Tuesday, January 23, 2018

Mayo Clinic Health System: Truth, Falsehood, and Ice Cream

The Mayo Clinic in Rochester has held the top spot on the U.S. News and World Report hospital rankings for the past two years, despite the closure of community hospitals that negatively impact rural Minnesota towns. 

Citing staff shortages, reduced inpatient censuses and ongoing financial challenges, Mayo decided to move all inpatient services from the hospital in Albert Lea, Minnesota, including labor and delivery, to a town more than 20 miles away. In response to pleas for reconsideration, Mayo Clinic Vice President Bobby Gastout callously remarked that 23 miles is not ideal — but “people are driving 23 miles to get their favorite ice cream.” 

A grassroots group, Save Our Hospital, galvanized the community by answering “we like our ice cream and inpatient care in Albert Lea.”

So how will our country, from the Midwest to here in Kitsap County, ensure health care access doesn't continue to come second to profits? 

Price transparency must be mandatory at non-profit hospitals if runaway healthcare costs are to be contained. Behemoth institutions are decimating rural areas after a decade-long buying spree. A study in Health Affairs magazine found nearly half of rural counties in the United States are without hospital-based OB services, a change affecting more than 2.4 million women. According to the University of North Carolina's Center for Health Services Research, 83 rural hospitals have closed since 2010. Hospital systems complain they are crumbling under the weight of lower reimbursements, rising bad debt from high-deductible plans, and dwindling admissions.

However, communities are entitled to see the proof in the pudding.

While touting $13 million in losses over two years as the central force behind the closure decision, in reality, Mayo misrepresented their facts and figures according to tax returns posted by ProPublica. Dr. Mark Ciota, CEO of MCHS-Albert Lea, reported the hospital lost $4.6 million in 2015, but the nonprofit's IRS 990 form showed a net income of $2.56 million. In 2016, the Albert Lea hospital projected a loss of $8 million, though residents eagerly awaited release of Mayo's tax returns to separate fact from fiction. Mayo conveniently overhauled its tax reporting process and filed a group return, a format which obscured financial performance of individual campuses, including Albert Lea.  Allen Baumgarten, a Minneapolis-based independent healthcare analyst, utilizes public records to calculate hospital profits and losses — he estimates the Austin-Albert Lea campus generated a net income of $1.2 million in 2016. 

Earlier this year, Dr. John Noseworthy, CEO of Mayo Clinic, feigned financial woes, complaining Mayo had to “prioritize commercially insured patients” over those on Medicaid and Medicare in the interest of long-term survival. Yet they had no reservations investing in the Destination Medical Center Project, a 20-year, $5.6 billion economic development initiative which will position Rochester (actually Mayo) as a global center to provide high-quality medical care to the wealthy across the world. Astonishingly, third quarter earnings show Mayo operating income more than doubled from $86 million to $182 million, with total revenue increasing 9 percent, from $2.72 billion to $2.97 billion.  In 2016, international investment income was $2.7 billion, while close competitors, Cleveland Clinic and Johns Hopkins, produced less than half that amount. 

Mayo benefits handsomely from public tax revenue while exempted from paying city, state, or federal taxes in exchange for “improving” healthcare access for struggling communities. While no one is questioning legality of these investments, ethically the loss of rural hospitals is hard to reconcile when Mayo pours $1.34 billion into offshore tax havens to reduce their tax liability.   

Ice cream may melt on a 23-mile drive, but ill and injured people may actually die traveling that same distance. Movements like “Save Our Hospital” are garnering national attention with good reason, as they are David bravely taking on Goliath.

To ensure access in rural communities, non-profit hospital institutions should provide transparent pricing to patients and share financial performance data with communities. Benjamin Disraeli said, “there are three types of lies – lies, damn lies, and statistics.” Mayo has fractured trust by misrepresenting operating losses in Albert Lea to justify hospital closure, Dr. Noseworthy condoned prioritizing patients based on their pocketbooks while third quarter earnings went through the roof, and hospital leadership condescendingly compared driving 23 miles in labor as being equivalent to buying ice cream. 

Places like Mayo are systematically dismantling rural care facilities without accountability for the generous tax exemptions they receive. The loss of one more rural hospital this year will be a loss for the entire nation. The battle for affordable, accessible, and high-quality health care is one worth fighting. Rural health care is far more important than ice cream. 

