Tuesday, August 22, 2017

Washington State Regulators Gave CHI a Monopoly. It is Time to Take it Back.

By Councilman Richard Huddy and Niran S. Al-Agba, MD

In a perfect world, Harrison Medical Center would not have been given to an out-of-state hospital conglomerate. In a reasonable world, CHI would not leave Bremerton without a hospital when it moves Harrison Medical Center to Silverdale. CHI would build a new 262-bed medical center in Silverdale, and operate an 85-bed hospital in Bremerton.

After all, with a population of 40,000, Bremerton is the largest city in the county. With a daytime population of 70,000, Bremerton is the largest employment center in Kitsap County. Bremerton also is home to the greatest concentration of skilled nursing facility patients, assisted living residents, and disabled people in the county. It makes sense that Bremerton would have a hospital, an emergency room, and a full array of medical services. CHI, however, wants only one hospital in the county.

In a rational world, Bremerton would be able to shrug its municipal shoulders, bid adieu to CHI, and welcome another hospital provider from around the Puget Sound to build a new hospital in the city. UW Medicine, Virginia Mason, Swedish Medical, and Kaiser Permanente to name but a few. Certainly, one of those outstanding organizations would be interested in serving the good people of Bremerton! Most everyone knows that Bremerton is on the ascent, and that Harrison is leaving just when they should be staying.

But, hold on… it’s not that simple. Bremerton is located in Washington, one of the 35 states with a certificate of need law. The regulators who work in the Certificate of Need (CON) program at the Washington Department of Health have given all of Kitsap County’s 336 acute care beds to CHI to operate as a monopoly. Eleven psychiatric beds remain, which CHI does not want to operate.

How did we get here? America has struggled to balance access to hospital services with utilization, quality and price for the past 50 years. In the mid-1960’s, certificate of need laws were established to limit the supply of hospital beds and equipment, prevent overutilization of services, control costs and improve quality.

New York became the first state to adopt a CON law in 1964. By 1980, with Federal encouragement, every state except for Louisiana had a CON law. The states reasoned if they could reduce unnecessary duplication of facilities, equipment, and services, costs and utilization would decrease, and quality and access would improve. It worked for a while; unfortunately, the CON laws had unintended consequences.

Over time, hospital reimbursement changed from cost-based fee-for-service to outcome-based value pricing. Hospitals shifted from a core mission of independent, non-profit service to corporate, for-profit competition. In an April 2017 white paper, Gaynor, Mostashari and Ginsburg observe, “there has been a great deal of consolidation in hospital, physician and insurance markets... hospital markets are significantly more concentrated… insurance markets are also often dominated by a small number of large insurers… and many physician practices are being acquired by hospitals.” Horizontal and vertical mergers and acquisitions have reduced competition, stifled innovation, and resulted in higher prices and lower quality.

For the last fifteen years, the Federal Trade Commission and the Department of Justice Antitrust Division have taken an active position against the continuation of CON Programs. In a joint report entitled, “Improving Healthcare: A Dose of Competition,” they stated, “The Agencies believe that, on balance, CON programs are not successful in containing healthcare costs, and that they pose serious anticompetitive risks that usually outweigh their purported economic benefits. Market incumbents can too easily use CON procedures to forestall competitors from entering the incumbent’s market… Indeed, there is considerable evidence that CON programs can actually increase prices by fostering anticompetitive barriers to entry.”

The Kaiser Family Foundation reported health care costs are 11 percent higher in states with CON laws compared to states without these restrictive statutes.   The evidence is clear CON laws not only increase costs, but also restrict access for the underserved, especially in rural areas.  Hospital bed access is expressed in the number of beds/1,000 population; on average, there are 3.62 beds/1,000 people in the United States.  Recent studies by Strattman and Russ found states with CON laws have 1.31 fewer beds/1,000 overall.  Kaiser Foundation found Washington and Oregon have the lowest bed ratios in the nation, at 1.7 beds/1,000, with Kitsap County having a woefully inadequate ration of 1.30 beds/1,000.  In short, the evidence supports the fact that CON regulations worsen access for rural residents. 

Due to these negative consequences, 14 states discontinued their CON programs, New Hampshire being the most recent one to repeal, effective in 2016.  As part of Senate bill 5883, our Washington State Legislature is currently evaluating the effectiveness of the Certificate of Need Program at the Department of Health. 

In Washington State, CON regulations encourage appraisal of the needs for a particular geographic region, usually a county, and as a part of that evaluation, regulators solicit input on behalf of the public or “affected” persons.  It is vital the public understands the complex CON process clearly, so we may actively participate.  In Kitsap County, the CON regulations currently support a monopolistic system by default; a single entity “owns” every authorized hospital bed.  Each of us living within Kitsap County are “affected” by this critical decision, but not all seem to comprehend the long-term consequences of relocating 100% of available hospital beds to Silverdale. 

