California’s Vanishing Community Hospital: An Endangered Institution0

This article first appeared in the Fall 2011 Issue of California Health Law News, a Publication of the California Society of Healthcare Attorneys.

Across the nation, America’s community hospitals are under siege. Once considered indispensible to our health care system, the twenty-first century finds the local hospital fighting an uphill battle against a convergence of factors that favors the sharing of resources by multiple facilities.  Rising health care expenses, challenging regulatory hurdles, and a reimbursement structure in the midst of transition all bear some responsibility for the obstacles faced by today’s community hospital.  Nowhere is this phenomenon more pronounced than in California, where regular hospital closings amid an ever-growing population stand as incentive for remaining hospitals to team up (or remain teamed up) under the potentially false notion that in modern American health care, there is safety in numbers.

Learning From Past Mistakes – What History Reveals About Health Care

Understanding the historical evolution of the American hospital is fundamental to recognizing the core problems faced by smaller hospitals today.  From the 1736 opening of an almshouse in New York City (which would eventually become Bellevue Hospital) through the expansion to nearly 5,000 hospitals by the 1920s, and continuing through the post-1960 shift toward multifunctional facilities, health care has responded to the socioeconomic and political influences of each era.  A trend of multihospital systems replacing freestanding community hospitals picked up speed after 1965, driven largely by a combination of economic factors (including the creation of Medicare) and technological advances in medicine.  The five hospital consolidations noted in 1961 ballooned to upwards of fifty per year in the 1970s.  By the 1980s, an estimated thirty percent of the hospital beds in the United States existed within hospital systems.[1] … Read more →

Our Fear of Health Care Reform and the Household Vacuum0

“That’s the nice thing about carousels, they always play the same songs.”  The Catcher in the Rye by J.D. Salinger

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

It starts with a vacuum.

The sudden, unfamiliar dissonance signals fear in his little mind, which grows quickly, magnified by the sight of an unexpected entanglement between the woman he trusts most and this monstrous machine. As he turns to run (or crawl), I find myself thankful to be just inches away, in perfect position to catch my 10-month old boy as he does his best to flee the frightful scene. His two outstretched arms secure a tight grip around my neck, while a sad face burrows deep into my chest. For one sharp moment I feel like a hero, a wholly necessary, trustworthy entity whose sole purpose is to be relied upon in times of trouble.

Fear is a formidable foe, and the ways in which we as grown ups react to its presence can often be inconsistent. Regardless of its origin, any meaningful cause for alarm typically signifies a commonality of chaos, to be first understood, and then vanquished. Though my son’s safety was obviously never compromised during his run-in with the vacuum cleaner, his reaction illustrates the fact that in the eyes of an infant the world is full of uncertainties. In the mind of a child, laughter and tears coexist every day, yet we seldom stop to consider how these emotions actually resonate. Rather, we tend to focus on the cause, which with luck might lead us to a solution, as a means to restore the calm and save the day. Indeed, some of the most seasoned parents have an entire cache of remedies upon which to rely when a crisis hits, and they wield them like weapons of precision, each one crafted and selected for just the right moment.

But what about the child in the midst of a trauma?  … Read more →

Providing Care for the Uninsured Without the Federal Case0

The article first appeared in Becker’s Hospital Review.

Estimated at close to 50 million strong, the fate of America’s uninsured has caused quite a stir of late. As the media anxiously reports on the U.S. Supreme Court’s acquiescence to assess the constitutionality of certain tenets at the heart of healthcare reform, the nation sits anxiously on the sidelines, awaiting the outcome. Indeed, a suggested, unprecedented televised hearing on the insurance mandate could potentially attract even more viewers than the record-breaking 111 million football fans who watched the Green Bay Packers beat the Pittsburgh Steelers in Superbowl XLV on Feb. 6, 2011.