Tuesday, January 16, 2018

Is the Marital Status of a 5 year old Child Important?

My pediatric practice is one which harkens back to days long ago when physicians knew their patients and pertinent medical histories by heart.  My 81-year-old father and I were in practice together for the past 16 years; he still used the very sophisticated “hunt and peck” to compose emails.  The task of transitioning to an electronic record system seemed insurmountable, so we remain on paper.  Our medical record system has not changed in almost five decades.  I would not have it any other way.  

This past spring, he walked into my office shaking his head in disbelief after thumbing through a stack of faxes.  “Can you believe this 16-page emergency room note has no helpful information about the patient?”  This was not a shock to me.  The future of medicine will include robots who are paid to collect reams of useless data to provide nothing in the way of health or care.   Regardless, the government and third-party payors will extoll upon the virtues of their inept system as life expectancy falls. 

Fifty years ago, there was a close relationship between a physician and their patient grounded in years of familiarity.  Physicians took a history, performed a physical exam, and developed an assessment and plan.  Diagnosis in a child with fever would be descriptive, like Bacterial Infection, Otitis Media, Fever of Unknown Cause, or Viral Illness.  Parents were advised to provide supportive care, involving clear liquids, fever medication, and follow up precautions if the child worsened.    

At the dawn of the technological age, the effortless simplicity previously existing between physicians and patients has all but evaporated.  It was traded away without our consent, relegating the role of physician to that of a data-entry clerk.  Physicians are discouraged from synthesizing information and utilizing it to guide our decision making.  Today, a 16-page document “appears” to contain crucial elements such as chief complaint, past medical and surgical history, medication list, and allergies, however, the information is then followed by more than a dozen pages of waste.

The particular case to which my father was referring involved a 5-year-old child with fever.  The provider documented the sexual history of this child, whether he was single or married, and whether or not he had children of his own.  My dad and I started chuckling as we contemplated collecting this kind of extraneous information from a child who had not even entered puberty.  As one would suspect, our young patient was single, as in not married; he had no children (which is physiologically impossible), and his years of formal education were noted “not pertinent to his medical situation.”  Interestingly enough, I volunteer at the school where this young boy attended kindergarten; his classroom was next door to the one with my second oldest child.  Three of his classmates were out with febrile illnesses, however technology cannot incorporate this kind of alternative data. 

We kept reading and laughing.  Occupational history was recorded as not on file; running a bustling lemonade stand in his neighborhood apparently was not clinically relevant.  It came as quite a relief that at the tender and impressionable age of five, this boy had managed to steer clear of regularly smoking cigarettes.  It was comforting to discover he had never used smokeless tobacco either; and for some reason, I never thought to inquire about such things before (insert eye roll.)  He also denied alcohol use, restoring my faith in the fact that not every youngster was consuming alcohol during their formative childhood years. 

Just when I thought things could not get more absurd, I came upon the sexual history; contemplating whether or not a five-year-old child was engaging in consensual intercourse was nauseating.  I reminded myself that data entry clerks were devoid of emotion and instead were tasked with collecting “critical” details to practice by protocol.  Sexual history: Not on file. 

The final summary and diagnosis section was the most entertaining part, which read: “primary diagnosis:  none.”   Seriously, are you kidding me?  No diagnosis?  This is the future, technology will seal the fate of our profession as one entirely devoid of the need for any cognitive skills.  This earth-shattering conclusion after sixteen (16!) pages of documentation was utterly astonishing.  Despite the considerable time and effort invested asking a febrile five-year-old whether he was married or having consensual sexual intercourse in his spare time, little to nothing was provided in regard to healthcare.

At this point, my father and I laughed so hard that tears were running down our cheeks.  There is no other reasonable response to the sheer waste of time, resources, and education invested in becoming a physician.  Doctors have spent decades honing their clinical skills and should be entitled to choose the documentation method they find most effective and efficient.  Some physicians find electronic records helpful and should be encouraged to use them.   My pediatric practice will keep surviving on a shoestring, a prayer, and good old-fashioned paper.  It warms my heart to know each chart note contains helpful information and not one human being leaves with NONE as their diagnosis. 

Footnote:  Page 16 states: “This chart is intended to document the majority of the information from this patient’s visit today.  Other items, such as the patient’s care timeline, are reported elsewhere and should be reviewed to better understand this encounter.”   (More eye rolling.)

