Hospital Unaccountability Extends to Outbreaks of Infectious Diseases

Contaminated_surfaces_increase_cross-transmissionSan Francisco     The Affordable Care Act has given health consumers, also known frequently as patients, more significant advances in transparency and information about hospitals and doctors. Medical records are being digitized and becoming accessible. Information is being made public on doctors, exposing some have Medicare mills. It appears the public is getting closer to being able rate and rank hospitals on cost and efficacy in handling various procedures. There’s hope we may be able to be better informed on questions that impact our own life prospects and therefore better able to make decisions and evaluate the opinions and prognosis of this powerful priesthood of doctors and the temples or hospitals where they practice.

Despite this glasnost, it was unsettling, perhaps even shocking, to read a story from the Los Angeles Times that showed light on the veil of secrecy practiced by hospitals in shielding information from the public on outbreaks of infections, whether from staph or so-called superbugs, or other seemingly inexplicable epidemics that suddenly take down otherwise healthy patients often passing through the hospital on minimal or routine visits. Worse, what we know is often only years later through tangential revelations in medical journals still disguising the names of the hospital and other critical details that might have saved lives when a stitch in time was still possible.

The Los Angeles Times told about six children having been killed suddenly in an unknown hospital due to a fungal infection that later information indicated had occurred at Children’s Hospital in Los Angeles several years before due to dust picked up from construction of an overhead sidewalk at the facility. Other examples in Florida and California caused what may be countless deaths, once again only puzzled out for the public years later, because of a design flaw in instruments that prevented complete cleaning. In another case, a doctor had inadvertently spread a staph infection into the hearts of five patients and eventually in sixty others before the health department was able to track the problem down and stamp it out. Tell me all of this isn’t scary as heck!

So, we can say that stuff happens, even bad and evil stuff, but that doesn’t excuse not warning the public as you would with other situations of public health outbreaks. The defense offered by the hospitals and some of their governmental minders is that if the hospitals were not promised confidentiality then they might not report any of the incidents to public health authorities at all, even though everyone agrees that the reporting is not comprehensive even with confidentiality. The hospitals argue that they don’t want to panic the public. The rationalizations seem unending. It’s hard to believe that this isn’t really about having to face liability and legal actions for such errors, but maybe that’s a euphemism for “panic.”

Amazingly, there seems to be virtually no legislation at the federal or state level that mandates reporting or assigns penalties for failing to report. Our legislators seem to be wittingly covering for the abuse and neglect of these priests and their sanctuaries just as we have experienced in other institution where inadequate accountability and disclosure are the rule. A law in California passed after an egregious case requiring a hospital report of how many of their patients get infections seemed a positive note, but then the mother of the victim was quoted saying that she was on the supervisory board and that 12 of the 17 members were doctors and hospitals and only wanted to protect “their employers.”

What do we do in a world where to stay healthy we have to stay away from hospitals? Public disclosure would advance public health and consumer health decisions and confidence. Why is this a hard thing to ask from our politicians?

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Jimmie Rodgers- TB Blues

Union Leaders Concerned about Schools, Wages, and Medical Debt

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welcome

Little Rock    When the forty leaders at the 34th Annual Local 100 Leadership Conference, held this year in Little Rock, were asked how many  of them were carrying medical debt, more than half of the hands in the  room went up.  When asked how many had family, friends, or neighbors  dealing with the burden of medical debt, all of the hands went up!  No  surprise that there was enthusiasm for Local 100’s twin initiatives of establishing citizen wealth centers and launching a campaign in Louisiana, Arkansas, and Texas around hospital accountability to provide  charity care and financial assistance.

Citizen Wealth workshop

Citizen Wealth workshop

There were some interesting surprises though.   In a plenary discussion of  the union’s partnerships and initiatives in campaigning for living wages  for state workers, school workers, and all of our workers with different  strategies, mentioning that many of the union’s struggles were with charter schools triggered an impromptu discussion and deep criticism of  charter schools from leaders throughout our geography.  Many repeated the promises that had led them to enroll their children in charters in their search for the best for their kids, but it was almost tragic to listen to the profound disappointment they felt with the results. In one case the lost year seemed a setback in math and science that had led a promising child to remedial work in a community college now.  In another case, fleeing the charter disaster meant two months out of school waiting for a place to open back up in a former school. The disillusionment with young, inexperienced teachers and a constant churning of the staff was also acute.  Many of Local 100’s leaders had drunk the Kool-Aid and were now spitting it up, which augurs poorly for the future of charters.

