Wednesday, June 20, 2018

When Profit Trumps Our Most Vulnerable: The push to deliver preemies in community hospitals

Neonatal Intensive Care Units are truly a miracle of modern medicine. As recently as the 1960s, infants born six weeks early stood little chance of survival. But thanks to advances in neonatal medicine, babies born fully eight weeks before term now have a 99 percent survival rate—although, to be sure, preemies remain at much higher risk of developing a wide array of health risks throughout their whole lives.

Recently, more hospitals have been investing in the kind of expensive equipment needed to care for premature newborns. In Kitsap County, for example, the CHI Franciscan Harrison Hospital has expanded its services for premature babies, which, on the face of it, sounds like a good thing.

But the counterintuitive truth is that the increasing availability of such technology may actually do more harm than good. Pre-term infants are so vulnerable—to infections, breathing problems, bleeding on the brain, to name just a few complications—that you need more than just the latest high-tech supplies. You also need expert know-how, honed through constant practice: You need a team of specialized doctors, known as neonatologists, and neonatal nurses who handle preemies all day, every day.

And not every hospital has that.

In the mid-1970s, the March of Dimes proposed the idea of regionalized networks as part of a bid to make sure every area had at least one specialized neonatal unit, or NICU. Under the plan, highly specialized facilities, what are referred to as Level 3 or 4, would have a neonatology physician available 24 hours a day. Nurseries with lower-level designations, Level 1 or 2 facilities, would handle healthier infants and, therefore, not require in-hospital neonatologist coverage. 

The idea was that when a pregnant woman went into labor early, she would be transferred to the nearest Level 3 or 4 facility—provided her condition allowed for relocation. Only when transport was deemed impossible would the delivery occur at a lower-level hospital, with the newborn being stabilized and later transferred to a high-level unit.

Research supports this measured approach. Studies have consistently shown it’s far safer to move the mothers to a higher-level facility while the baby is still in the womb than to attempt transfer after birth, when the jostling of an ambulance ride or medevac can cause life-threatening complications, like bleeding in the brain, which can trigger permanent disabilities.

But now, with smaller, community hospitals buying more neonatal equipment, there’s increasing pressure to monetize the investment. That means taking the calculated risk of not transferring women in pre-term labor and allowing delivery at a location that neither has the specialized staff nor sufficient expertise to provide the kind of care premature infants require.

Taking this chance allows the community hospital to be paid for delivery and for providing the infant short-term stabilization care. However, this business-driven logic turns a willful blind eye to the toll that disruptive transfers can have on these vulnerable infants, putting them at unnecessary risk of complications. 

Statistically, the evidence is clear these fragile newborns fare best at the units that have more experienced staff and see the highest volume of patients.  Leap Frog collects data on the volume of high-risk infants cared for at hospitals in the region. Swedish First Hill, a Level 4 unit , managed 190 high-risk infants last year; the University of Washington, which is also Level 4, treated 137; while the CHI Franciscan Health Level 3 NICU, based at St. Joe’s Hospital, oversaw the care for 31 amongst its hospital system. These numbers are telling.

In my experience as a pediatrician in Kitsap County, I’ve had to readmit every single one of my pre-term patients who were born at the CHI Franciscan Harrison this year. In stark contrast, I haven’t had to readmit any of my patients who were delivered at Swedish or the UW.

This is not a risk that hospitals should take in the interest of their bottom line. The stakes are far too high. And if community hospitals are “selling” pregnant women on the convenience of giving birth close to home while glossing over the dangers of delivering high-risk, pre-term babies at a lower-level facility, then community physicians, like me, are obliged to speak out.

Every child deserves the best possible start in life, and the statistics show that specialist neonatologists practicing at high-volume NICUs are in the best position to provide it. Just because smaller community hospitals that have invested in state-of-the-art equipment can, technically, deliver preemies, doesn’t mean they should.


