Friday, September 22, 2017

Musings on a Micro-Hospital for the City of Bremerton






Recently, Chelan County overwhelmingly passed a bond for $20 million to build a new hospital, with 64.87% approval.  The community felt their aging hospital was not viable and took matters into their own hands.  After the Bremerton Harrison Hospital closes, access will become more challenging in case of medical emergencies.  Bremerton has a large population of elderly, poor, disabled, or otherwise medically fragile. While most are resilient, this community deserves a viable solution for its healthcare needs. 

From what I understand, much of the hospital structure is aging and needs to be torn down, however it is possible there are recently remodeled sections which may be viable.  If a structural evaluation yields favorable results, I propose we maintain those sections and complete a targeted demolition where appropriate.

My ideal vision would be construction of a Harrison Community Campus, to include a micro-hospital for short-stay admissions, an emergency department, and a primary care clinic.  Micro-hospitals are defined as independently licensed facilities with 8-25 inpatient beds, a fully equipped emergency department, and ancillary services, such as pharmacy, lab, and imaging studies.  Micro-hospitals can handle acuity levels comparable to those of any standard community hospital and already exist in nineteen states.

The idea of micro-hospitals is gaining traction because costs of construction are far lower than that of more traditional hospital facilities –costing anywhere between $7-$30 million, depending on the range of services available, according to Advisory Board statistics.   Micro-hospitals can meet 90% of the community healthcare needs.  They seem to flourish best in markets with critical service gaps.  Ideally, micro-hospitals are located within 20 miles of a full-service hospital, facilitating the transfer of patients to larger facilities if higher-acuity needs arise.  Hospital stays anticipated to be longer than 48 hours are sent to higher-acuity facilities.  

To date, micro-hospitals are only found in states without certificate of need (CON) laws.  Washington State has strict CON regulations.  Depending on the Silverdale Hospital expansion timeline, by 2023 Bremerton may have an opportunity to recover 74 beds; however, if CHI completes Phase II on time, a micro-hospital in Bremerton will require a certificate of need (CON) approval. While this obstacle may prove difficult, it is not insurmountable. 

Emerus is the nation’s largest operator of micro-hospitals, with 22 facilities in operation and 25 currently under development.  Structures range from 15,000 to 50,000 square feet in size and function as “healthplexes,” including primary care clinics.  According to Vic Schmerbeck, executive VP of business development at Emerus, the goal is to provide care “in a place where people work, live and play.”  Some experts worry their small size is not adequate to serve large populations, however, remaining slight in scale allows for versatility within unique communities to provide a comprehensive array of services.

Most experts believe micro-hospitals are a cost-effective healthcare delivery option for those in urban, suburban, and rural areas.  An associate director of policy development at the American Hospital Association (AHA), Priya Bathija said “We [the AHA] really think they have the potential to help in vulnerable communities that have a lack of access.”  Peggy Sanborn, Vice President of strategic growth for Dignity Health, a hospital system considering a merging with Catholic Health Initiatives said “micro-hospitals have a shorter build time, allowing the health system to bring healthcare services to patients in the community faster.”

Micro-hospitals are becoming a small giant of healthcare—a highly successful model in the new era of value over volume.  Healthcare costs at a micro-hospital are slightly higher than those of an urgent care center, yet lower than a more traditional hospital setting.  As the healthcare industry trends towards greater emphasis on the health of communities, micro-hospitals are a perfect fit, delivering care close to home, while suitably sized to meet the evolving needs of the community. 

Bremerton is a community at risk of losing access to basic healthcare services.  Building a Harrison Community Campus would be an innovative solution to deliver care that is cost-effective and efficient.  With careful planning and conservative execution, a micro-hospital could benefit patients, providers and insurers, who are crumbling under the weight of increasing costs.  Our community needs primary care, plus inpatient, urgent, and emergency care services which are accessible to everyone.  If we are ever going to contemplate passing a bond for capital improvements, a micro-hospital is one plan worth serious consideration; it would be a worthwhile investment in our children, our neighbors, and ourselves.