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The discussion got back eventually to the recent victory in Houston  Independent Schools where on a 6-1 vote we won a starting wage of $10 per hour for all employees. The union is now targeting a special effort for the cafeteria workers to increase hours, since even with the raise, they are not getting enough hours to equal a living wage.In Arkansas we have identified 900 state workers under $10 and are making headway there.  Neil Sealy, the executive director of Arkansas Community Organizations, joined the discussion with us as a partner along with KABF radio on this campaign.  He reported on ACORN’s victory for Pine Bluff city and contract workers where wages are over $12 now thanks to a city referendum several years ago.  Dallas indicated that they had identified 1000 workers making less than $13 per hour in the schools there that they are targeting.

President Henrietta Collins

President Henrietta Collins

Before the end of the meeting there was a union wide commitment to see if the new NLRB rules on quicker elections will make a difference.  Nursing home workers in Arkansas seem to be stirring, and the union is looking at whether this might be a good test.

Anytime a meeting ends with a dinner that includes catfish fried in front of us, tender beef brisket, and homemade peach cobbler, you know you are in Arkansas and you know it was a good meeting!

Leadership Conference Participants

Leadership Conference Participants

Clear Standards for Charity Care for Nonprofit Hospitals

03-11-top7-UPMC-Logo*750Little Rock    For millions there is a collective sigh of relief as 6-3 affirmation of the Affordable Care Act subsidies for low income Americans sinks in and allows us to stop pinching our arms about whether or not this is real. If there’s anything we’ve learned, it’s that the Supreme Court can “giveth,” as it did with Obamacare, and it can “taketh away,” as it did with the Presidency some years ago. More than 1200 rural hospitals, many of them nonprofits, were reportedly ecstatic at the decision since many, if not most, run deficits every year, so knowing there is going to be insurance matters hugely. Other hospitals and health insurers were also relieved.

For the more than 30 states still not operating exchanges, and in most cases not having expanded coverage for their uninsured who would be eligible for expanded Medicaid, this decision should mean that it’s time for an end to posturing and some serious business. In the meantime, the urgency of compelling tax exempt, allegedly nonprofit hospitals to provide their fair share of charity care to justify their shopping cart full of benefits in many states, is immediate.

It was initially intimidating to look more deeply at the giant University of Pittsburgh Medical Centers (UPMC) after my visit there recently because of its size and scope. Fortunately in some early window shopping, our Pittsburgh affiliate stumbled immediately on a fascinating document written by a locally prominent law firm at the request of the Alleghany solicitor on whether or not UPMC truly qualified for any sales, property, or other tax benefits based on alleged nonprofit and charitable status. The 13-page memorandum said it would be a lift given the firepower UPMC would bring to the battle, but firmly argued throughout the review that according to Pennsylvania law and court decisions they felt there was no doubt that UPMC did not meet all of the required five tests.

For a minute let’s just look at the tests, rather than at UPMC or any other hospital’s failures, because the Pennsylvania courts provide a useful guide everywhere for judging nonprofit hospitals and others.

· Advances a charitable purpose;
· Donates or renders gratuitously a substantial portion of its service;
· Benefits a substantial and indefinite class of persons who are legitimate subjects of charity;
· Relieves the government of some of its burden; and
· Operates entirely free from private profit motive.

When the modest average nationally for the provision of charity by nonprofit hospitals is 6% and hospitals are routinely failing this measure even under the most bend-over-backward liberality, we clearly have a problem. UPMC for example seems to toggle between a bit over 1% and 3% using a standard that goes way past liberality in counting things as charitable. The vast array of for profit enterprises nested in so many of these hospital systems as well as their lengthy and harsh recitation of procedures to squeeze every penny from the poor, would seem to disqualify many on the “private profit motive” count. Defining a “substantial portion” as even 6% also seems a bridge to far to stretch to define something as charitable. Seeing their service area and client base as a “substantial…class…who are legitimate subjects of charity,” would also leave many institutions lacking as they shutter inner city facilities and build grant suburban monuments to their pride and profit, rather than their mission.

Nonetheless, these five rules in Pennsylvania might be useful in setting the standards for hospitals everywhere, even if Pennsylvania hasn’t quite gotten around to enforcing their rules within their own boundaries yet.

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Please enjoy Compound Fracture by My Morning Jacket.  Thanks to Kabf.