In response to requests by the City of Bremerton and two other affected parties, the Washington State Department of Health granted a reconsideration of its CON decision to relocate all hospital beds from Bremerton to Silverdale. A public hearing will be held at 10:30 am on Friday, September 8, 2017, in the meeting room at the Bremerton School District Office located at 134 Marion Avenue N in Bremerton. The City of Bremerton seeks rejection of Phase 2 of Harrison’s relocation in order to build and operate a new Bremerton Community Hospital that will provide a choice to all Kitsap County residents who need hospital care and all doctors, nurses, technicians and other workers seeking employment. Please attend the public hearing.

Tuesday, August 15, 2017

A Hospital With No Beds Cannot Stand.


America has struggled to balance access to hospital services with escalating prices for those amenities over the past 50 years.  While there are many factors contributing to this challenge, the state certificate of need (CON) laws—those requiring state approval for hospital expansions and new construction—are examples of regulations that were designed to help but have had unanticipated negative side effects. 

In 1964, New York became the first to grant a state this power with a CON law. By 1978, with Federal encouragement, 36 states had enacted CON laws. The states reasoned if they could reduce unnecessary duplication of facilities, equipment, and services, costs would decrease and access would improve. Over time hospitals have shifted from a core mission of cooperation to one of competition, and it has become clear CON laws are in fact, discouraging competition, propping up prices, and aiding the creation of monopolies.  The Kaiser Family Foundation reported health care costs are 11 percent higher in states with CON laws compared to states without these restrictive statutes.   

The evidence is now clear CON laws not only increase costs, but also restrict access for the underserved, especially in rural areas.  Hospital bed access is expressed in the number of beds/1,000 population; on average, there are 3.62 beds/1,000 people in the United States.  Recent studies by Strattman and Russ found states with CON laws have 1.31 fewer beds/1,000 overall.  Kaiser Foundation found Washington and Oregon have the lowest bed ratios in the nation, at 1.7 beds/1,000, with Kitsap County having a woefully inadequate ration of 1.30 beds/1,000.  In short, the evidence supports the fact that CON regulations worsen access for rural residents. 

Due to these negative consequences, 14 states discontinued their CON programs, New Hampshire being the most recent one to repeal, effective in 2016.  As part of Senate bill 5883, the Washington State Legislature is evaluating the effectiveness of the Certificate of Need Program at the Department of Health. 

In Washington State, CON regulations encourage appraisal of the needs for a particular geographic region, usually a county, and as a part of that evaluation, regulators solicit input on behalf of the public or “affected” persons.  It is vital the public understands the complex CON process clearly, so we may actively participate.  In Kitsap County, the CON regulations currently support a monopolistic system by default; a single entity “owns” every authorized hospital bed.  Each of us living within Kitsap County are “affected” by this critical decision, but not all seem to comprehend the long-term consequences of relocating 100% of available hospital beds to Silverdale. 

Recently, letters to the editor have suggested “bringing in another corporation to build a hospital in Bremerton” as a viable solution. While I endorse this sentiment wholeheartedly, our state CON laws will prohibit this as a feasible choice. CHI Franciscan controls all of the beds available for Kitsap County, except for 11 psychiatric hospital beds in which they have no interest.  No hospital corporation will step forward, tear down an aging facility, and build a new one for the miniscule potential 11 hospital beds would serve. 

The CON process can take a minimum of one to two years and cost between $50,000 and $5 million depending on time-to-approval and the appeals process.  Once both phases are completed in Silverdale, ANY city or corporation wishing to build or remodel the Bremerton campus will be required to complete the CON process.  It is highly unlikely a new organization will focus on the Olympic Peninsula for some time due to these massive investment requirements.

The Washington State Department of Health granted reconsideration of the decision to relocate EVERY single hospital bed to the Silverdale area. Reversing this decision would not oppose the Phase 1 hospital expansion in Silverdale, which is already under way.  Encouraging the State to reevaluate this decision is trying to ensure adequate health care choices remain in two locations. If the City retains 85 hospital beds, the possibility of tearing down, rebuilding, or relocating the Harrison Campus becomes a reality.   

The moment to change our destiny is now.  It is imperative local lawmakers, City representatives, and the entire community engage in this multifaceted process and  stand up, together, for choice, competition, better access, and lower health care costs for every man, woman, and child residing in Kitsap County.  In my humble opinion, supporting this reconsideration endeavor is categorically in the best interest of this community.  Please attend the public hearing scheduled for Friday September 8th at the Bremerton School District Conference Room on Marion Street and share your thoughts.  This is our chance to be on the right side of history. 

Tuesday, August 8, 2017

The Little County That Could: The Fight in Lee County, Georgia for Hospital Choice

…“I think I can.  I think I can.  I know I can,” The Little Engine that Could.   

As hospital consolidations sweep the nation, the monopolies being created are like insurmountable peaks over which rural communities must climb on their quest to find affordable healthcare.  Lee County, in Southern Georgia, is a little place with big dreams; they are resolutely determined to build a 60-bed community hospital and provide local residents with real choices.  For years, two competing hospitals served the population of 200,000 spread over six counties:  Phoebe-Putney and Palmyra Park. Phoebe-Putney Memorial Hospital put an end to that by securing a 939-bed hospital monopoly and an ample market share.

