data is available.

All ACOs in the two-sided model that satisfy the requisite performance standards and generate savings in excess of the minimum threshold would also be eligible to share in savings on a first dollar basis.

The new regulations would also provide for an incentive to smaller ACOs by using a lower confidence interval. ACOs with at least 5,000 beneficiaries would have a minimum savings rate based on a 90% confidence interval.  ACOs with 50,000 beneficiaries would have a minimum savings rate based on a 99% confidence interval.

FQHCs and RHCs may not form their own ACOs under current regulations. These entities may join an ACO as an ACO participant, however, along with other organizations. Therefore, these proposed rules offer incentives to ACOs that choose to include FQHCs and RHCs in their mix.

Additional information about the Shared Savings Program can be found HERE.




Health Care Is Up in Arms About Firearms

Physicians around the nation are up in arms about some proposed legislation that may limit their communications with patients. One such measure is from Florida, where the State Legislature recently passed the “Don’t Ask” bill. It waits for the likely signature of Governor Rick Scott. Florida House Bill 155 will prohibit in part a physician or other health care professionals from asking patients or members of their families whether they own a firearm or have one in their home.

Supporters of the bill, including the National Rifle Association, contend the legislation is important to stop doctors from invading their privacy, especially when they are concerned the information may be used against them by insurance companies. According to Marion Hammer, executive director of United Sportsmen of Florida: “Simply, it’s none of their business.”

Representatives from the American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA) all agree on the importance of the physician-patient relationship, and the importance of maintaining these open channels with strict confidentiality exists at its very core.

Together, these three groups oppose any legislation — including laws relating to the possession of firearms and an office visit discussion about guns in the home –  that places limitations on the free exchange of information within the patient-physician relationship. Any restriction, according to the groups, may cause harm to the patient’s and family’s health.

The 300,000 plus physicians within these organizations firmly believe that they must have open and honest communication with patients about all aspects of health and safety. One critical aspect of this process is safety and injury prevention. By providing meaningful patient education, physicians can help improve patient well being.  The AAFP, ACP and AOA have long standing policies in support of this notion.

The AAFP is one of the largest national medical organizations, representing more than 100,300 family physicians, family medicine residents and medical students nationwide. Founded in 1947, the group’s mission is to preserve and promote the science and art of Family Medicine, and at the same time advance high-quality, cost-effective health care for everyone.

The ACP is a national organization of internists who specialize in the prevention, detection and treatment of illnesses in adults. The largest medical-specialty organization and second-largest physician group in the United States, the group’s 130,000 members include internists, internal medicine subspecialists, as well as medical students, residents, and fellows.

The AOA serves as the professional family for all osteopathic physicians (DOs) and osteopathic medical students. In addition to being the primary certifying body for DOs, the AOA is also the accrediting agency for all osteopathic medical schools, and it has federal authority to accredit hospitals through its Healthcare Facilities Accreditation Program.

AAFP President Roland Goertz, MD, MBA, explained: “The AAFP believes that patient confidentiality must be protected. Any proposal that seeks to intrude on these rights and place restrictions on what can be discussed jeopardizes a patient’s health and represents unwise governmental intrusion.”

Only in an environment of confidence and trust can a patient freely share the necessary information for a physician to understand, diagnose, and treat patients properly.  ”The American Osteopathic Association opposes any and all efforts to censor communication that occurs between patients and their physicians,” said AOA President Karen J. Nichols, DO. “Any legislation that impedes on this relationship jeopardizes the health and safety not only of our patients, but also their families.”

Representatives from the physician groups content that the proposed legislation in Florida and other states attempts to preclude physicians from asking patients about firearm ownership, thereby preventing any discussion about safe storage and handling. Historically such education has been shown to decrease the likelihood of unintentional injury or death.

“On this particular issue, ACP’s policy encourages physicians to inform patients about the dangers of keeping firearms, particularly handguns, in the home and to advise them on ways to reduce the risk of injury,’” said ACP President Virginia L. Hood, MBBS, MPH, FACP. “However, this issue is much bigger than guns, it is about whether the government or any other body should be allowed to tell physicians what they can and can’t discuss with their patients.”