Tuesday, September 19, 2017

Is It Time for Physicians to Unionize?






Since the birth of our nation, labor unions have existed in one form or another in the United States.  Unions are a force to protect the ‘working population’ from inequality, gaps in wages, and a political system failing to represent specific industry groups.  Historically, unions organize skilled workers in a specific corporation, such as a railroad or production plant, however unions can organize numerous workers within a particular industry.  Known as “industrial unionism”, the union gives a profession or trade a collective and representative voice.  The existence of unions has already been woven into the political, economic, and cultural fabric of America; it may be time for physicians and surgeons to unionize.

A labor union, is a body of workers who come together to achieve common objectives, such as improved safety, higher pay and benefits, and better working conditions.  Union leadership bargains with employers on behalf of union members to negotiate labor contracts (collective bargaining.) This may include the negotiation of wages, work rules, complaint procedures, and regulations governing hiring, firing and promotion, or workplace policies.

In 2010, the percentage of workers belonging to a union in the U.S. was 11.4%, compared to 27.5% in Canada.  There are strong, causal linkages between a diminished proportion of the workforce unionizing and loss of worker bargaining power.  Obviously, the leadership of corporations prefers workers having less leverage while negotiating; unions allege this employer-incited opposition has contributed to the decline in membership over time. 

However, the popularity of unions is growing, according to a January 2017 survey conducted by Pew which found 60% view unionization favorably.   More than half of young, millennial Republicans are in favor of unions as well, something that would have been shocking a decade ago.  Maybe the time is right for physicians to unionize?

In 1972, Dr. Sanford A. Marcus, a surgeon in private practice formed the Union of American Physicians and Dentists (UAPD).  It has been the most successful physician union and is affiliated with the AFL-CIO.  A quote from their website is apropos, “Hospital administrators easily manipulated physicians, treating them as if they were hired hands.  Insurance companies were dealing with them as if they were employees.  Government programs… controlled key aspects of doctors’ work, told them how much they would be paid, and what procedures they would be paid for.”  This sentiment sounds familiar.

Dr. Marcus saw medicine being ripe for takeover by corporations who were more concerned with profit than ensuring high quality care was provided to patients.  Medical associations were and still are overlooking the needs of front line practicing physicians; Dr. Marcus believed a union was the only organizational structure which could level the playing field.  He met with the AMA and they were ardently against unionizing.  The AFL-CIO initially balked at his suggestion, saying “Come back in ten years”, assuming most physicians would be employees at that point in time.  It has taken more than a decade, but our profession has arrived at the point where the majority of physicians are employed.  Large corporations are stripping physicians of professionalism and belittling our management role.

The Economic Policy Institute recently released a report with objective data supporting the assertion that unionization benefits workers in the long-term.  The EPI report found unions definitively raise wages for both union and nonunion workers.  A worker with a union contract earns 13.2 percent more in wages than a peer with similar education and background experience.  Through establishing wage “transparency”, unions raise earnings of women, black, and Hispanic workers, groups whose pay tends to lag behind that of their white, male counterparts.  Hourly wages for women are 9.2 percent higher than nonunionized women across similar occupations.  Black unionized workers in New York City earn 36.1 percent more than nonunion laborers in the same demographic. 

In addition, unionized workers have better health and wellness because unions ensure employers are held accountable for safe, non-abusive working conditions.  Unions can strengthen families by obtaining better leave policies, retirement benefits, and health insurance, while at the same time, safeguarding that employees have due process in promotions, dismissals, or terminations.  Front line workers often face tangible challenges often overlooked by management; as a result, they have a tremendous knowledge to suggest improvements to the workplace, make it safer, and increase productivity. 