The uninsured conundrum

At the core of the debate lies an enormous price tag. The sheer volume in dollars it takes to provide medical treatment to the uninsured is astounding, and its ramifications affect many fundamental aspects of our healthcare structure. In 2008, uncompensated medical care in the United States approached an estimated $57 billion, of which nearly $43 billion was paid by federal, state and local governments from funds earmarked for this very purpose. Although the federal government typically foots close to half of this annual bill, its contribution equals only 2 percent of federal healthcare spending yearly. The great bulk of responsibility for America’s uninsured falls to our nation’s hospitals, who shoulder approximately 60 percent of uncompensated medical care, due largely to a regulatory structure mandating that emergency departments at hospitals participating in Medicare or Medicaid must treat just about anyone who arrives in need of medical care, regardless of citizenship, legal status or ability to pay.

To add to the friction, most Americans have a stronger grasp on the rules of professional cricket than they do the leading constitutional challenge to President Obama’s 2010 Patient Protection and Affordable Care Act. … Read more →

Tracing the Evolution of American Health Care Through Medicare0

This article first appeared in the journal Health, Culture and Society.

I. Before Medicare

Since its inception as a government sanctioned public health insurance program, Medicare has been both a bone of contention between political parties and a beacon from which to gauge the changes in American health care as a whole. Passed as part of the Social Security Amendments of 1965, Medicare had as its focus individuals sixty five years of age and older, with a similar yet state-run program, Medicaid, addressing the medical needs of people with certain disabilities and low income families. Over time, however, Medicare has grown to be the preeminent standard for our nation’s health care in its entirety, with nearly every substantive change to its core foundation signaling a corresponding restructuring of our overall health care system.

The modifications imposed on Medicare, both by market forces and federal legislation, stand as a series of growing pains from which to mark the evolution of the American health care model. By charting these changes through the decades we can better understand the ways in which health care as a whole has morphed from a cost based system to one of performance evaluation. In turn, this may provide us with a glimpse into health care’s future if certain fundamental issues are not addressed in current reform legislation.

The rise of the government’s role in providing health care to its citizens came relatively late in America’s history. For much of its first two centuries the burden of caring for the sick and injured fell to neighbors, friends and relatives, with additional support from individual communities and religious groups. Visits by an actual doctor were generally limited to the home and dictated by local demographics. Almshouses and charity wards provided a certain degree of medical service, as hospitals were few and far between, and often existed solely upon the largess of the surrounding vicinities. Those who had the opportunity to visit a hospital prior to the twentieth century more than likely did so after an accident or as the result of an unfortunate designation of insanity.

Read the complete article here.


Keeping score on health care reform0

This article first appeared in the Daily Journal on November 9, 2011.

As 2011 enters its penultimate month, the fledgling Patient Protection and Affordable Care Act continues to unfold, and at times, unravel. Nearly two years after its passage, federal regulations are still building upon the original 2,700 pages, even as the threat of repeal dangles over the Executive Branch like a Sword of Damocles. With its fate resting in the hands of the U.S. Supreme Court and Electoral College, and speculation as to whether the justices will make a move before the American voters have a chance to weigh in making headlines daily, it appears that many of health care reform’s latest additions may be here to stay.

The New and Improved Accountable Care Organizations

At the forefront of reform stand the new and improved accountable care organizations (ACOs), health care partnerships designed to monitor the quality and efficiency of doctors and hospitals and create new quality standards for compensation. The original version of the ACOs released last April met with significant industry-wide opposition, so much so in fact that three additional federal agencies exerted their authority heavily on the rewrites. First, the Office of the Inspector General clarified the implications of physician self-referral laws and federal anti-kickback statutes, thought by many to be glaring omissions from the original version.  Likewise, the Federal Trade Commission confirmed that entry into ACOs will not require a mandatory antitrust review, while at the same time creating an antitrust “safety zone” for ACOs approved by the Centers for Medicare and Medicaid Services. The Internal Revenue Service provided another critical component by establishing participation guidelines for charitable organizations without compromising any tax-exempt status.

