Bush and Medicare. We need more physicians and medical students.
Bush Administration Plans Medicare Changes - New York Times July 17, 2006 Bush Administration Plans Medicare Changes By ROBERT PEAR WASHINGTON, July 16 ó The Bush administration says it plans sweeping changes in Medicare payments to hospitals that could cut payments by 20 percent to 30 percent for many complex treatments and new technologies. The changes, the biggest since the current payment system was adopted in 1983, are meant to improve the accuracy of payment rates. But doctors, hospitals and patient groups say the effects could be devastating. Federal officials said that biases and distortions in the current system had created financial incentives for hospitals to treat certain patients, on whom they could make money, and to avoid others, who were less profitable. Michael O. Leavitt, the secretary of health and human services, said the new system would be more accurate because payments would be based on hospital costs, rather than on charges, and would be adjusted to reflect the severity of patientís illness. A hospital now receives the same amount for a patient with a particular condition, like pneumonia, regardless of whether the illness is mild or severe. Medicare pays more than $125 billion a year to nearly 5,000 hospitals. The new plan is not expected to save money, but will shift around billions of dollars, creating clear winners and losers. The effects will ripple through the health care system because many private insurers and state Medicaid programs follow Medicare’s example.
Dr. Alan D. Guerci, president of St. Francis Hospital in Roslyn, N.Y., said the new formula would cut Medicare payments to his hospital by $21 million, or 12 percent. ìIt will significantly reduce payments for cardiac care and will force many hospitals to reduce the number of cardiac procedures they perform,î Dr. Guerci said.
A coalition of patient organizations, including the Parkinsonís Action Network and the Society for Womenís Health Research, told the government in a letter that the new system ìcould have a devastating impact on payment for critical treatments for seriously ill patients, with reimbursement for some essential procedures cut as much as 30 percent.î The basic payment for surgery to open clogged arteries, by inserting a drug-coated wire mesh stent, would be cut by 33 percent, to $7,590. The payment for implanting a defibrillator, like the one used by Vice President Dick Cheney, would be cut 23 percent, to $22,000, while the payment for hip and knee replacements would be reduced 10 percent, to $14,500. ìThis is a bit of a catastrophe,î said Dr. Herbert Pardes, president of NewYork-Presbyterian Hospital. In its zeal to cut the profits of doctor-owned specialty hospitals, including cardiac hospitals, Dr. Pardes said, the government has inadvertently hit many nonprofit academic medical centers.
Drug and device makers have been lobbying Congress and the Bush administration to delay the changes to allow further analysis. Device makers are scheduled to meet with top White House officials this week. More than 200 members of Congress have signed letters supporting a one-year delay Peter L. Ashkenaz, a spokesman for the Medicare agency, said officials had received the letters but could not comment because they were working on a final regulation, to be issued in a few weeks. Hospitals and members of Congress are also complaining about the role of a government contractor that helped develop the new payment system and now stands to profit from it.The new system is based on a commercial product developed by 3M Health Information Systems, a unit of 3M, the Minnesota-based technology company. In July 2005, the Bush administration awarded a ìsole source contractî to 3M, to analyze whether it was feasible for Medicare to use a payment system modeled on the 3M product. The company said yes. Influential members of Congress, including Senator Charles E. Grassley, Republican of Iowa, the chairman of the Finance Committee, have objected to Medicareís reliance on a proprietary system controlled by a single company. A competing company, Ingenix, said, ìThe contract was awarded to 3M without the solicitation of competitive bids.î Moreover, Richard H. Anderson, chief executive of Ingenix, a unit of UnitedHealth Group, said that 3M had a conflict of interest because it was evaluating its own proprietary software as the basis for a new Medicare payment system. The software analyzes the characteristics of each patient and assigns the case to a ìdiagnosis related group,î which in turn determines how much the hospital will be paid. In recent weeks, 3M has sent out marketing materials that urge hospitals to buy 3M software and use 3M experts to help them ìmake a successful transitionî to the new Medicare payment system. Richard F. Averill, research director of 3M Health Information Systems, said the sole-source contract was justified and denied that his company had a conflict of interest. As an inventor of the 1983 payment system, Mr. Averill said, he and his colleagues at 3M know more about it than their competitors. Moreover, Mr. Averill said in an interview: ìThe contract required us to use the 3M system in our analysis. There was no evaluation of alternatives.î The goal of the new payment system is to pay hospitals more accurately for the