Physicians certainly qualify as an industry sector whose bargaining power has fallen far below the value of their effort.  Labor unions exist to protect workers against imbalance in negotiations.  In a recent Washington Post article, Jared Bernstein posed that collective bargaining should be structured by industry sector instead of by individual corporations.  Interestingly enough, Larry Mishel, President of EPI and the report author, told Bernstein, “We need a design where people have collective bargaining rights as restaurant workers, as opposed to one where they gain those rights one restaurant at a time.”  Physicians may need collective bargaining rights as an industry, not as employees of Everyday Hospital, USA. 

UAPD has survived over four decades because they have offered traditional and innovative approaches to assist physicians with boots on the ground.  While officially opposing unionization, the AMA did try their hand at it during the mid-1990s, when President Clinton was working on universal health care.  After spending $3 million, they brought in 38 physicians, but the effort ended in colossal failure. 

For physicians in private practice, UAPD developed a grievance process when insurance companies unfairly deny reimbursement.  Their organization is run by physicians and for physicians.  They have won battles against large hospital corporations, advanced pro-physician legislation, organized a compassionate strike of physicians, and countered doctor-bashing in the media. 

Dr. Marcus once said, “There are no dinosaurs left…, they were unable to adapt to changing environmental conditions.  We stand a much better chance of preserving our professionalism through the process of becoming unionized workers – admittedly a terribly unprofessional thing to do... But then, that’s just the sort of adaption those dinosaurs were incapable of making, isn’t it?”  As the world becomes more divided, politically, economically, and medically, physicians stand to lose the profession we love dearly.  The moment has arrived for physicians to put aside our differences, of gender, specialty, or political ideology, and support an organized body standing up for the collective voice of physicians. 


Tuesday, September 12, 2017

Hold the Mayo and Save Our Hospital








There is a grassroots movement, 4500 strong, known as “Save Our Hospital” gaining notoriety in Albert Lea, Minnesota.  This story is symptomatic of the fact that hospital consolidation has slowly become a national pastime.  With declining revenue under the Affordable Care Act, mergers increased by 70%, leaving small communities scrambling for healthcare access.  The latest casualty in the ‘hospital-consolidation-for-sport’ trend is Albert Lea, a small city located in Freeborn County, Minnesota.



Known affectionately as the ‘Land between the Lakes,’ it has a population of 18,000 spread over 14 square miles.  Not surprisingly, Mayo is their largest employer; the 70-bed hospital serves almost 60,000 in a region including patients who live in Iowa.  In Rochester, MN, the Mayo Clinic is regarded by many as one of the premier medical facilities in the country.  Originally of humble origins, founder William Mayo opened a practice during the Civil War and later, passed it down to his sons; today, the Mayo Clinic flagship is located in Rochester, Minnesota and plans to become a renowned premier medical destination for the world. 



Corporations with such lofty ambitions tend to make “small” sacrifices along the way; often, on the back of a beloved rural town.  On June 12, Mayo clinic administrators announced they would transition all inpatient services to Austin, more than 20 miles away.  Mayo cited ongoing staff shortages, reduced inpatient censuses, and ongoing financial difficulties as their reasons for hospital closure.  Rural care was mentioned to be at a crisis point, which is an altogether callous assessment of the troubling situation facing communities across this country. 



The Albert Lea City and County Hospital Association formed in 1905 when concerned citizens raised funds to build a community hospital.  Renamed Naeve Hospital, after a prominent donor, it became the lifeblood of this rural community.  Physician groups collaborated to start the Albert Lea Clinic and Albert Lea Medical and Surgical Centers.  For financial reasons, on Jan. 1, 1997, Albert Lea’s Clinics and Naeve Hospital merged with the Mayo Medical Center in Rochester.  At that time, a now-retired local physician expressed concern about the challenges of recruiting physicians to the rural locale.  Mayo, however, scoffed at his assertion.  Recently, Dr. Bobbie Gostout, Vice President of Mayo Health Clinics, confirmed it was indeed difficult to recruit newly trained physicians to small areas with a heavy night call burden.