Their efforts began in 2003, when Phoebe-Putney Memorial Hospital in Albany, Georgia successfully opposed a bid for a Certificate of Need (CON) to open an outpatient surgery center.  Frustrated from a free-market perspective, accountant Charles Rehberg and a local surgeon, John Bagnato, began sending anonymous faxes to local business and political leaders, criticizing the financial activities of the local hospital.   These faxes quickly gained notoriety, becoming known as “Phoebe Factoids.”  Concerned about negative publicity, Phoebe Putney executives hired FBI agents to intimidate these men. 

Undeterred, these two renegades discovered Phoebe-Putney Hospital was charging uninsured patients far more for services than insured patients.   This brought widespread attention to the plight facing millions of uninsured Americans.  Many began to question what obligation a nonprofit hospital has to provide charity care for those in need.  Phoebe-Putney was caught using aggressive collection tactics, such as wage garnishment and the placing of liens on homes of patients unable to keep up with payments.  Their experience inspired a documentary called “Do No Harm.”

In-depth research uncovered millions hidden in offshore bank accounts disguised under the auspices of a non-profit— not only at Phoebe, but also at other non-profit hospitals across the country.  As whistleblowers, Rehberg and Bagnato were subsequently targeted by Phoebe and indicted on fraudulent charges of telephone harassment, aggravated assault and burglary; charges without merit which were dismissed in 2006.  

After successfully blocking the surgery center CON, Phoebe-Putney set its sights elsewhere looking to acquire the only other hospital facility in the surrounding six-county area:  Palmyra Park.  In 2011, the Federal Trade Commission (FTC) attempted to block this proposal on the grounds that the combined entity would control in excess of 85% of the market share.  Phoebes’ CEO insisted hospital consolidation was necessary to deliver cost-effective, high-quality medical care, calling the merger “the right thing for citizens.’’   The FTC argued the deal was anti-competitive (which it was) and health costs would increase significantly (which they did.)  The FTC secured a preliminary injunction but Phoebe prevailed, arguing Georgia CON laws prohibited the sale of Palmyra Park to an independent entity.  

Ultimately, the FTC was obligated to settle with Phoebe, making the dream of a hospital monopoly a reality.  However, the settlement had three stipulations:  1) Public acknowledgement the acquisition would substantially lessen competition within the six-county market; 2) Phoebe was required to provide the FTC with prior notice of transactions acquiring any part of a general acute-care hospital, or controlling interest in other facilities; and 3) Phoebe was precluded from opposing CON applications from other entities for five years.

Barring Phoebe from challenging CON applications was an innovative solution to a monopolized region; however, Phoebe already handily dominated the market.  The Certificate of Need process is expensive and time-consuming; therefore, legal experts anticipated this limitation alone would be ineffective in enticing new competitors to enter the region.  Yet, predictions can sometimes be incorrect.

Enter “The Little County That Could,” a.k.a Lee County, Georgia, with its population of 29,000 and land mass of 362 square miles.  The community and their steely resolve have yielded unexpectedly positive results.  Lee County officials filed a Certificate of Need application for a 60-bed hospital earlier this year.  The Lee County Development Authority will own the hospital structure and a separate entity will lease the facility.  Services offered will include acute and emergency care, including an ICU, medical/surgical unit, inpatient and outpatient beds, and full radiology capabilities, such as CT and MRI.  The hospital will create more than 350 "good-paying jobs" and provide access to health care for all, regardless of their ability to pay. 

While Phoebe Putney agreed not to challenge a CON application until 2020, the settlement does not preclude engaging in “sneaky” public relations tactics.  Phoebe commissioned a study to calculate the effect the Lee County Medical Center would have on the financial outlook for Phoebe-Putney.  DHG Healthcare projected Phoebe will lose more than $250 million in revenue over five years.  The firm found by the third year of operation, annual losses will be $30.1 million for inpatient care, $23.7 million in outpatient care, and $6.4 million for emergency care at Phoebe.

Lee County is on their way to achieving something extraordinary; challenging the dominance of a hospital monopoly.  On July 21, 2017, the CON application for Lee County was deemed complete by the Georgia Department of Community Health.   A decision is anticipated by Nov. 15.  If granted, the county plans to break ground on the new structure in early 2018. The CEO of Lee County Medical Center, Mr. G. Edward Alexander, stated “Our goal is to ensure that decisions for the hospital are made locally by people who live and work in Lee County.”  

Lee County, I salute you.  Medically underserved communities everywhere are supporting your efforts to transform the healthcare landscape for the better.  May your success inspire a revolution, proving that healthcare can be repaired by patients, physicians, and communities – working together.     