cost of care. But Jayson S. Slotnik, director of Medicare policy at the Biotechnology Industry Organization, a trade group, said that payments would, in many cases, be less accurate because the government had relied on old hospital cost reports and claims data that did not reflect the use of new technology. Without a delay, Mr. Slotnik said, hospitals can expect to see a 35 percent reduction in Medicare payments for stroke patients treated with clot-busting
drugs. The basic payment for such cases is now $11,578. It is no surprise that the Greater New York Hospital Association, which represents many teaching hospitals in a high-cost area, objects to the new system. But hospitals in North Dakota are also concerned. Arnold R. Thomas, president of the North Dakota Healthcare Association, said the new system would cause ìradical shiftsî of money among the stateís 52 hospitals. ìThe effects would be rather random and inequitable,î Mr. Arnold said. When hospitals lose Medicare revenue, they often seek higher reimbursement from private insurers. J. Brian Munroe, vice president of WellPoint, one of the largest private plans, said he feared that the Medicare changes ìwill introduce a significant amount of disruption to the commercial health insurance marketplace, driving up health care costs and causing marketplace confusion.î
New Orleans Recovery Is Slowed by Closed Hospitals - New York Times
July 24, 2007
New Orleans Recovery Is Slowed by Closed Hospitals
By LESLIE EATON
NEW ORLEANS ù At the tip of Bayou St. John in the Mid-City neighborhood here, the brown and white bulk of Lindy Boggs Medical Center looms behind a chain-link
fence. Nineteen people died at the medical center after Hurricane Katrina, and now the hospital itself is dead, sold to developers who plan to replace it with a shopping mall.
On the surrounding streets ù Bienville and Canal and Jefferson Davis ù lies the wreckage of a once-bustling medical corridor. Doctors offices sit empty behind five-foot-high water marks, and nearby clinics wait to be demolished. In back of one medical building, a gaping refrigerator still holds jars of mayonnaise and Mt. Olive Dill Relish.
Harder to see, but just as tangible, people here say, are the other ripple
effects of the flood and the closed hospital: workers displaced, houses for sale and, of course, patients forced to seek health care many miles away. If they have returned to New Orleans at all, that is, given the grave wounds to the health care system.
I╒ve been telling people, don╒t bring your parents back if they are sick, said Dr. David A. Myers, an internist who lived and worked in Mid-City before the flood and has moved his home and practice to the suburbs.
Of all the factors blocking the economic revival of New Orleans, the shattered health care system may be the most important ù and perhaps the most intractable.
Except for tourism and retailing, health care was the cityÆs biggest private employer, and it paid much higher wages than hotels or stores. But there are now 16,800 fewer medical jobs than before the storm, down 27 percent, in part because nurses and other workers are in short supply.
Only one of the city Æs seven general hospitals is operating at its pre-hurricane level; two more are partially open, and four remain closed. The number of hospital beds in New Orleans has dropped by two-thirds. In the suburbs, half a dozen hospitals in adjacent Jefferson Parish are open but are packed.
Fixing the city╒s health care system ╘is critical both for the short and the long term,╒ said Andy Kopplin, executive director of the Louisiana Recovery Authority. ╘Short-term, having confidence that the health care residents need will be available and accessible is vital for folks who are returning,╒ Mr. Kopplin said. Long-term, it Æs important for employers and health care is a huge business in New Orleans."
Studies suggest that hundreds of doctors never returned. And some of those who did, especially specialists and young physicians, are leaving, said Dr. Ricardo Febry, president of the Orleans Parish Medical Society, which has lost more than
200 of its 650 members. The exodus has been a steady trickle, Dr. Febry said.
The city╒s mortality rate appears to have risen sharply in 2006, although state and local officials disagree about the level and persistence of the increase. With the stress of life in the flood-ravaged city, the limited health care and insurance, the lingering mold and the discomfort of living in trailers, doctors report that the patients they see are often far sicker than those they treated before the storm. And even residents with health insurance can have a difficult time finding someone to treat them.
Government officials and civic leaders are floating plans for the future of the city╒s medical system, for a state-of-the-art hospital, for a cutting-edge system to cover the uninsured, even for a bio-innovation center that would be an engine for economic growth. The question is what will happen in the meantime, which is likely to be many years long.