Some States Governments Step Up on Hospital Accountability

hcbp_logo2New Orleans    It took a long time before hard questions were asked of churches given the faith so many people have in them, but the process has produced important and powerful results.  Modern faith has created a priesthood of doctors and an altar of medicine where hospitals are their high churches.  Even as the Affordable Care Act is offering the promise of more accountability – and access – to care, it turns out according to a comprehensive report by the University of Maryland Baltimore County’s Hilltop Institute and their survey of state laws around the USA that state and local authorities in some places have forged the tools to require more accountability as well, having broken ground that other jurisdictions need to follow.

Here’s more good information that has come down from The Hilltop:

  • Twenty-three states require nonprofit hospitals to provide community benefits.

The list includes California, Delaware, Florida, Illinois, Indiana, Maine, Maryland, Massachusetts, Mississippi (yes, Mississippi!), Montana, Nevada, New Hampshire, New Mexico, New York, Ohio, Pennsylvania, Rhode Island, South Carolina (yes, South, not North), Texas (believe it or not!), Utah, Virginia, Washington, and even West Virginia.

  • Nine states have broad and unconditional community benefit requirements in law or regulation.

That list includes California of course, but Florida is also in this number and needs to do a lot more with these tools and so do Montana and Nevada.  The rest are Indiana, Maryland, Maine, New Hampshire, and Washington.

  • Six require non-profit hospitals to provide community benefits as a condition of certificate of need approval and three as a condition of hospital licensure.

The big six are Delaware, Massachusetts, Mississippi, stepping up again, New Hampshire, South Carolina and Virginia – that’s three in the south, none in the West or Midwest, if you’re keeping score.

The three that hold the licenses up for grabs are Massachusetts of course, New Mexico finally representing the West, and little Rhode Island, part of the Massachusetts slipstream.

There are also jurisdictions willing to use strong local handles to force accountability and community benefits.

  • Six require community benefits as an express condition of property tax exemption.

These six are Illinois, Mississippi, Pennsylvania, Texas, Utah, and West Virginia, meaning that community groups and beleaguered patients, if able, could appeal a hospital’s highly valued multi-million dollar free ride on property tax for failing to provide adequate financial assistance, if you’re following my thinking here.

And, when the going gets tough, Illinois and Pennsylvania are willing to made hospitals pay sales taxes, and those are hefty, if the hospital doesn’t provide benefits to the community and New York and Ohio are willing to refuse any part of state reimbursements with their funds for charity care expenses if the hospital isn’t doing the job providing community benefits.

Let’s be realistic.  These are small steps towards accountability from private institutions receiving immensely valuable public benefits.It should be the least we should expect from all state and local jurisdictions, rather than an honor roll of the many and the few.

Our work in winning accountability from hospitals to our communities is cut out for us, but at least there are many that have been there and done that at least at the legislative level in creating the handles for us to make the work easier.

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JOHN LEE HOOKER & SANTANA – The Healer

States Need to Make For-profit Hospitals Accountable for Strapped Families

l_shutterstock_49869556New Orleans    We have been beating the drum regularly here, there, and everywhere around the country about the organizing and campaign “handles” that could allow aggressive and vigilant community and labor based organizations to demand and require more accountability for tax-exempt nonprofit hospitals.  We have trumpeted Senator Charles Grassley of Iowa’s late stage amendment to the Affordable Care Act in 2010 requiring such hospitals to stand and deliver significant charity care or risk losing their tax exemptions.All of that was right, but it turns out we may have shooting for the stars with hopes and dreams in the IRS and the feds, when a fair number of states may have already armed us for battle.

Living and working so long in the backwaters of the bright, red states in the United States it is easy for me to forget that there’s another, kinder gentler world out there, and sometimes that world has even leeched into these hardscrabble places.  I was reminded of all of this by a throwaway comment while talking to Will Pittz, the executive director of the Washington Community Action Network on Wade’s World recently.  Pittz and Washington CAN have done exciting, groundbreaking work in holding hospitals accountable for better care for lower income and working families in Tacoma, Seattle, and Spokane.  We were talking
about the fact that they won a gold standard poverty guideline giving up to 75% medical debt forgiveness to people at 500% of the federal poverty standard and had done so with a private, for-profit hospital.  Asking him why they had agreed to such a thing other than the pressure applied by the campaign, Pittz mentioned, almost offhandedly, that Washington State required for-profits to all have financial assistance policies.  That caught me up short.  I had been grabbing at the sky, when there might be solid dirt right under our feet for all the hospitals.