Tuesday, August 1, 2017

Healthcare Plan: Reboot and Rebuild

I told you so.  I also told the POTUS in my open letter, but he did not read it.  Who could honestly believe the nation would support dumping coverage for 22 million people?  According to an op-ed in the New York Times: “They [Republicans and President Trump] had only one big weakness, in fact: They weren’t dealing in reality.”  When faced with reality, it is interesting what a few good Senators with a conscience will refuse to do.    
Success is never attained by taking shortcuts.  We do not need reform of health care; we need to renovate the entire system.  Special interests do not belong in the picture.  They are superfluous to achieving innovative solutions that place profits on the back burner.  Healthcare reform is like learning to discipline a tantrum-throwing 3-year-old; it will not conform to rhyme or reason.   Congress is making this too difficult.  They need to roll up their sleeves, go back to the drawing board, and start again.  My suggestions:
Step 1:  Every member of Congress should participate in a mock hospital admission as a patient, starting with presentation to the ER, being poked and prodded, having surgery if necessary, and staying overnight to recuperate.  After your experience, you should be provided a “bill” on your way out the door and pay the balance by cash or check. 
Step 2:  Go see your own primary care physician for two reasons.  The first is to have an annual exam and to connect with your constituents in the waiting room, solicit their comments, thoughts, or suggestions, and converse with office staff to understand their perspective.  The second reason is to elicit feedback directly from your primary care physician.  Listen for groundbreaking solutions to the perplexing boondoggle of caring for greater numbers at a lower cost.
Extra credit:  Follow a primary care physician in a Health Professional Shortage Area (HPSA) for three days.  Listen, engage, clarify, empathize, and most importantly absorb how monumental this undertaking of reforming health care will be. 
Step 3: Return to Washington D.C. inspired and reboot, resolving to do it right this time. 
The nation has been having entirely the wrong conversation; that dialogue must change.  The biggest obstacle faced by lawmakers is maintaining access while reducing cost.  Providing coverage without coupling it to budgetary constraints is sheer lunacy.  However, reducing government involvement in coverage without ensuring the needy can afford health care will never garner widespread support.  Affordability has become an impossible dream and is currently our largest stumbling block. 
The U.S. spent $10,345 per person annually in 2016.  The average OECD country spends $3997 per person annually in comparison.  During the 1980’s Spain created a network of community health clinics within a 15 minute radius of every citizen, a system which was funded by the taxpayers.  In 1975, the average life expectancy from birth was equivalent in both nations, at 69 years of age.  Today, life expectancy in Spain is 83 years compared to 78.8 in the United States.  We are spending twice as much as Spain and our life expectancy is significantly lower. 
An appropriate policy goal would be to focus on developing a durable healthcare foundation, poured only after great deliberation.  Scaffolding already exists, in community clinics and Public Health departments; these facilities are cost-effective, yet grossly underfunded, underutilized, and unappreciated.  Every single man, woman, and child needs primary care services, a fact which in incompatible to the insurance model.  We must sever the connection between insurance and primary care.  Providing basic care universally is something we must accept as reality. As I have written before, investing in primary care as a solution is a no-brainer; increasing by one PCP/10,000 persons decreases mortality by 5.3%. 
Basic care will bring us all out from the shadows and into the light.  Provide immunizations, screenings, and annual exams to everyone in this country.  Those working in the community clinics will be employed by the government and salaried.  These clinics could have evening or weekend walk-in hours and handle urgent matters.  The electronic medical records system should be universal and patient-centric.  People will no longer live in fear of our government eliminating access for chronic conditions or emergencies.  Struggling families will not be one catastrophic illness away from losing their hopes and dreams. 
As we continue filling in the grid, specialty care should be added at the public health facilities or community clinics.  A specialist would cover a greater number of patients when overseeing or consulting on difficult cases with the primary care physicians.  These specialists would be employed by the government and salaried as well.  If an individual becomes severely ill or injured and requires very specialized treatment, hospitalization, or surgical management, either they have Medicaid, Medicare, or their catastrophic insurance plan kicks in to cover these needs. 
No discussion would be complete without including third party payers, who distance patients and physicians from being cognizant of cost.  For what we do in our offices, services could be far cheaper.  For example, a self-employed middle-aged patient with a $25,000 deductible sustained a 4cm laceration to the head and went to buy glue to repair it himself.  On this particular holiday weekend, the stores were already closed.  He inquired as to the cash price for repair after texting a picture. 
I had no answer, but primary care physicians love repairing lacerations and I am no exception to the rule.  He came to my office; I cleaned the wound and sutured it.  He handed me his credit card, similar to the cashier at a grocery or hardware store.  Supplies cost roughly $50; the laceration repair took 15 minutes.  I figured $150 seemed reasonable.  He paid $200 and was thrilled. 
While the lack of transparency hindered my research, I compared the cost to repair a 4 cm laceration in the emergency room.  The estimated charges were:  $1000 emergency room facility charge, physician cost $500, and the procedure bill was $200.  My hardworking patient would have coughed up $1700 at a minimum (some estimate as high as $1000 per stitch) and waited well over 15 minutes for the privilege.  
Allow the free market forces to remain a part of the infrastructure.  A great deal of the population fears a universal basic system because they are afraid of losing choice.  Direct Primary Care practices would flourish in a system with a basic care safety net for those in need.  Those who can afford choice would have options to patronize the private market, which absolutely should not be eliminated.  
Reviewing the events this week reminds me Rome was not built in a day. Repairing the tangled web of health care will take unconventional thinking and the tincture of time. Costs have spiraled out of control past the point of affordability.  The nation will only support reform once Congress overhauls our broken system prior to embarking on repealing anything.  Finally, everyone is profiting except the two most critical components: the physicians and their patients.  Renovate, reboot, and rebuild from the ground up and when you do, start by putting patients ahead of profits. 