Under the revised regulations, retrospective assignment of patients gave way to a preliminary prospective-assignment method, identifying beneficiaries quarterly with an opportunity for a final reconciliation after each performance year.  The new regulations also cut in half the number of quality measures to which ACOs must adhere (from 65 to 33) while adding some flexibility within each calendar year as to when ACOs must perform. Compliance with electronic health records has also been discarded as a condition of participation, although the digital medical record remains an important quality measure.

The Many Ways To Save

As the nation’s growing financial struggles threaten health care reform’s very survival, it is no wonder the government is trying to tighten its belt in any way it can. … Read more →

Advice from Antiquity0

“Life is like riding a bicycle. To keep your balance you must keep moving.”  — Albert Einstein

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

Every so often I stop to reflect upon the seemingly random series of events that have led my life to its current point. In times like these my mind rarely gravitates toward any single individuals who left lasting impressions, positive or negative, but instead remains fixed on the patterns that have emerged over time.  Make no mistake, I still search for a seemingly insignificant or banal event from my past that might offer some magical context to help define the person I have become, especially in light of my newfound fatherhood.  And yet, while I am not holding out for such an epiphany any time soon for myself, such a revelation could do wonders for my son as he crawls faster and faster toward the conclusion of his first year.

At the age of eleven, I read my first Greek myth, and I was hooked. Eleven years later, I graduated from college with a major in classical studies, a discipline I have described as familiarization with an abundance of Greek myths experienced in a written rather than spoken format, in a language that dates back seven to ten thousand years.  From this historical depository of dactylic hexameter and Socratic dialogue, a few key tenets have remained permanently etched in my brain, and it is not uncommon for me to draw upon these scraps of wisdom on any given day. While often overshadowed by the technological advances that largely define our fast-paced modern society, I continually find that those bits of knowledge I learned twenty years ago are more than enough to help me navigate through even the most baffling of days.

Victory comes to men in turns.”

This famous quote from a traditional English translation of Homer’s Iliad is a source of comfort and hope in troubled times as well as a gentle reminder for us all to strive for humility at any stage. … Read more →

Facebook and EHRs: A Very Fine Line Just Got Even Finer0

This article first appeared on

Americans love their privacy. And yet, as the ever-increasing trend of social networking illustrates, they also love to share the facts of their lives. As a result, defining privacy can be tricky in this modern age and often depends on the venue in which information is presented and the form it takes.

In today’s world of electronic health records, straddling the fence between harmless information and sensitive data is no longer such an easy task, and the repercussions for the slightest transgression can be severe.

On August 22, HHS issued a press release challenging software developers to create new Facebook applications to assist in emergency preparation efforts. If Facebook was a nation, its “population” would be more than double that of the United States. If online minutes for Facebook users were the functional equivalent of “dollars spent,” the social network’s estimated $84 trillion in annual “spending” would top the collective gross national products of all nations across the globe, even if the U.S. or European Union were counted twice.

While Facebook is a great way to stay connected to friends and family, it also can blur the line between privacy and the public domain. With a few quick clicks you may come to learn that Susan is at the coffee shop with Billy, Milton is attending a marketing seminar, or David is recovering nicely from a recent appendectomy at a hospital in Florida.

While Facebook might be given free rein to spread news of David and his recently removed appendix, other mediums must proceed with caution. If someone from David’s hospital was to leak his news, the hospital would face great scrutiny because health care providers are bound by law to obtain in advance David’s express, written authorization to publicly disclose details about his physical well-being. This is true even if said metadata were common knowledge among David’s 268 Facebook friends. … Read more →

Preparation Does Not Guarantee Perfection0

This article first appeared on California Healthcare News.

