Tuesday, October 17, 2017

Do Physicians Deserve Our Mercy? #silentnomore





This past week a video went viral when a woman complained about the lengthy wait time at a clinic.  On video, we see the physician asks if the patient still wants to be seen.  The patient declines to be seen, yet complains patients should be informed they will not be seen in a timely manner.  The frustrated physician replies, “Then fine…Get the hell out. Get your money and get the hell out."  While we do not witness events leading up to the argument between doctor and patient, we do know staff at the front desk called the police due to threats made by the patient to others. 
Based on the statement released by Peter Gallogly, MD, he is a humble, thoughtful, and compassionate physician who was very concerned for the safety of his staff, which he considers “family.”  Physicians like Dr. Gallogly do their best to serve patients, ease their suffering, and avoid losing ourselves to burnout at the same time. Every human being deserves our compassion, kindness, and clemency.  Patients and physicians must accommodate each other when possible.
Do physicians actually deserve our mercy when necessary?  Yes, they do.  I should know.  The kindness shown to me by my patients over the past month has been unparalleled, leaving this physician thankful beyond words. 
My father has been a practicing pediatrician in our community for 47 years.  As I type these words, he is dying in a hospital bed.  We have worked side by side for the last 16 years.  It is difficult to make it through the day, desperately hoping to hear his voice one last time in the clinic hallway.  He was carrying a full patient load before an unexpected cardiac arrest ended his career.  The patient load doubled overnight; it is a burden I am carrying alone.
Many families have brought their children, grandchildren, and great-grandchildren to us for more than 40 years.   We have seen them through the darkest moments of their lives, at their most vulnerable, and brought them into the light.  Now, our patients must guide me through unimaginable heartache and grief. 
Long wait times can be terribly frustrating.  Punctuality has long been a personal obsession. Lately, I have been unable to keep up; patients with appointments are waiting more than two hours to be seen.  Every new encounter begins with an apology for tardiness followed by an update on the condition of my father.  Most families are aware of my overwhelming task -- running a practice built for two when I am but one physician.  Not a single parent or child has complained, yelled, accosted, or threatened.  Each family has shown me desperately needed mercy.
 
Over the last twenty-one days, patients have provided 15 home-cooked meals.  Some have assisted by car-pooling my children or taking care of them when my presence at a last minute hospital care coordination meeting was required.  Others have simply offered a helping hand, by filing charts, running errands, or landscaping the grounds.  This is the physician-patient relationship as it was meant to be, simple, beautiful, and perfect. 
Yesterday, after apologizing yet again, a mother reassured me she would wait as long as it took to have her child seen, hugged me tightly, told me to take a deep breath, and offered me her chair to rest.  She reminded me to take care of myself.  In the next room was a grandmother who has been patronizing our practice since 1977, when I was barely three years old.  She offered billing services free of charge and emphasized how grateful she was for the loving care provided for two generations to her family.  
The clinic my father established is a place where mutual admiration between physician and patient has existed seamlessly for a half century.  Magic happens when patients walk through our doors.  The next time your physician is running late, consider the challenges they might have faced that day.  Accommodating their delay will be treasured more than you can possibly imagine.
Medicine is not a hospitality industry.  Patients are not customers and physicians are not restaurant wait staff.  We gave up our youth to become educated, skilled, and compassionate.  Saving the life of human beings is not equivalent to ordering a hamburger and having it served your way.  Physicians genuinely work hard to serve patients at their most desperate hour.  Remember, we are also human beings, who unequivocally need and deserve your mercy.      
     

Tuesday, October 10, 2017

Building Better Metrics: Immunizations and Asking the Right Question?






As policy experts cling to pay-for-performance (P4P) as an indicator of healthcare “quality” and shy away from fee-for-service, childhood immunization rates are being utilized as a benchmark.  At first glance, vaccinating children on time seems like a reasonable method to gauge how well a primary care physician does their job.  Unfortunately, the parental vaccine hesitancy trend is gaining in popularity.  Studies have shown when pediatricians are specifically trained to counsel parents on the value of immunizations, hesitancy does not change statistically. 