Monday, July 24, 2017

To CHI and Back: A Journey of 85 Hospital Beds in Kitsap County, Washington

Last week, the Washington State Department of Health (DOH) agreed to reconsider CHIs’ proposal to relocate 250 hospital beds from Bremerton to Silverdale.  A public hearing will take place, the date and location of which are to be decided.    

I have spent the weekend reflecting on this news, personally and professionally.  CHI's rebuttal to the reconsideration request was submitted by Thomas Kruse, Senior Vice President and Chief Strategy Officer for CHI.  It focused on whether the individuals requesting reconsideration were actually “affected” persons. 

I confess this is my first rodeo.  I am neither knowledgeable nor experienced in the Certificate of Need (CON) process.  I was not aware that as an “affected” and “interested” person, submission of a request for reconsideration could make a difference.  There is an opportunity to be heard in light of granting reconsideration by the State DOH.  My passion for this issue was ignited after visiting Harrison Bremerton ER for the first time as a patient recently.    The care provided by nurses, physician, and ancillary staff was exemplary.  The facility location in Bremerton was convenient and accessible to my residence.

Reconsideration is not in direct opposition to CHI expansion plans;  rather, this effort is focused wholly on retaining  85 hospital beds (74 general plus 11 psychiatric) to ease the burden of access to care facing many after the Bremerton facility closes and to ensure Kitsap County residents have choice.

The Bremerton Hospital is ailing and in need of repair; it can be torn down and rebuilt or remodeled and repurposed.  If the Bremerton community can regain 85 of the 250 beds conditionally relocated to Silverdale, a small-scale Harrison "Healthplex" could be erected, to include a hospital and primary care clinic. 

The City could attract an outside corporation, a teaching institution, or raise capital funds by creation of a hospital district and passing a bond or levy to build a community-owned facility.  I do not have all the answers, however, for progress to be made; the City of Bremerton must be able to clarify how residents would substantially benefit from access to emergency and hospital services INSIDE city boundaries. 

Many have inquired how to support this effort.  Here are my thoughts:

To effectively support the notion we need 85 hospital beds in Bremerton, I propose we present (either verbally or in writing) 85 compelling accounts which best illustrate the reasons access to emergency and hospital services is essential for the health and wellness of city and county residents.  11 of the 85 beds are psychiatric, so I am in search of at least 11 persuasive narratives showing the impact of mental health illness locally.   

If you are not comfortable sharing your “story” publicly, I am offering to collect them, removing all identifying information to keep them confidential, and asking volunteers to present them at the hearing on your behalf.  I need help editing, compiling, and organization these submissions. 

I would like these letters to accurately reflect our community composition, being inclusive of all racial, religious, educational, and socioeconomic backgrounds and representative of all cultures, ethnicities, and citizenship statuses.  It is my understanding most reconsideration hearings permit submission of written testimony prior to hearing commencement, though am not certain public comment will be allowed.  Irrespective to outcome, we should not miss this opportunity to ensure our voices are heard and acknowledged by decision makers at the Department of Health. 

Ideally, all submissions should be assembled by August 15, 2017 to ensure readiness when hearing day is announced or arrives.  Finally, I encourage all INTERESTED and AFFECTED Kitsap County residents attend the reconsideration hearing in person.  Our solidarity may move mountains.  We will never know, if we do not try. 

Any suggestions, offers of assistance, and additional coordination efforts are welcome.  Please know many who are unable to speak for themselves are cheering us on from behind the scenes, crossing their fingers, and holding their breath.  If we successfully retain 85 hospital beds, we will have transformed the future of healthcare, for ourselves and other struggling communities across the country. The nation is watching us; let us unite and give this our very best effort.  

One Vision.  One Voice.  Our Choice.

Tuesday, July 18, 2017

An Open Letter to the Future Mayor of Bremerton:

The single most critical issue facing your tenure will be improving access to healthcare for the population of Bremerton.  On May 1, 2017, the state Department of Health granted Catholic Health Initiatives (CHI) a long awaited Certificate of Need to transfer all of the available hospital beds outside of the city and complete a $600 million dollar hospital expansion project in Silverdale, at the expense of healthcare access. 

Recently, I attended a town hall meeting where neighbors came to brainstorm how to best advocate for themselves and hospital staff, who are struggling under the cost-cutting measures being implemented to prop up revenue.  We learned  a great deal about the experience of Piece County residents after CHI merged with Franciscan three years ago. 