MedPAC: Keeping an Eye on the Medicare Program

Established by the Balanced Budget Act of 1997 (P.L. 105-33), the Medicare Payment Advisory Commission (MedPAC) advises the U.S. Congress on all matters of Medicare. This independent agency enjoys an expansive mandate — from advising Congress on payments to private health plans participating in the Medicare program to the assessment of access to, and quality of, Medicare treatment.

MedPAC’s 17 members are appointed to three-year terms by the Comptroller General. The commission meets publicly to discuss policy issues and prepare recommendations to Congress. MedPAC may consider information contained within staff research, presentations by policy experts, and comments from interested parties.

MedPAC issues two reports each year (March and June). The March 2011 report contains 13 chapters, including one chapter that provides context for documenting the rise in Medicare and total health care spending nationwide, another setting forth the Commission’s framework for assessing the integrity of Medicare’s payment process, nine chapters relating to Medicare payments and program integrity concerns, one chapter discussing the Medicare Advantage plans, and a final chapter on Medicare prescription drug coverage.

The entire report, consisting of more than 350 pages, can be found HERE.

The Commission’s schedule of public meetins can be found HERE.

In a recent press release announcing the newest members to the commission, Gene L. Dodaro, Acting Comptroller General of the United States and head of the U.S. Government Accountability Office (GAO) stated: “Policymakers continue to rely on MedPAC’s expert advice, and with the passage of health care reform, MedPAC’s role will continue to be particularly important. I am pleased to report that, once again, we had many qualified applicants for MedPAC. The four new individuals selected will bring impressive credentials and valuable experience and insights to the commission.”



HHS Issues Final Rules To Review Insurance Premium Increases

The Department of Health and Human Services (HHS) issued a final regulation to review large health insurance premium increases while at the same time providing consumers with clear access to this information.

HHS hopes that this transparency will help lower insurance costs, especially when in September 2011 state or federal agencies must review rate increases of 10-percent or more.

“Effective rate review works – it does so by protecting consumers from unreasonable rate increases and bringing needed transparency to the marketplace,” said HHS Secretary Kathleen Sebelius. “During the past year we have worked closely with states to strengthen their ability to review, revise or reject unreasonable rate hikes. This final rule helps build on that partnership to protect consumers.”

Starting September 1, 2011, the rule requires independent experts to review any proposed increase of 10-percent for most individual and small group health insurance plans. States will have the primary responsibility for oversight, and HHS will serve in a backup role if certain states are unable or unwilling to comply. Starting September 2012, the 10-percent threshold will be replaced by state-specific thresholds that reflect the insurance and health care cost trends in each state.

“Strong and transparent rate review processes are necessary to help bring down costs for consumers,” said Steve Larsen, director of the Center for Consumer Information and Insurance Oversight. “Rate review will ensure that increases are based on reasonable estimates and real-time data on medical cost trends and health care utilization.”

For more information about recent trends in health insurance rates and the final rule, visit HERE.


Zombie Apocalypse Preparedness 101

The Centers for Disease Control and Prevention has posted information on how to prepare in the event of a zombie invasion. Assistant Surgeon General Ali Khan provides valuable information from stocking up on food to first aid supplies to “where you would go and who you would call if zombies started appearing outside your door step.”

The CDC blog also explains:  “If zombies did start roaming the streets, CDC would conduct an investigation much like any other disease outbreak, CDC would provide technical assistance to cities, states, or international partners dealing with a zombie infestation. This assistance might include consultation, lab testing and analysis, patient management and care, tracking of contacts, and infection control (including isolation and quarantine).”

Among other things, the CDC also recommends advance planning of the appropriate escape route:  ”Plan your evacuation route. When zombies are hungry they won’t stop until they get food (i.e., brains), which means you need to get out of town fast! Plan where you would go and multiple routes you would take ahead of time so that the flesh eaters don’t have a chance! This is also helpful when natural disasters strike and you have to take shelter fast.”