Washington State Law allows vaccine exemptions on the basis of religious, philosophical, or personal reasons; therefore, immunizations rates are considerably lower (85%) compared to states where exemptions rules are tighter.  Immunization rates are directly proportional to the narrow scope of state vaccine exemptions laws.  Immunization rates are used to “rate” the primary care physician despite the fact we have little influence on the outcome according to scientific studies.  Physicians practicing in states with a broad vaccine exemption laws is left with two choices:  refuse to see children who are not immunized in accordance with the CDC recommendations or accept “low” quality ratings when caring for children whose parents with beliefs that may differ from our own.   

The more willing a physician is to care for those with differing philosophical, religious, and cultural beliefs, the more CMS metrics will discriminate against our open-hearted approach.  Reflecting upon my medical school admissions interview, my open heart and mind are some of the reasons for entering medicine in the first place.  As I contemplated my tumbling quality indicators by continuing to see children regardless of immunization status, I stumbled upon some ICD-10 code gems: 

  • Z28.0 -   Immunization not carried out because of contraindication
  • Z28.01 - Immunization not carried out because of acute illness of patient
  • Z28.02 - Immunization not carried out because of chronic illness or condition of patient
  • Z28.03 - Immunization not carried out because of immune compromised state of patient
  • Z28.04 - Immunization not carried out because of patient allergy to vaccine or component
  • Z28.09 - Immunization not carried out because of other contraindication
  • Z28.1   -   Immunization not carried out because of patient decision for reasons of belief or group pressure
  • Z28.2  - Immunization not carried out because of patient decision for other and unspecified reason
  • Z28.20 - Immunization not carried out because of patient decision for unspecified reason
  • Z28.21 Immunization not carried out because of patient refusal
  • Z28.29 - Immunization not carried out because of patient decision for other reason
  • Z28.8  - Immunization not carried out for other reason
  • Z28.81 - Immunization not carried out due to patient having had the disease
  • Z28.82 - Immunization not carried out because of caregiver refusal
  • Z28.89 - Immunization not carried out for other reason
  • Z28.9 - Immunization not carried out for unspecified reason

Surprisingly, ICD-10 and the advanced coding technology might have had some unanticipated benefits.    If a physician uses vaccine refusal codes appropriately, the patient in question should be removed from the denominator being used to calculate immunization rate for a given clinic or physician. 

This allows immunization rates to reflect “quality” while accounting for factors outside the control of the primary care physician.  Vaccine exemption laws must be considered confounding variables when using immunization rates as a quality metric; eliminating confounding variables purifies the data set.   This is a simple concept, so why are metrics being collected by CMS not controlling for caregiver refusal when it is mandated by law?  Accuracy is the point of collecting data in the first place, right?  If you believe CMS is interested in accuracy, then I have a bridge somewhere to sell you on the Olympic Peninsula.

ICD-10 codes already allow for regional specificity; a physician in Washington State has codes when a patient is pecked by a chicken (W61.33) or bitten by a cow (W55.21); there is even a code when a one is struck by an Orca Whale (W56.11), an event more likely to occur in Washington than Idaho.  If we can code for injuries sustained when our water skis catch on fire (W91.07) after a civilian boat collided with a military watercraft (V94.810) while waterskiing on the Puget Sound near the Naval Undersea Warfare Center Keyport, then we certainly should be capable of controlling for confounders which do not reflect the “quality” of care a physician provides.  

Claude Levi-Strauss, once said, “The scientific mind does not so much provide the right answers as ask the right questions.”  Immunization rates are clearly NOT an accurate quality indicator.  Maybe it is time for policy experts and physicians to question what constitutes the provision of high-quality health care in the first place.  Only then, can this country move in the right direction. 