St. Joseph Hospital in Tacoma sent $21 million in profit to headquarters in Denver rather than reinvesting it locally, quality ratings have fallen to an F grade, and the population lives 7 years less than the state average while paying $1000 more to reach that substandard milestone. 

On February 13, 1965, Harrison Hospital opened a new facility, the one in which I was born almost 10 years later.  At its inception, Harrison was a source of pride for our community.  Originally, the ER was staffed by community physicians of all specialties, including my father, who volunteered for monthly 12-hour shifts.  As a non-profit organization, Harrison was exempted from paying property taxes in exchange for providing charity care to citizens when necessary.  For decades, Harrison Memorial remained true to its mission, contributing a great deal to the health and wellness of our residents. 

Much has changed since Harrison Hospital was acquired by CHI in 2013. Over the last that time, spending on charity care has decreased from $27 million to $5 million annually, a reduction of 81%.  The number of patients receiving financial assistance for medical bills has been cut in half, from 10,685 to 5,040 individuals.  Some decrease is in part due to Medicaid expansion under the ACA; however, 11% of the population remains uninsured. 

CHI is in significant debt.  Our local hospital, one of many owned and operated by CHI across the country, is one of the few profitable locations.  As a result, revenue is sent elsewhere to prop up ailing locations.  This revenue should be reinvested in OUR community, not sent out-of-state to support others.  Over the last three years, there have been significant cuts to staffing and availability of necessary medical supplies resulting in a detriment to the health and safety of patients and a decline in quality ratings. 

CHI is a non-profit organization and as a result, currently enjoys a property tax exemption in the City of Bremerton of almost $950,000 annually.  This number does not include exemptions such as federal taxes, payroll taxes, and sales tax to which they are additionally authorized.  Over the next five years, CHI will leave an aging Bremerton facility with no plans for repair.  Re-evaluating the property tax exemption in the City of Bremerton is an issue worth some of your time and energy. 

CHI proposes building a brand new facility offering primary care and urgent care.  This structure will house the Family Practice residency program, training physicians who will hopefully join our community once completing their education.  As part of a non-profit organization, this “new” clinic will reap the benefits from requisite property tax exemptions; money the City of Bremerton will absorb in exchange for having access to charity care for those in the community in need. 

Instead of accepting leftover crumbs from CHI because we are starving for access to care, the City of Bremerton needs a comprehensive plan of their own. Please go back to the drawing board and find suitable alternatives rather than kowtowing to a corporation which is destroying the morale of staff, physicians, and our community.  Do not let CHI do to Kitsap County what it has already done to the Louisville, Kentucky community. 

CHI has demonstrated in the past how they cut costs:  by laying off employees, pruning supply budgets and shrinking employee benefits.  Through social media, countless CHI employees throughout the country have contacted me, including those in Kentucky, Nebraska, and Tennessee.  “Employee morale and retention are at an all-time low.”  The have shared difficulties faced working in an environment which is constantly in upheaval.  In a typical day, senior management changes tactics, outsources more services (like telemetry), and eliminates resources necessary to do our job.” 

They share their experience being pushed to the limits by administrative requirements.  “Profit drives decision making now, patients are no longer the top priority.” High acuity areas are reportedly short-staffed requiring employees to do overtime.  High standards of care are difficult to maintain as staff are being asked to do “training” on downtime during shifts.

In closing, the best predictor of future behavior is past behavior.  Once elected, please consider innovative solutions for solving the issue of reduced healthcare access in the City of Bremerton.  The lives and livelihoods of your constituents depend on it. 

Thursday, July 6, 2017

Welcome to the Kitsap Independent Physicians Group!

Happy Fourth of July!

In the Kitsap Sun, today, is this

example of the solidarity amongst medical professionals in ONE small community. Please share far and wide. I am so very proud to be amongst this group of diverse medical professionals, who collectively are fighting for a future which values the physician-patient relationship above all else.


On this Fourth of July 2017, we, the undersigned independen...t physicians in Kitsap County, solemnly pledge that we will continue to provide the highest quality medical care to our patients through its purest, most original form -- the small private medical office. We hold sacred the one to one relationships we have with our patients. Our allegiance is to you, the individual patient, is unwavering. We commit ourselves to continuing to strive to place you, our patients, at the heart of all that we do. 