For more information about what to do when the zombies arrive, or information about disaster preparedness in general, visit the CDC’s Website HERE.


A Final Newsletter0

Hello Everyone:

In many respects, today is like any other for Coast Plaza Hospital. Just as we have since opening our doors more than 50 years ago, we stand proud and ready to address any emergency our community might face, welcoming one and all in times of need. And yet, though unbeknownst to our many neighbors, patients and friends who have come to look upon the hospital as a constant, fixed entity toward which to turn in the midst of chaos, behind the scenes a torch will shortly be passed from one hospital owner to another.

Under the past twenty-one years of present ownership I have shared the title of Chief Executive Officer with only one other. In this, my final report to the Coast Plaza Hospital community, I would like to honor the individual who held my title for the 12 years before me, my father, Gerald J. Garner, since in my opinion it is his legacy that has made our hospital a name our community has come to trust.

Born December 17, 1936, my father was raised in New York and did not move his family to California until he was 40. It was to be another decade before he assumed the position of Coast Plaza’s CEO, a role he accepted with pride. His sudden death on April 28, 2002 came as a great surprise to both his immediate family and the employees at Coast Plaza, many of whom knew him from the beginning of his tenure.

Today, my father is survived by my mother Joan, my sister Robyn and her husband Keith, my brother Scott and his wife Karen, me and my wife Natalya, and six grandchildren. While he adored Robyn and Keith’s children Tyler and Evan, sadly Gerald never had the chance to meet Scott and Karen’s three children, Espen, Annika, and Helena, or our newborn son Rodion. I like to think he would be proud of the new elements within his family.

Gerald taught many people many things in life, but it was perhaps his passing that taught our hospital family its most important lesson: We achieve greatness together, and only together. I have heard it said that the whole is by nature greater than the sum of its parts, and when it comes to health care in the modern age that is certainly true, be it the correlation between community and hospital, employees and hospital, or even investors and hospital. As different as each of these entities may seem from the others, all three survive only by existing together. Just as the loss of my father affected my immediate family greatly, the transition from old guard to new will have its moments of uncertainty for the Coast Plaza family. Even so, though these past few weeks have given me the opportunity to witness first hand the ways in which change can make for a stressful environment, I have also been pleased to regard the strength and dedication shown by our members in their effort to maintain the superlative standard of health care that our community has come to expect, regardless of any temporary internal fluctuations. Nine years of consistency will undoubtedly lead to a certain amount of confusion for a time, no matter who is waiting in the “on-deck circle.”

But that is what makes a hospital such a special place to work. As chaos tries to rule the day, something happens, and a wake up call of sorts is given, reminding us all of the reason we have come together in this building on any given day. Our daily dose of reality connects us with the real issues at hand, as we remember that our community truly values the support we provide in times of need, just as we do the same for one another. After all, that is what relationships are all about.

Throughout this period of transition, Coast Plaza Hospital did exactly as it should, relying on a network of relationships already in place and building on the new to continue its focus on providing care to the community. In hindsight, the past nine years under my tenure were in many ways defined by these relationships, and our focus was strong. As a result, the community received exactly what it had come to expect and deserve — a first-rate hospital.

Seven months ago I met the individuals who will write the next chapter for Coast Plaza Hospital. They are a competent, generous, able group, to be sure. But though they may steer the course, they will not write this story alone. If there is one fact which Gerald and I knew to be true while tending our posts, it is that the strength of this particular hospital comes not from its leadership, but from the dedication of its nearly 400 stellar employees. Working together for the common good, you are indeed greater than the sum of your parts, and I do not expect that to change.

Regardless of what the future holds for Coast Plaza, there is one thing of which I am sure: The extended family that has for nine years made it an honor and a privilege for me to lead this hospital will continue to provide excellence in care for the people in and around Norwalk. Indeed, that is what health care at Coast Plaza Hospital is all about.

Thank you all.

Bringing the Relationship Back Home0

This article first appeared on the PBS affiliated Website This Emotional Life.