So, his throwaway line got me searching with my Google research department and together we found a goldmine in a fairly recent, March 2013, report from something called the Hilltop Institute of the University of Maryland Baltimore County that had comprehensively studied the state legal landscape for community benefits after the passage of the Affordable Care Act.This study was an eye opener so we will be talking a lot more about its treasures!  On the immediate point I found hidden in a footnote a listing of the seventeen (17) states that require hospitals to have financial assistance policies.  The states are California, Colorado, Illinois, Indiana, Massachusetts, Maine, Maryland, Montana, New Hampshire, New York, Oklahoma, Pennsylvania, Rhode Island, Texas, Utah, Virginia, Washington of course, Wisconsin, and West Virginia. Except for New Hampshire and Utah, the Financial Assistance Policy requirement applies to both for-profit and nonprofit hospitals.  Eureka!

And, are you kidding me, Texas is on the list.  So is Oklahoma, West Virginia, Montana, and Maine, so this is not just the favored few.  It turns out Texas is even the only state that requires hospitals to publish their charity and financial assistance policies in the local newspapers, so we need to get on the stick and find those notices.

And, maybe even better, as we check the mail every day in Dallas and Houston to see if any of these hospitals have replied to our request to meet and discuss their policies for financial assistance, the Hilltop report contains this other shiny nugget:

New Hampshire and Texas both specify that the needs assessment process must include consultation with members of the public, community organizations, and local government officials. Texas further requires input from private business, insurance companies, and health science centers.

Yes, you heard right:“community organizations” and “members of the public.”

The one thing that Pittz and I beat to death on the show was the fact that it didn’t matter what was on the books, we all had to make these hospitals do right, and in the meantime they will be hiding out in plain sight and doing everything they can to get over and pretend the laws don’t matter when it comes to them and their money.

We need to get these kinds of hospital accountability laws on the books in all of the states and local governmental jurisdictions!

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The Hollies – He Ain’t Heavy, He’s My Brother

Unnecessary Medical Care and Over Prescription by Doctors

cover--310x465New Orleans      I go for a physical annually, like you’re supposed to do.  I basically trust my doctor, largely because she keeps it simple, doesn’t make me do some tests I don’t want, stretches out the EKGs for years, and sometimes forgets to make me, how should I say this, bend over.  To get insurance to pay, they require the calendar to be rigidly followed no more than one year after the last one, which put me having my visit after I came back from Montana in 2014.  Having taken a bit of a dive over a piece of a mountain to fortunately be stopped by a tree, I had a bump still protruding on one leg weeks after the fact, so there I was, and there the doctor was, so what the heck, I asked her about it, rather than just going with Google.  She was worried that it might be a clot in the vascular system and wanted me to immediately, as in that minute, go have an ultrasound to make sure. I tried to push back a bit, and she basically snapped at me that, hey, it was up to me if I lived or died.   Needless to say, I drug my ass across town to a hospital and was lucky to get the test done and find out that it was a problem that only time could heal.

The moral of this story is simple.  Doctors do have a way of getting you to take tests with some unanswerable arguments, no matter what we might think or feel about our health and well-being, so it’s an awesome power, and often unaccountable power.  In this case, she was likely right, and I was undeniably stubborn.

The other side of this problem is the fact that doctors and their institutions have until recently had huge incentives to order tests by the truckload.  Dr. Atul Gawande writing in The New Yorker recently reported that “thirty per cent of healthcare spending, or some seven hundred and fifty billion dollars a year” is waste.  In painful detail, he documented the vast number of tests that are simply useless and not even predictive in determining the problems at hand.  He noted elsewhere that “twenty-five to forty-two per cent of Medicare patients received at least one of…twenty-six useless tests and treatments.”  Maybe that’s not painful to read, but reading the whole article about surgeons seeing something as successful, simply if someone lived through the operation, regardless of whether or not it prolonged life, much less added quality to life, was just heartbreaking in addition to stupid and wasteful.  What happened to the Hippocratic Oath’s requirement for doctors to “do no harm?”

Gawande, some six years ago, had written a path breaking piece on Brownsville, Texas and why it was the most expensive place for medical treatment in the country.  The good news in this report is that his earlier article – and important new incentives provided by the Affordable Care Act to allow doctors and healthcare facilities to share hugely in sharing in the savings – had shamed and shuffled them into doing better.  This needs to catch on around the country!

In the meantime, having read all of Gawande’s pieces in The New Yorker and earlier his recent book, Being Mortal: Medicine and What Matters in the End, the only thing I’m one-hundred percent clear about it is that as much as I like my doctor and have learned to live with her, I have to admit that I wish Gawande would be my doctor whenever I come to have a serious problem.  Not having that, I hope I end up with a doctor who has read his stuff and drunk his Kool-Aid.   In fact I wish that for all of us!
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10cc – The Hospital Song