Silverdale Pediatrics, LLP
Niran S. Al-Agba, MD,
Saad K. Al-Agba, MD

Achieve Eye and Laser Specialists
Dana Jungschaffer, MD,
Martha Motuz Leen, MD
Deanne Nakamoto, MD,
Todd Zwickey, MD

Bainbridge Anesthesia Associates
Blake E. Reiter, MD,
Carol Wiley, MD

Bainbridge Skin Surgery and Consultative Dermatology
Dr. Whitaker

Cole Aesthetic Center
Eric Cole, MD

Dr. Gillian G Esser
Gillian Esser, MD,

InHealth Imaging
Manfred Henne, MD

Kitsap General Surgery
Kristen Guenterberg, MD,
Tom Wixted, MD

Kitsap Podiatry
Paul Aufderheide, DPM,

Paul Kremer, MD

Member Plus Family Health
Blain Crandell, MD,
Viola Medina, ARNP

Michael Metzman, MD,

Pacifica Medicine & Wellness
Andrea Chymiy, MD
Marie Matty, MD,

Peninsula Cancer Center
Heath Foxlee, MD
R. Alex Hsi, MD,
Berit Madsen, MD
Aaorn Sabolch, MD,

Retina Center Nw David Spinak, MD

Sheila C Lally,DO Sheila Lally, DO

Silverdale Eye MDs
Glen Rico, MD

Sound Family Health
Charles Power, MD,
Brad Andersen, MD
Teresa Andersen, MD,
Mark Hoffman, MD

The Manette Clinic
Alisa Blitz-Siebert, MD,
Bill Minteer, DO
Tanya Spoon, DNP,
Kristen Childress, DNP
Teri Scott, ARNP,

Vintage Direct Primary Care Peter Lehmann, MD

Bronx-Lebanon Hospital: Believe Them the First Time

I remember the first time someone threatened my life as a physician.  It was my day off, so I was not in the clinic that day; a Children’s Hospital specialty group was working there instead, and after a staff member called the police, she notified me.  A father had walked in saying he wanted to kill me for “taking his children away from him.”  Wracking my brain as to this man’s identity, I drew a blank. 

The police found him in a local park a short time later and judged him to be “harmless.”  Somehow, I did not share their reassuring sentiment.  I figured out who the individual was, tracked down his mother, and promptly explained the situation.  She provided a recent photograph so my staff could be trained to recognize him and contact the authorities the moment he entered our building.  That photograph still hangs in our “Most Wanted” section of my front office, amongst other pictures which have been added.  Occasionally, I request an updated picture to make sure we are keeping our office environment safe. 

The second time a parent threatened my life was over the phone.  I was taking call on the weekend for a group of pediatricians.  One of them had evaluated a child for a finger injury and had not quite done their due diligence.  It sounded infected and in need of repair as the father described its appearance over the phone.  I recommended he take his daughter to the local Emergency Room.  He threatened to stab me instead.  I called to warn the ER staff and then notified the other practice.  The response was less than vigorous from my call partners, “you must have done something to upset him.” Their reaction astonished me; “blame the victim” is an unacceptable response to a colleague in this situation.    

When a patient or disgruntled coworker threatens to kill us, that threat should be taken very seriously.  Physicians must become less tolerant. Tolerance is defined as an objective or permissive attitude toward opinions, beliefs, and practices that differ from our own.  In my opinion, the administration of hospitals and some large clinics are far too permissive of violent threats against their staff.  I have heard numerous stories from across the country of physicians being told the “patient is always right” as patient satisfaction scores reign supreme. 

We have been taught when a patient threatens to commit suicide, we take them at their word.  Why is it any different when our very own lives are at stake?  The idea that physicians, nurses, pharmacists, and ancillary medical staff are expendable is ridiculous and policies must be enacted to protect the lives of medical personnel.

As I reflect on the tragic events that unfolded inside the Bronx-Lebanon Hospital last weekend, it is difficult to comprehend. My first thoughts are for the victims and their families, in particular those who knew Dr. Tracy Sin-Yee Tam.  She was a family practice physician in the hospital that day by chance, filling in for a colleague.  My second thought is to recall a quote from Maya Angelou, “When people show you who they are, believe them the first time.” 

According to the New York Times, Dr. Henry Bello had a background which spelled trouble right from the start.  His life story reveals a chaotic trajectory of bankruptcy, alleged addiction, workplace difficulties, homelessness, and brushes with the law.  He declared bankruptcy in 2000.  In 2004, Dr. Bello was charged with unlawful imprisonment and sex abuse involving a 23 year old woman in Manhattan.  In 2009, there were allegations of unlawful surveillance when he was caught using a mirror to look up the skirts of two women. 

In 2014, he was hired by Bronx-Lebanon Hospital as a family practice physician with a limited medical license and in February 2015 was forced to resign in lieu of termination after an allegation of sexual harassment.  After his resignation, Dr. Bello warned former colleagues he would return someday to kill them.  On Friday, June 30, he exacted his revenge, entering the Bronx-Lebanon Hospital carrying an AR-15 rifle and opening fire — fatally shooting a physician and wounding six others before killing himself.  Something more should have been done about this man to protect the hospital staff and patients. 

This post was not penned to “Monday-morning-quarterback” the events of last Friday.   I want to emphasize in the future, these threats should be taken seriously and closely monitored to keep those inside the hospital, medical facility, or clinic walls safe.  Two hours before the shooting, Dr. Bello emailed the New York Daily News to say the allegations that ended his medical career were “bogus.”  He stated, “This hospital terminated my road to a licensure to practice medicine.”  In addition, a week prior to the rampage, he was reportedly fired from his job assisting AIDS and HIV patients by the city.  This was a clear sentinel event and foreshadowed the possibility of something ominous. 