It is estimated the facility in Albert Lea sees 500 patients per day including office visits, dialysis, cancer care, and other outpatient services.  Approximately 7 patients per day will be affected by this move.   Freeborn County Attorney David Walker is evaluating if Mayo violated their bylaws by not holding a vote for the consolidation decision.  Mayo is denying a vote was necessary.  Walker has asked the state Attorney General to weigh in on the debate. 



Hospitals across the nation are focusing on efficiency while trying to improve care quality and maximize revenue.  Consolidation can help lower overhead expenses; however, over time, the heartland and the people being served suffer for a variety of reasons.  Mayo administrators blame $13 million in losses over the last two years at the Austin and Albert Lea campuses as the cause for hospital closure.   Prior to making this pivotal move, Mayo conducted an 18-month internal review; unfortunately, neither the City Council nor County Commissioners were consulted.  In July, Albert Lea City Council unanimously approved a resolution requesting Mayo halt the process until 2018, in order to solicit feedback from the community impacted by this decision.  The Freeborn County Board also called for a six-month moratorium from Mayo.  Both requests were denied by the behemoth that is Mayo. 

Not every community member in Albert Lea is opposed to hospital closure.  Some physicians working at Mayo feel they are stretched too thin and cannot survive with two rural facilities to staff.  Recruiting nurses and physicians has been extremely challenging, according to them.  The hospital in Austin is 20 minutes away, which they feel is adequate, alternatively, Owatonna is 25 minutes north, and Mankato is 35 minutes away and has a Mayo helicopter stationed there for medical evacuation needs.



Mariah Lynne, co-founder of Save Our Hospital, said "Our mission for Save Our Hospital is to maintain a full service, acute hospital in Albert Lea, Minn., for the benefit of our citizens and our surrounding citizens."  This grassroots organization is asking Mayo to return the hospital facility to Albert Lea so they can find another company interested in providing hospital services for their residents.  The Service Employees International Union (SEIU), which covers healthcare workers, is also supporting this community effort. 



Mayo plans to move intensive care, labor and delivery, and surgery services to the Austin facility, which is more than 20 minutes away.  Reduced access to timely medical care can actually translate into higher mortality in rural areas overall.  Since 1990, maternal mortality in the United States has been increasing steadily.  Today, more American women are dying of pregnancy-related complications than in any other developed country throughout the world. Rural hospitals, which are financially struggling, are less prepared for maternal emergencies today than they were two decades ago.  Potentially fatal complications which are initially treatable may become lethal in the setting of fewer resources and longer travel distance when seeking care.     



Mayo appears to be sacrificing a rural hospital in Albert Lea to pursue ‘champagne wishes and caviar dreams.’  Mayo plans to invest in the Destination Medical Center Project, focused on drawing foreign visitors who will bring with them not only champagne and caviar, but also open wallets.  Two major projects in Rochester are currently under way – the expansion of the Mayo Civic Center to the tune of $84 million and $93 million in upgrades at Mayo’s St. Mary’s Hospital.   When asked about complaints regarding the loss of services in Albert Lea while making elaborate plans in Rochester, Dr. Gastout said investments are helping to shore up Mayo’s long term survival.   She denies allegations the exorbitant Destination project is related to the Albert Lea Hospital closure, stating “Growth should not be misinterpreted as easy sailing in one place, and difficulties in another.”  



Reflecting on the loss of rural hospitals across the nation, my thoughts circle back to residents in Lee County, Georgia and my hometown in Kitsap County, Washington.  All three groups are engaged in clashes of David and Goliath-esque proportion against conglomerate hospital corporations threatening to destroy their respective healthcare landscapes.   While they might make strange bedfellows, City and County leaders are finding common interests aligning with local unions supporting healthcare workers, such as the SEIU (Minnesota) and UFCW-21 (Washington State.)  Together, these innovative alliances are making significant progress which may turn the tide.   For some of the large hospital systems, “easy sailing” may soon look like nautical navigation during a tropical storm.  While corporate headquarters is distracted with their dwindling bottom lines, betting on the underdogs seems prudent; after all, they are the ones gambling with their lives.  