“As you get older, it is harder to have heroes, but it is sort of necessary.” — Ernest Hemingway

It starts with lavender.  Then I notice the tiny, neatly folded outfit set aside by the changing table. A dragon in the corner smiles at me, performing ironic double-duty as humidifier and protector, providing respiratory ease rather than spewing the requisite fire so common to his kind.

Through the dim lighting I spot a small bottle waiting to provide the next meal when necessary, along with an array of accoutrements placed strategically throughout the room in anticipation of what the night may bring. And, of course, I hear the alternating tonic and dominant harmony in D flat.  This is my house, and yet I cannot help but ask myself where this room has come from.  It seems to have magically appeared overnight, while I was at the office crunching numbers and doing my best to contain health care-related chaos.

As I have mentioned in earlier articles, the last few months have been interesting for me, for a variety of reasons. Thus far, 2011 has seen fit to grant me a beautiful baby boy as I relinquished ownership of a family hospital handed down to me by my father.  Never before have I seen the Wheel of Life turn so up close and personal than in the last few months, and the combined experience has forced me to take account of the daily minutiae.  Simply put, things are changing, and fast.  The past seems suddenly far behind while the future stretches out before me, full of exciting new events that remind me just how far out of my league I am.  And through it all, the scent of lavender lingers as a reminder of my transition.

With the livelihood of over 400 employees – who I consider extended family members – at stake during the ongoing sale process of a local hospital on which the very community has come to depend for more than 50 years, I am the first to admit that the last two months have not afforded me as much time to spend with my newborn as I would have liked.  Late night phone conferences and early morning briefings have left little time for more than the occasional bottle-feeding or diaper change. That’s what comes to mind as I make my way across this odd little room in the heart of my house and realize just how much work my wife has put into creating a warm, safe haven in which to raise our son.  My lack of familiarity with many of the products on the nightstand only serves to reinforce how much she has learned recently, and put into practice on her own.

While I have been managing to survive my recent professional upheaval with the support of a hospital family nine years in the making, two strong-willed brothers, a handful of professional advisors with over 75 collective years of experience, and plenty of luck, that dragon’s smile stands as a reminder that she alone has borne the brunt of maneuvering through the uncharted waters of first time parenthood.  Any initial feelings of personal guilt as a result of my situation are quickly succeeded by the pride I feel on her behalf as it dawns on me that the foundation she has so gracefully provided exists not just for my son in his first months, but for me as well as I close out an important and emotional chapter in the history of my family tree.

While I was focusing my energies on external responsibilities, it was my wife who kept the home front intact. We never did plan any such allocation of duties, nor could we have anticipated this perfect storm of sorts when her pregnancy was first announced.  Yet somehow during the process, perhaps when I wasn’t even paying attention, Natalya became both anchor and life preserver, in many ways taking care of me in much the same way as she did our son.  In this forum I have had ample opportunity to discuss the many relationships that have formed my understanding of health care and its continued survival throughout innumerable pressures. But I may have been remiss by not making it unmistakably clear that the relationships that form behind the scenes within the family nest are often what make it possible for health care workers to give their best in emergency situations day in and day out. Personally speaking, my support group is an army of one. On behalf of my son, my hospital family, and myself, I am forever grateful to my wife and my hero, Natalya.

As an aside, my mother-in-law recently arrived from Belgium to lend a hand and offer advice.  Her arrival underscores what I am sure the dragon must also be thinking as he watches what transpires in that little room: “A mother’s work is never done.”

The Relationships Behind the Healing0

This article first appeared on the PBS affiliated Website This Emotional Life.

In an 1889 essay, The Decay of Lying, Oscar Wilde argued that life often imitates art because “the self-conscious aim of life is to find expression,” and art provides an appropriate release. In many ways the same could be said of the current relationship between those who provide health care to the community and those who draft legislation governing such care. As the debate around health care reform enters its second year, perhaps it is time to stop and consider the full impact of the bill, not just on the health care system as a concept, but on the fate of the local hospital as a living, breathing entity.