Physicians on the “front-lines” are facing a battle for their survival, literally and figuratively.  Friday, June 30, I lost a physician colleague in a senseless tragedy.  We do not handle threats haphazardly when they occur in airports, schools, or police stations.  We cannot properly care for a patient when we are in fear for our lives.  It should not be tolerated any longer.  There are many valuable lessons to be learned from the events of June 30th. We need to sit up, pay attention, and make changes.  The loss of Dr. Tracy Sin-Yee Tam and injuries to the other victims should not be in vain; physicians and other medical staff deserve to feel safe in their work environment while trying to save the lives of others.  

My sincere condolences go out to the friends and family of everyone inside the Bronx-Lebanon Hospital that day.  May you find peace, hope, and healing and may we, as collective communities of healers, refuse to tolerate serious threats to our lives, those of our colleagues, and those of the patients we serve. 

Tuesday, June 27, 2017

One Difficult Day

As a pediatrician, I work to keep children healthy so they can grow up and achieve their dreams.  Occasionally, my na├»ve optimism has gotten the better of me.  I especially have a soft spot for angry, defiant children.  These children are given my undivided attention and respect and I expect the same in return. I never call them names, insult them, or label them.  On the contrary, I have high expectations and am always encouraging them to be their best selves.  I often hug them tight as their anger gives way to tears, reassuring them as much as possible. 

A decade ago, I took care of a blended family with three children by three different fathers.  The oldest boy, Bobby, was an “angry” seven year old with wide eyes and an endearing, crooked smile.  His mother was exasperated and demanded tranquilizers be prescribed to him or she would switch physicians.  I asked Bobby what was going on.  He talked about conflicts with his mothers’ new boyfriend and how he resented this man calling him lazy and stupid. He had tears in his eyes, which broke my heart. 

I talked to him about ways to deal with his anger and recommended a nearby family counselor.  I hugged him, acknowledged his frustration, and told him he was neither lazy nor stupid.  I reminded him to never give up on himself and no matter what happened, I would always believe in him.  Needless to say, his mom changed physicians and I did not see Bobby again. 

When children enter the Juvenile Detention system, they lose Medicaid insurance coverage.  As a result, I was the consulting physician at our local juvenile facility.  I cared for children who were addicts, thieves, vandals, and committed a variety of other crimes.  I reviewed their health history, updated immunizations, and prescribed medications when necessary.  It was difficult to reconcile my job as a physician looking into their eyes and seeing their fear, yet knowing I could do nothing to alleviate the obstacles they faced. 

My toughest day was the one when I unexpectedly ran into Bobby.  I had been consulting over the phone with the RN at Juvenile Hall on a teenager who sustained injuries during arrest by coordinating care with a local specialist.  Over the five day time period, I never asked his name. 

Each week, I drove to Juvenile Hall to sign orders and examine children when necessary.  That day, I came upon Bobbys’ chart.  “This is my injured boy? I know him.” I declared.  She smiled and replied, “He said you were his doctor when he was little, and he is excited to see you.” 

As the guard left to get Bobby, I told him, “Be prepared.  I am going to hug this next one like he is my own son.  I do not care what he did.”  The guard gave me a funny look as he sauntered away.   I had thought of Bobby so often over the years, yet had the sinking feeling things had been far from rosy.  As Bobby walked through the metal double doors, I was struck by how much he had changed in both size and stature (now well over 6 feet tall.)  We hugged as if no time had passed, “Bobby, you are so much more grown up than I remember.”  He smiled with that same crooked grin I found so endearing a decade before.  “You are so much tinier than I remember,” he replied looking down at me.

Over the last decade, his mother and her children moved multiple times, had done their fair share of couch surfing, and Bobby had been suspended for misbehavior and truancy.  A few months before his arrest, his mother kicked him out, he moved back to the area, was stealing, using drugs, and suspected his 17 year old girlfriend was newly pregnant. 

Crestfallen, I almost started crying, then and there.  My dreams for this young boy from ten years ago were shattered into tiny little pieces.  In my mind, at the tender age of seven, he had been a ball of clay ready to be molded into something beautiful.  Instead, all hope had been extinguished from the young man who stood before me now.  There was no sparkle in his eye; the devilish grin was all that remained of that innocent child I once knew.    

Honest to a fault, we talked about lost opportunities and lasting consequences of his poor decisions.  I encouraged him to dream of a future outside of prison walls.  I reminded him of how kind, warm, and genuine he was with a great deal to offer the world. 

Unprepared for my own feelings of sadness and disappointment, this experience hit me unexpectedly like a ton of bricks.  I have yet to recover the abiding faith that all children can achieve their dreams.  It has been an extremely tough lesson to accept; yet it reaffirmed my commitment to continue encouraging, loving, and supporting each and every child who walks through my doors and into my heart.   

While I do not know where Bobby is today, I hope our brief encounter had as profound an impact on him and he did on me.  Kiddo, I think of you every day and hope you are safe, know you are loved, and remember you have much to offer the world.