Tuesday, September 5, 2017

A Two-Hospital Solution in the Event of a Mass Casualty Incident (MCI)




An Open Letter to the Washington State DOH Certificate Of Need Office:


CHI has had persistent operational and financial losses since 2012.  According to CHI’s Fiscal Year 2016 financial report, the company suffered a $460 million operating loss. According to Moody’s, CHI's total debt is at $9.0 billion and their outlook remains negative. The continued weak balance sheet will lead to further downgrades of long term and short-term bond ratings in the future.  As a result, they are seeking a merger with Dignity Health yet another conglomerate organization.

CHI turnaround strategies are: 1) Cutting staff, as salaries and benefits make up 50% of operating costs, 2) Reducing supply stockpiles for emergencies, 3) Outsourcing and 4) Speeding up revenue cycle operations.  “Turnaround strategies” have failed because staff may only be reduced to the extent they can save lives.  In particular, resource limitations of a financially-strapped corporation will be unable to mount an adequate response in the event of a mass casualty incident (MCI.) 

This past week, the nation watched as Hurricane Harvey became the costliest natural disaster in U.S. history.  Some have called it a “1,000 year storm.”  Tens of thousands were evacuated from their homes and needed shelter.  The death toll is slowly climbing.  Parts of Houston may be uninhabitable for weeks to months as the city works diligently to recover from the damage, physical, psychological, and emotional. 

In June 2016, Kitsap County emergency personnel participated in Cascadia Rising, a large-scale earthquake drill.  At the time, three local hospitals planned to coordinate management of injured casualties:  Navy Hospital, which would treat the “walking wounded” (least injured), or Harrison Silverdale and Harrison Bremerton, which would clear their emergency departments to receive the flood of injured patients.  While those plans have changed, the grave risk to our community in the event of an earthquake should not be ignored. 

In a Mass Casualty drill more than twenty years ago at Madigan Army Medical Center, I learned that optimum survival unequivocally depends upon sifting the distribution of injured casualties through the filter of expert triage.  Working fifteen years as a regional pediatric CPR instructor for the American Heart Association has taught me the value of ensuring emergency skills keep up with scientific progress.  Likewise, Kitsap County emergency plans will need modifications to reflect our changing healthcare landscape. 

The World Health Organization defines a Mass Casualty Incident (MCI) as “an event which generates more patients at one time than available resources can manage using routine procedures.”  Successful medical management depends upon the rational utilization of resources to ensure the timeliest treatment for the greatest number.  It is well accepted that smaller hospitals (those with Level 3 or 4 designations) face challenges treating larger numbers of casualties due to resource limitations. 

The ‘golden hour’ is the 60-minute period when medical intervention is most effective at reducing mortality following trauma.  Remoteness can preclude timely access to a Level 1 Trauma Center, like Harborview, which is 65 miles away.  Quick evacuation and transfer to an appropriate receiving hospital can be a highly critical task.  Casualty distribution decisions must prevent overwhelming a single facility, as exceeding hospital capacity can jeopardize care quality.  If only one hospital emergency department remains, there will be no alternative.

The Seattle Fault runs through Kitsap County from the Hood Canal to the Puget Sound. FEMA predicts an earthquake of 7.0 or greater magnitude could injure 400 people severely enough to require hospitalization and kill more than 150 people; thousands more could sustain minor to life-threatening injuries.  Survival outcomes will depend upon this ‘golden hour’ response time. 

Hospitals, because of their 24-hour operation and emergency services, are seen by the public as a vital resource for diagnosis, treatment, and management of injured people.  However, relying on one Level 3 hospital does not allow for the possibility it could be damaged or destroyed.  In Houston this week, 20 hospitals have had to evacuate, quarantine, or divert incoming casualties.  An internal emergency, such as loss of electric power or potable water, turns a hospital “back-up” into a critical life-line for our community.  According to Darrell Pile, chief executive of an advisory group for a 25-county region in SE Texas overseeing medical crisis preparation and management, the storm “challenged every plan we’ve written, every resource, every piece of inventory.”