California has always found its way into the public spotlight, and 1975 was no exception. That is the year in which Jerry Brown became the state’s 34th governor, Nolan Ryan started the season for the California Angels, President Ford survived an assassination attempt in Sacramento, actors Jon Voight and Marcheline Bertrand gave birth to their daughter Angelina Jolie Voight in Los Angeles, and the state’s Medical Injury Compensation Reform Act of 1975 (MICRA) was passed.

At its core, MICRA was the end result of efforts to save California’s physicians from the fallout of a multitude of lawsuits, runaway jury verdicts, and draconian responses by insurance liability companies. With its $250,000 cap on non-economic damages in medical malpractice litigation, MICRA made history as its backers trumpeted the salvation of medicine in California. Controversial from the day Governor Brown first signed it into existence, MICRA continues to face challenges these 36 years later. For better or worse, however, MICRA addressed a critical issue and assuaged what were at the time very real fears that issues of liability and catastrophic jury verdicts would bring California’s medical system to a halt.

California’s hospitals are not alone in their need to proactively address situations involving unforeseen events. In this present era of health care reform, providers across the nation have an even greater abundance of legal issues on which they must focus their attention. For example, in the not too distant past a new concern appeared on the horizon some 2,700 miles from Sacramento. August 2005 saw Hurricane Katrina wreak havoc throughout southeastern Louisiana, with a death toll in excess of 1,800 and an $80 billion price tag, to say nothing of the sociological and environmental collateral damage that quickly followed.

Once the storm had passed and the dust had begun to settle, a frightening discovery at Memorial Medical Center in New Orleans captured the nation’s attention anew and resonated in the hearts and minds of every hospital administrator across the nation. Forty-five Memorial Medical Center patients died from the Hurricane, a number greater than any other New Orleans hospital, and blame was quickly directed to the hospital and its failure to provide for its community in an emergency situation. … Read more →

PBS’s ‘This Emotional Life’: Medicine By the Numbers

PBS’s “This Emotional Life”: Medicine By the Numbers

Lewis Carroll wrote: “If you want to inspire confidence, give plenty of statistics. It does not matter that they should be accurate, or even intelligible, as long as there is enough of them.”

When people are first told that a loved one is in the hospital, they want answers. Straight answers. And they want them fast.

But oftentimes in today’s medical centers, what patients and family members alike are met with is numbers: Hypotheticals, probabilities and percentages. When combined with complex medical jargon, this can quickly lead to confusion and uncertainty, as those involved must make sense of the stats before they can understand the state of the patient’s condition. Without the proper frame of reference, this type of information can quickly exacerbate fears and increase emotional distress. Rather than serve as beacons to shed light on a patient’s chances, these figures quickly become barriers to the truth. For many of us, the numbers are to be feared, not followed.

Still, whether we like it or not, playing the percentages is a medical necessity. In the modern age, health care is all about the bottom line. As technology advances and life expectancy increases, today’s treatment options become more and more focused on the probabilities of success or failure. From prenatal care to geriatric services, every patient ultimately wants to know one thing: “Where do I stand?” More and more, the answer is delivered as a number, culled from experience, testing, and appropriate clinical research trials. This often leaves the physician to mediate between patient and procedure, as he or she attempts to present new information in such a way that those involved can both understand and take comfort from that most dispassionate of messengers, the statistic.

The numbers themselves are not to be blamed. At the risk of making modern health care sound like a sports bar in Las Vegas, the purpose of statistics in a medical environment is to give the facts about a patient’s condition in black and white, which, if not done humanely, can seem lacking in compassion. The key to recognizing the value of such numbers is to use them as guidelines, not ultimatums.

Properly used, statistics perform a dual function: When correctly interpreted and explained, these numbers can act as a security blanket, breaking down frightening uncertainties into hard facts in which patients can wrap themselves during a time of emotional upheaval, while also providing a solid understanding of treatment options and outlooks. From a doctor’s perspective, they stand as a buffer, protecting the physician from being forced into the unrealistic role of savior, no matter what the condition. In their way, percentages help to reinforce the idea that nature, and not the doctor, will ultimately make the final call as to a patient’s future. Such impartiality goes a long way toward strengthening the doctor-patient relationship, especially when the prognosis is not as good as a patient might have expected.