Friday, October 6, 2017

What do Playground Slides and Golf Carts Have in Common?




Statistics on childhood injuries from playground slides and golf carts were presented this weekend as a part of injury prevention efforts at the annual meeting of the American Academy of Pediatrics.  Injury prevention has long been a focus for pediatricians as it is an important element of child advocacy.  As a result of injury prevention efforts, bicycle helmet use has become almost universal across this country, sports gear has been adjusted to be more protective, and even automobiles come with factory-installed airbags, LATCH systems, and backup cameras.  The next frontiers for injury prevention are playground slides and golf carts.  

Backyard playground slides are a rite of passage for most small children.  This past summer, one little patient of mine was injured on a slide in her backyard while playing naked with her three sisters.  Unbeknownst to their mother, the four decided to hose down the slide in the effort to increase their sliding speed.  When that was not adventurous enough, they put gravel at the bottom to “liven things up” even more.  The middle toddler was brought in after sustaining a gluteal laceration containing small pieces of gravel.   While cleaning the wound and removing pieces of gravel with small tweezers, the mother was lamenting the fact that her daughters were so fearless.  I smiled, reassuring her this is what children do – push the envelope.  

Playground slides injured an estimated 352,698 children less than 6 years of age between 2002 and 2015.  A recent abstract, “The Mechanisms and Injuries Associated with Playground Slides in Young Children:  Increased Risk of Lower Extremity Injuries with Riding on Laps,” evaluated playground slide injuries in more detail.  According to the data, the riskiest age for injury is 12-23 months.  36 percent sustained fractures, mostly involving the lower leg.  The most common mechanism of injury is when the child’s foot catches the slide edge while sitting on the parents lap.  

Understandably, parents believe assisting children on playground slides is protective but the number and nature of injuries sustained tells a different story.  If parents were made aware of this potential for injury, the chance they would stop going down slides with their children is highly likely to change. Educating parents about the risk of playground slides can be clear, effective, and likely to generate changes for pediatricians and parents.

Golf carts are increasingly becoming popular in small communities across this country and a recent study: “Golf Carts and Children:  11 year Single State Experience,” has demonstrated the possibility of  sustaining injuries which are fairly significant.  Researchers collected information from a trauma center in Pennsylvania and identified 108 children between 2004-2014 injured by golf carts.  On average, children were 11 years old and hospitalized between 1 and 26 days to recover.  

While golf cart injuries are not necessarily common, the injuries can have significant sequelae.  Admission to the ICU was necessary 36 percent of the time.  More than three-fourths of children studied sustained a fracture and 44% of those were skull fractures, which were actually more common than fractures of the extremities.  For those sustaining head injuries, 27% had concussions, and 25-30% had intracranial injuries with associated bleeding.  

In closing, injury prevention is something near and dear to the hearts of most pediatricians.  As the world changes, so must our conversations with the parents of young children.  Based on these two abstracts presented at the AAP annual meeting, I will incorporate reminding parents to stay off playground slides with their children, and ensure their children are 16 years of age before being allowed to drive a golf cart independently while maintaining speeds of less than 10 miles per hour.  While childhood injuries will continue to be a rite of passage, pediatricians have the opportunity to reduce those with long-term consequences, such as skull fractures and intracranial bleeds. Educating parents   will go a long way toward ensuring the next generation grows up to make their own mark on the world in the future.

Tuesday, September 26, 2017

As Ohio Goes, So May the Nation: The Patient Access Expansion Act









According to recent Ohio statistics, 1.3 million people have limited or no access to primary care physicians. Based on the 2015 Ohio Primary Care Assessment, 60 of 88 Ohio counties have medically-underserved populations.  The Patient Access Expansion Act (HB 273), co-sponsored by Representative Theresa Gavarone (3rd District) and Representative Terry Johnson (90th District), specifically addresses healthcare access by prohibiting physicians from being required to comply with maintenance of certification (MOC) as a condition to obtain licensure, reimbursement for work, employment, or admitting privileges at a hospital or other facility. 