By all means, if 16 pages did not cut it, twenty more should make sense of arriving at no diagnosis.  Forgive me for not running out and requesting those records immediately.  

Tuesday, January 9, 2018

Life Expectancy Declined Again... No Surprise

Newborns born in 29 other countries of the world have life expectancies exceeding 80 years; yet, an infant born in the US in 2016 is expected to live only 78.6 years according to recently released statistics.  While death rates fell for 7 of the 10 biggest killers, such as cancer and heart disease, they climbed for the under-65 crowd.  The irrefutable culprit is the unrelenting opioid epidemic. 

Last year life expectancy declined for the first time since 1993.  The last two-year decline was in 1962 and 1963, more than a half-century ago.  I predicted (accurately) it would decline again this year unless there was a dramatic change in the primary care physician workforce.  We are dying at a younger age today than two years ago– two months earlier to be exact.  It might not sound monumental, but life expectancy is the king of noteworthy health statistics, making it quite significant in the grand scheme. 

In the past, epidemics by definition were temporary; the narcotic epidemic will be anything but transient; there is no foreseeable end for the scourge of opioid addiction sweeping the nation.  In my humble opinion, the solution to this dilemma is no different than it was last year, we must correct the primary care physician shortage.   Time is of the essence.  The last three-year decline occurred in 1912- 1914 as a result of the Spanish flu.  Unfortunately, life expectancy will continue to decline until the nation makes comprehensive changes. 

One in five Americans live in a primary care shortage area; the ratio of the population to primary care providers is greater than 2,000 to 1 (Bodenheimer & Pham, 2010), when it should be closer to 1,000 to 1.  I am a third-generation primary care physician, with a unique historical perspective on how medical practice has changed since my grandfather made house calls back in 1940.   My practice is currently located in a shortage area and the difference in volume compared to 16 years ago when I first hung a shingle, is extraordinary.  Only 37% of doctors serve in primary care, yet 56% of the office visits are completed by that particular group of physicians (Health Resources and Services Administration, Bureau of Health Professions, 2008.)  In my grandfathers’ time, primary care physicians made up 70-80% of the physician workforce.

Adding one primary care physician per 10,000 population, reduces mortality by 5.3%, avoiding 127,617 deaths annually. As an added bonus, primary care has a high rate of return on lives saved per dollar invested. Some healthcare policy experts believe the answer to the primary care physician shortage is to encourage physician extenders, such as nurse practitioners or physician assistants, to practice independently, a role for which their education was not originally intended.  The misguided belief that the comprehensive education of a physician can be condensed into less than 5 years is preposterous.

The number of opioid prescriptions written in this country has doubled from 109 million in 1998 to over 200 million by 2011.   As one example, studies show mid-level providers have markedly different prescribing practices when compared to their physician counterparts, a visit-by-visit comparison showed PA’s prescribe narcotics 19.5%, NP’s 12.4%, and physicians at 10.9% of visits overall.  The differences between NP’s and physicians prescribing practices were most dramatic in rural areas, where the primary care physician shortage is most palpable.  In the 2014 Drug Trend Report, NP’s and PA’s wrote 15.8% more opioid prescriptions for injured workers in 2013 than physicians. 

Mid-level providers deliver high quality care in their role as physician extenders, however, if practicing independently right out of school, their fewer years of education reveal significant variations.   Mid-levels report their patients are more satisfied when compared to patients with primary care physicians.  Ironically, it is a well-established fact that the happier and more satisfied the patient, the more likely they are to die. 

Life expectancy number will worsen in direct proportion to the primary care shortage.  No one needs a crystal ball to predict the number and frequency of narcotics prescriptions will continue to increase nationwide when financial incentives emphasize the “satisfied” patient over one that is alive.  A recent Huffington Post article lamented the fact the Canadian government ignored primary care physicians who predicted the impending physician shortage. “It’s precisely the front-line healthcare workers that know where the flaws and inefficiencies are.  It’s time for governments to connect with them… to help fix the problems in healthcare.”  Primary care physicians in the U.S. have been relegated to the back room.  As a result, people are dying younger than before.  One year ago, I asked whether declining life expectancy was just the tip of the iceberg, suggesting we should turn our attention to the dwindling supply of primary care physicians.  What will it take for those in charge sit up and pay attention? How low will life expectancy have to go?  Stay tuned…