Numbers can be persuasive to those patients faced with making important yet difficult lifestyle changes or deciding upon end-of-life treatments. For patients diagnosed with serious illnesses and their families, much of today’s medical data provides hope. For example, according to the information available at the end of 2009, life expectancy in the United States reached an all-time high in 2007 — 77.9 years (75.3 years for men and 80.4 years for women). Between 2006 and 2007, rates dropped for nearly half of the leading causes of death in the United States (cancer, heart disease, stroke, hypertension, accidents, diabetes, homicides and pneumonia), reaching a new low of about 0.76 percent of the population (760.3 deaths per 100,000 people). That is approximately one half the rate from 1947. Once fatal illnesses are slowly being reclassified, provided the patient heeds the warnings found among the numbers and takes the appropriate steps to live in a healthier manner.

On the other end of life’s spectrum, many newly pregnant couples become surprisingly imaginative upon first hearing their good news and spend much time contemplating the worst. To calm the parents’ nerves (and to protect the doctor’s interests), it is now standard practice to administer a series of tests to assess the baby’s health throughout development. Then end result of most of these tests comes back in numbers. Statistics again.

Without debating the ethics and morality of abortion, which is not a doctor’s role, many of these tests seek to ascertain the health of the fetus and predict the odds of certain birth defects such as Down syndrome, trisomy 18, or trisomy 13. The number of things for a pregnant couple to worry about can be staggering, yet doctors are often obligated to advise them of the chances in advance. For example, in North America, 1 in 260 females carry the chromosome for Fragile X (also known as “Martin-Bell”) syndrome, a genetic disorder that results in an array of physical and mental limitations, ranging from severe to mild in manifestation. Likewise, 1 in 149 Ashkenazi Jewish individuals carry the gene for Nemaline Myopathy, a neuromuscular disorder that causes muscle weakness of varying severity. In its most potent form, Nemaline Myopathy results in death after just a few years. By incorporating these tests with such relevant factors as the age and overall health of the mother and the genetic background of each parent, doctors can provide a statistical model on which to gauge the probability of the baby’s being born to normal health. This can provide parents with peace of mind if the chances of defects are low, or the opportunity to prepare themselves or consider their options if the outlook is not favorable.

At least one reason behind the surge in statistical diagnosis is the continued rise in medical malpractice claims. Having been forced into the role of omniscient healer as a result of advances in diagnostic testing, doctors must now use this same technology to cover themselves in the event of a statistical improbability. A recent study by the American Medical Association concluded that “defensive medicine” (defined as medicine relying upon diagnostic and other therapeutic measures to safeguard against malpractice claims first, and the health of the patient second) increase health care costs by as much as $150 billion each year. To be sure, throwing the title of statistician into a doctor’s medical bag of magic tricks does not help to further the doctor-patient relationship.

There is no numeric substitute for direct and clear communication between a doctor and patient. That said, making sense of medical statistics can go a long way in helping a patient understand diagnosis, prognosis and treatment. If you or a loved one has been diagnosed with a potentially life-threatening illness, your decisions about treatment can often be linked to “quality of life” concerns. No matter what age, patients want answers to certain questions, often combined with supporting statistics, such as:

  • How will this disease affect my life on a day-to-day basis
  • Is this disease terminal, or if left untreated, will it become terminal?
  • How will the treatment affect my life on a day-to-day basis?
  • How will the disease, treated and/or untreated, alter my life expectancy compared to my anticipated decline in health as I age?

It is important to remember that statistics are numbers, plain and simple. While numbers may not lie, they have no bedside manner and can be interpreted in a variety of methods and made to suit many arguments. The best way to know where you or your loved one stands is to discuss your situation clearly and openly with your doctor, taking into consideration the big picture as well as the percentages.

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