Monday, June 18, 2018

27 Pediatricians on the Chopping Block.

In the fiscal fight over health care costs, pediatricians are on the chopping block. In hospitals and clinics across the country, pediatricians are being laid off in droves, leaving the clinical burden to mid-level providers, family physicians, and emergency room doctors. These decisions are being made by suits over scrubs, and they are putting patients at risk.

Recently, three pediatric facilities closed in Dallas when MD Medical Group acquired Children's Health Medical Center and consolidated pediatric operations, terminating twenty-seven pediatricians. In April, Maryland's MedStar Health announced the immediate closure of inpatient pediatrics and the pediatric emergency department at Franklin Square Medical Center. Last October, Boone Hospital Center in Missouri announced it was closing its pediatrics unit. Last September, Pottstown Memorial Medical Center closed its inpatient pediatric unit. And last summer, Mount Sinai hospital in Chicago ended its pediatric services.

“Pediatric hospital care is less available than it used to be..." said senior author Dr. Michael McManus, a pediatrician and professor at Harvard Medical School. "Hospitals are paring back on certain lines of business, and pediatrics is one I think they look at very closely..." said Allan Baumgarten, an independent health care financial analyst.

What's driving this phenomenon? It's largely an attempt for providers to maintain -- or in some cases, maximize -- profitability on a growing share of Medicaid patients. There have been more than 22 million new Medicaid enrollees since the beginning of 2010, when the Affordable Care Act, which greatly expanded the program, was passed. One in two births in the country is now paid for by Medicaid. Yet Medicaid's reimbursement rate is only about half that of privately-insured patients. As a result, hospital executives are looking to cut labor costs, which make up about 60 percent of hospitals' operating costs. 

Faced with these dynamics, many providers, including the prestigious Mayo Clinic, have selectively restricted or refused to treat Medicaid patients. Roughly half of doctors are unwilling to treat new Medicaid patients because they are not profitable. But this approach does little more than foist Medicaid patients onto already overburdened emergency rooms.

Laying off pediatricians in favor of NPs and emergency room physicians is an attempt to monetize these patients. But this is also problematic.

Most importantly, it puts patients at risk of substandard care. NPs require four years of college and a thousand hours of clinical experience -- significantly less than the eight years of college, three years of residency, and 20,000 clinical hours needed by physicians. While NPs can do a wonderful job caring for many problems, they receive far less rigorous training than even medical students, who would never be allowed to treat any patients unsupervised. Worryingly, there are also signs that NP training is becoming watered down by assembly line programs.   

Of course emergency room and family practice doctors will pick up the slack to some degree. But they also don't have the same familiarity or training necessary to meet the unique needs of children, whose physiology, treatment, and responses are often different. In our decades of clinical practice, adult physicians universally recognize the need for pediatric patients to receive care from the doctors who are specially trained to treat them.

Consider an example, which is representative of many other similar experiences throughout our careers. Dr. Al-Agba was able to catch the subtle signs of an unusual condition in an ill toddler during flu season. She was able to determine that the patient had ingested multiple small magnets, which were then attracted to each other and connected inside her intestines, which could have been fatal. She was immediately operated on and recovered uneventfully. 

Missing subtle signs in pediatric patients can lead to deadly consequences. Such cases demonstrate that all children, regardless of income, deserve access to adequate pediatric care.

Is there a solution to this problem short of comprehensive health care reform? Potentially. Instead of looking to pediatricians and other specialty physicians to cut labor costs, providers should look to cut administrative jobs, which have expanded to the point where there are now ten times as many administrators as physicians. Many of these bureaucratic positions offer little-to-no value to the patient or the doctor. In fact, they often impede physician productivity, reducing profitability. 

But for now, pediatricians must speak for children's right to access the physicians specially trained to care for them. Because it is increasingly clear that health care executives will not.

Niran Al-Agba is a pediatrician in solo practice and a board member of Practicing Physicians of America. Marion Mass is a pediatrician and co-founder of Practicing Physicians of America. 

This piece was originally published in the Hill.