The best scientific studies were conducted in Israel following accidents or terrorist attacks.  They demonstrated that utilizing two lower level ER/hospital facilities in tandem was critical to efficient management of injured casualties, particularly occurring outside a metropolitan locale.  For Kitsap County specifically, the best case report in the literature involves a passenger train and truck collision in a geographically isolated Israeli town.  Air evacuation by helicopter enabled rapid transport of casualties from the accident scene to two lower-level trauma centers and permitted equitable distribution of the wounded.  According to the study, 289 passengers were injured and 7 were killed.  Six helicopters participated, evacuating 35 victims by air, with an elapsed time between first helicopter landings to mission completion of 83 minutes.

Due to the fact access could be complicated by geography, air-medical evacuation has been strategically incorporated into the county MCI response plan.  Understanding our topographical limitations, I spent six weeks on Life Flight Teams 1 and 3 in Colorado conducting helicopter and fixed wing patient transports in preparation for independent medical practice on the Olympic Peninsula.  One helipad at one hospital plus one accessory landing zone will not allow adequate means by which to transport the high volume of casualties conceivably produced by a MCI.  The Israeli case report specifically highlights the value of using unconventional solutions when navigating geographic challenges. 

In the event of a devastating earthquake, our community could be isolated for days or even weeks, as connection to mainland, by bridge or ferry, may be temporarily disrupted.  The Peninsula has 3 level III centers, Harrison Bremerton and Silverdale (336 beds), and Olympic Medical Center (126 beds.)  Jefferson Healthcare and Mason General have Level IV designations.  Due to the fact that access to high level trauma care requires crossing a bridge, evacuation by helicopter will be essential.  Cold” loading (the method used by non-military medical teams) is safest; yet requires landing, shutting the engine down, loading the patient, and then lifting off, with a turnaround time of 13-15 minutes at a minimum.  A single facility will quickly become massively overwhelmed; whereas, having two to four landing zones at two hospitals provides the opportunity to meet the needs of wounded casualties most efficiently.

The pattern of distributing casualties to multiple receiving centers after MCI’s in the United States is well-established. Victims of the Columbine massacre were evacuated to six different hospitals.  After the devastating Virginia Tech shooting, 29 victims were triaged through four facilities.  One hospital assisting that effort was Montgomery Regional, with a Level 3 designation; they had the capability of receiving only 15 wounded, yet successfully stabilized them all.  Three who were more severely injured were directly transported to the nearest Level 1 Trauma center 27 miles away.  Outcomes absolutely depend upon matching casualties with facilities having the adequate resources to stabilize them.

In Aurora, CO, 100 injured people from the movie theatre were sent to six different hospitals.  Not only did first responders coordinate flawlessly, but they also used unconventional distribution procedures which improved outcomes.  For the first time, victims were transported two to three at a time inside of police cars.  A retrospective analysis concluded this single decision saved the lives of many, even though emergency personnel took a chance.  CHI consolidation plans involve a calculated risk too, one which may cost more lives than initially anticipated in the long-run.

A two-hospital solution provides our best chances for survival in the event of a MCI, an assertion backed by solid scientific evidence.  The procurement of every hospital bed by a corporation on the brink of financial implosion and their ill-fated hospital consolidation is gambling with our lives.  Since Cascadia Rising, the ER at Naval Hospital has downgraded to an urgent care, leaving fewer options for allocating casualties.  Moreover, Kitsap County is poorly situated geographically, precluding timely access to high level trauma care, which makes thoughtful triage, evacuation, and transport of victims even more critical. 

In my opinion as a mother, community physician, and county resident, a two-hospital solution is best for the entire population of Kitsap County.  This hospital consolidation controversy has mostly focused upon CHI financial quandaries, the fact monopolistic systems drive up cost, and guaranteeing freedom from their religious directives.  Additionally, we must prioritize preserving and protecting the 250,000 innocent lives of those residing in our beloved community in the event of a mass casualty incident.