Recently, I spoke with Representative Gavarone on the critical importance of this legislation for Ohio.  Physician family members have grumbled about the expense of MOC compliance however, a practicing cardiologist better clarified the connection between MOC regulations and the growing physician shortage.  “He shared his frustrations at the time and money involved participating in a program that has absolutely no scientifically-proven benefit for patient outcomes,” said Representative Gavarone.  The cardiologist discussed numerous hours wasted preparing for an exam with little to no bearing on his day-to-day work serving his patients.



While the public may not be familiar with the harm of MOC regulations, many have experience searching for a new physician when their doctor retires earlier than anticipated.  “Patients are waiting months for appointments,” said Representative Gavarone.  “As physicians leave their practices through cutting back or early retirement, this translates to reduced access to care for everyday Ohio citizens,” she said.   Gavarone is touching on a vital issue facing practicing physicians across the country:  there are fewer incentives for compassionate, brilliant minds to enter the field of medicine.    



Oklahoma was the first state to enact Anti-MOC legislation and six more states (Georgia, Maryland, Missouri, North Carolina, Oklahoma, Tennessee and Texas) have passed laws prohibiting the use of MOC as a condition for obtaining medical licensure and hospital admitting privileges.  Doctors are being “boarded to death”.  To become licensed to practice medicine in the U.S., we must pass 4 exams, each lasting 16 hours in duration over 2 days.  The US Medical Licensing Exam (USMLE) has three parts:  USMLE Step 1 and 2 are taken during our second year and fourth years of medical school, and Step 3 is taken over a two-day “vacation” during internship year. 



After a 3-5 year residency program, we must pass a specialty-specific board exam, such as internal medicine, pediatrics, or surgery to become licensed.  While drowning in more than $100,000 in educational debt, the $1500 exam fee seemed exorbitant, yet passing the pediatric certification exam was only a one-time requirement. States already mandated completion of Continuing Medical Education (CME) hours annually for physician licensure, so why were additional requirements necessary?



The American Board of Medical Specialties (ABMS) eliminated “lifetime” certification to shore up their financial outlook; a modification having little to do with quality and much to do with rate of return.  Between 2003 and 2013, the ABMS member boards’ assets ballooned from $237 million to a staggering $635 million, an annual growth rate of 10.4%.  MOC is outrageously lucrative.  Almost 88% of their revenue came from certification fees.  



The testing environments to which physicians are subjected are abominable; those who are disabled, ill, pregnant, or nursing find their requests for accommodations in accordance with federal ADA guidelines denied, having no recourse for blatant discrimination.  MOC requirements violate our basic right-to-work, an intrusion deemed intolerable in other professions.  



Groups lobbying heavily against anti-MOC legislation will likely be hospitals, insurance companies, and specialty groups, such as the American Society of Plastic Surgeons (ASPS) and Ohio Valley Society of Plastic Surgeons (OVSPS), who are out of touch with front line physicians.   Both organizations vehemently opposed a tax on elective (read: unnecessary) procedures projected to add $25 million to the state budget, calling it “discriminatory, economically damaging, and fiscally unsound.” They oppose HB 273 on the grounds that allowing board certification to “lapse” will prevent patients from receiving the “highest quality of care;” a statement that is altogether unproven, misleading, and deceitful. 



If you like your doctor, support HB273 --the Patient Access Expansion Act so you can keep them. The MOC program forces physicians to spend time away from our patients, clinics, and families for no demonstrable benefit.  Financial corruption touches every facet of MOC; the American Board of Medical Specialties has $701 million reasons to oppose this bill.  Representatives Gavarone and Johnson are David bravely battling Goliath.  Physicians and patients must help them fight for high-quality, affordable healthcare to be delivered by physicians free of futile testing regulations.  




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.