We have to find a way to survive to that point, to provide care, or our city will collapse,ö said John J. Finn, president of the Metropolitan Hospital Council of New Orleans.
Waiting for Care
The problems with health care hit hardest on the poor and the newly uninsured, but they also affect doctors and patients, politicians and entrepreneurs, the displaced and the returned ù and everyone at any level who has the misfortune to turn up in a jam-packed emergency room.
Consider the case of Bernadine R. Fields, 50, who learned firsthand how far people have to go for major medical care. A supervisor of city 911 dispatchers,
Ms. Fields was among the many laid off after the storm.
The money she had saved for her retirement went for repairs to her house in New Orleans East. By last July, she could no longer afford the $367 a month it cost to continue her health insurance, or all the medicines she needed to treat her high blood pressure, or the $250 it would cost to see a doctor.
So she kept ending up in one of the few open emergency rooms, waiting for hours. After one of these episodes in April, she was told she needed transfusions to treat anemia ù but there was not a bed available in New Orleans for an uninsured
patient. Ms. Fields finally got the treatment she needed ù but only after an ambulance took her to the state-run hospital in Baton Rouge, 80 miles from her home and family. She stayed there four days.
ôI devoted 15 years of my life to serving the public,ö she said, ôand when I
need to be served, there is no one to count on.
Ms. Fields╒s neighborhood in the eastern section of the city, like other
stretches of town, cannot recover unless medical care becomes available there,
officials say, and neither can large sections of the economy. Doctors and
hospitals, though, are reluctant to return unless the population does.
I╒m just hoping and praying nobody dies,ö said Frederick C. Young Jr.,
president of the Methodist Health System Foundation, which is working with the
city to try to reopen a hospital there.
The sharp contraction in the health care industry has economic effects, too, for
coffee shops and florists and medical-supply companies. Marshall F. Gerson,
whose family has owned the Ellgee Uniform Shop downtown for almost 70 years,
said sales of scrubs and other medical uniforms had fallen to about half their
pre-storm level.
ôAt this time of day when times were good, it was bustle-bustle here,ö said Mr.
Gerson, 63, standing in his shop late one recent afternoon. Now, ôthe foot
traffic is almost nil.ö
By working harder and selling more industrial and restaurant uniforms, Mr.
Gerson has kept his business going but, he said, ╘I m not a happy person when I
get home.╒
An Era╒ s End
The future of Mr. Gerson╒s shop ù and in many ways the future of health care in
New Orleans ù is bound up in the thorny question of what if anything will
replace the hospital known as Big Charity.
Since it opened in 1939, Charity Hospital╒s imposing building downtown has
provided basically all the medical care ù emergency, acute and basic ù for the
cityÆs poor, and served as a training ground for generations of doctors.
Despite some community protests, Louisiana State University, which ran the
hospital, closed it permanently after the storm, saying it was too damaged by
basement flooding. The state plans to replace it with a $1.2 billion complex
that officials believe will attract insured patients as well as the poor, will
also care for veterans and will serve as an economic catalyst for the city. But
the hospital╒s future is now the subject of a debate about the best use of
federal health care dollars, even after the state agreed to pay $300 million to
get the project off the ground.
The federal government would prefer that the state build a small hospital and
use its federal dollars to buy private insurance for the poor. Dr. Frederick P.
Cerise, the secretary of Louisiana╒s Department of Health and Hospitals, said
that plan would help less than half of the uninsured.
On a positive note, the city╒s trauma center, which treats gunshot wounds and
other serious emergencies, reopened in February at University Hospital downtown,
which like Charity is part of the Medical Center of Louisiana at New Orleans.
But the number of beds at University remains limited, and the building is so
outdated that it will eventually have to be replaced, said Dr. Cathi Fontenot,
the medical director.
In the meantime, the sick have to go somewhere. Often, that somewhere is Ochsner
Medical Center, a huge private hospital complex in the western suburb of
Metairie that looks like a mall, with a computerized grand piano that entertains
patrons in a sunny atrium.
Before Hurricane Katrina, patients waited just 20 minutes to be seen, said Dr.
Joseph Guarisco, chairman of emergency services at Ochsner, and surveys found
that 99 percent were satisfied with their care.