The obvious uncertainties brought to life by today’s health care climate have over time become an unfortunate source of anxiety affecting nearly every patient-doctor relationship, as well as giving pause to the hundreds of thousands of health care workers industry-wide. For those on either side of the equation, the future of these relationships is now at a crossroads, in large part because neither professionals nor patients know what may be waiting around the next corner. Sadly, this all too often adds undue pressure to the already difficult task of care for the sick in the event of an emergency.

Next month will mark my nine-year anniversary as CEO of a hospital in Los Angeles County, California, in a role I had honestly never expected. I remember walking into that job on my first day, to face a group of intelligent, dedicated hospital managers who were devastated by the loss of their former leader.  As I addressed this room full of people – some of whom were in tears, some of whom remained stoic, all of whom were scared of what the future might hold – I wondered how I could ever comfort them for the loss they had just endured and assuage their fears of what was to come. The Hospital’s former CEO had died the day before from injuries sustained in a car accident, and it was my job to regain control of the facility and keep things functioning while learning the ropes as I went. There was no question I had some rather large shoes to fill, and but for the fact that the prior CEO had also been my father, I imagine I never would have accepted the challenge.

On the day of that first meeting with my new staff, we did not focus on our need to provide health care to the surrounding community.  Instead, we addressed the obvious issues of how best to continue forward as a team. Even so, no one working that day forgot the primary goal of any hospital, regardless of the surrounding chaos. Notwithstanding, for the next 3,300 consecutive days – almost 80,000 uninterrupted hours – the hospital did exactly as it should, using the network of relationships already in place and building on the new to continue its focus on providing care to the community.  In hindsight, the past nine years under my tenure were in many ways defined by these relationships, and our focus was strong.  As a result, the community received exactly what it had come to expect and deserve — a hospital.

Five months ago I began what would become a new chapter in this story, although initially I had no reason to anticipate the scope of its impact. It had become increasingly clear that the time had come to enter into discussions to sell the hospital to a larger health care group with the resources necessary to continue providing the area with top quality care. Throughout the process, which was long, arduous, and quite emotional for me, our focus was always to ensure that the community received what it deserved — that same hospital it had come to rely on for over fifty years.  Yet even in those moments when my focus waned, I knew I could depend on an extended family nearly 400 strong who made sure that we were well-positioned to deliver medical care to those who needed us. In the end, that’s what health care is all about.

Just the other day I entered that same room, filled with many of the same people from nine years ago.  While there were plenty of new faces as well, most of them had long ago become a part of our family. I explained that I had been preparing for this day for nearly nine years, although what was originally a day to which I had looked forward with anticipation was now one I truly dreaded. This time, I was to deliver a different message – that I would soon be stepping down as their leader. Looking out at the crowd as I gave news, every face reminded me of a lesson taught or learned, a favor asked or granted, or an experience shared.

I’ve heard it said that the whole is greater than the sum of its parts. When it comes to health care in the modern age that is certainly true, be it the correlation between community and hospital, employees and hospital, or even investors and hospital. As different as each of these bonds is from the other, all three survive only by existing together. These past few days I have witnessed first hand the ways in which change can make for a stressful environment.  The staff is nervous, the patients may be confused, and emotions run high. Nine years of consistency will undoubtedly lead to fear and uncertainty for a time, no matter who is waiting in the “on-deck circle”.

But that is what makes a hospital such a special place to work.  As chaos tries to rule the day, something happens, and a wake up call of sorts is given, reminding us all of the reason we have come together in this building on this day. Our dose of reality connects us with the real issue at hand. We remember that our community truly values the support we give in times of need, just as we do the same for one another.  After all, that is what relationships are all about.

If life could really imitate art, or at least the spirit of the law, it would make health care reform a much easier pill to swallow. To succeed in this endeavor, our primary goal should be to remember not just why we are here, but what the underlying purpose of health care in America is really all about.  For me, it has always meant faithfully serving the people who depend on us.  Though we may all sometimes forget why we do what we do, the relationships around us that maintain the hospital infrastructure so that it can operate all day, every day, are too important to ever be taken for granted.  Hopefully those who oversee the nationwide debate will one day come to accept this fact.