After the storm, the number of people coming to the emergency room jumped, on
some days reaching nearly twice the pre-hurricane volume. The number of
psychiatric patients soared.
The uninsured, who had made up a small percentage of emergency patients at
Ochsner, began accounting for more than a quarter of emergency room patients.
Waiting times routinely topped an hour. The patient satisfaction rate fell to 34
percent.
This year, Dr. Guarisco reorganized the emergency room and cut the waiting time
back to about 20 minutes.
But the other problems remain. ôThe hospital, post-Katrina, struggled
financially,ö Dr. Guarisco said, and it still struggles to this day.
Bad Time for a Fracture No one thinks that emergency rooms are a good way to provide basic everyday health care, but government efforts to attract doctors and to open more neighborhood clinics have gotten off to a slow start.
Volunteers and nonprofit groups are trying to fill the breach, treating thousands of patients a month in more than a dozen low-cost clinics in the city.
In many ways, the clinics have been a success for their patients, as they are elsewhere in the country, but they represent just a drop in the city╒s ocean of medical need, health officials say.
Some were open before the storm but have expanded; others are new, like the Common Ground Health Clinic, which provides free medical care four days a week in an old corner store in the Algiers neighborhood, across the Mississippi from
the French Quarter. People wait outside in the heat for the clinic to open, and
it is always jammed. One recent Tuesday, the patients included a city employee with a neck problem, a
college student with uncontrolled menstrual bleeding, a bartender with high blood pressure and glaucoma, and Nellie M. Lindsey, 54, a scrap hauler who was suffering from what she called ôcancer stones.
Before the storm, Ms. Lindsey said, she would have sought treatment at Charity, but she is so happy with the Common Ground clinic ù despite the long waits that she took her adult sons and daughter there for checkups.
Most of the people who come to the clinic hold at least one job, and many are working two, said Anne Mulle, a family nurse practitioner who came from
California after the storm to help and ended up staying.
In addition to longstanding problems like hypertension, diabetes and heart disease, most patients have anxiety, depression and stress, which are even harder to treat, the clinic staff says. We can take the health piece off your worry list,╒ said Dr. Ravi Vadlamud, a Tulane University doctor who serves as the clinic╒s volunteer medical director.
But we can╒t get you a better job market or housing market; we can╒t do anything about the schools; we can╒t do much with police problems. I can╒t do anything about most of what bothers you.
For patients who need more complicated care, including mammograms, stress tests and vision treatments, the clinic can make referrals to St. Thomas Community Health Center, which Dr. Donald T. Erwin founded in 1987. The fact that clinics are now collaborating ù and recently qualified for federal financing is a new
and welcome development in what can seem like a bleak medical landscape, Dr. Erwin said. Another change he has seen, he said, is that even people with insurance are having a hard time finding doctors, getting tests and continuing prescriptions, so are turning up at his clinic, where they now make up about a quarter of the patients. ôBefore the storm?ö Dr. Erwin continued, and held a thumb and forefinger together to make a zero.
Counseling and mental health treatment are notoriously hard to find in New Orleans these days, and doctors say this is an especially bad time to break a leg, given the shortage of orthopedists.
Even patients with the means to pay and doctors who have returned can face waits for treatment. Dr. Myers, the internist who used to practice in Mid-City, said recently that a new patient would probably have to wait two months for an appointment, though he would find a way to get existing patients in sooner. He estimates that 80 percent of those patients have returned. Dr. Myers said he had been trying for months to lure another doctor to the area to join his practice This is a great opportunity for people who have courage, he said. So far, he has found no takers.
“I do not feel as if I am `filling the gap’ for anyone. Nurse practitioners are registered nurses with advanced education and the ability to assess, diagnose and treat patients from cradle to grave. We are not medical doctors, but we are very capable of providing quality care to patients. Most of us have been in nursing more years than the average age of a new physician just out of school.”
“The majority of my patients come to me because they cannot get in to see their primary care physician, or they have no insurance and cannot afford the high costs associated with a new-patient visit to a family practice physician. My previous practice was in a rural health care clinic which has always been staffed with nurse practitioners because of the lack of physicians willing to work in the rural areas.”
“The lack of primary care physicians certainly should not cripple the nation’s health care system, since there are over 125,000 educated, qualified nurse practitioners ready, willing and able to continue providing quality health care to the people of our country.”