Chicago Top Docs Named But What's Missing?

The January 2008 Chicago magazine (yet to hit the web and news stands) names Chicago's top doctors.  It is a great honor to be on the list. Those selected have been nominated by peers and vetted by a fairly rigorous selection process designed by Castle Connolly Medical LTD. 

First, a disclaimer, and a congratulations.  My wife, Dr. Michelle Gittler, has been named for the 3rd time as a Top Doc in her field of Physical Medicine and Rehabilitation at Schwab Rehabilitation Hospital. And she truly is one. I'm very proud of her.  Imagine coming home to that every night! And hopefully,  I get to be the spouse guest again this year  at a swank downtown reception in honor of this year's Top Docs.

But something is missing from the Chicago and Castle Connolly Report.  The major safety net hospital serving patients without regard to the ability to pay is conspicuously left off the magazine's index to hospitals. 

That's right, John H. Stroger Jr. Hospital of Cook County is apparently not a hospital in the minds of Chicago magazine or Castle Connolly.  

Ignore its  244,112  emergency department and urgent care visits in 2006* (University of Chicago 80,000 -- Northwestern 73,500 -- Cook County safety net Provident 53,974 -- University of Illinois 52,000 --  Mt. Sinai 50,250, -- Rush 46,000 -- Advocate Illinois Masonic 38,122).  

Also ignore their good health outcomes -- the fact that the Cook County Bureau of Health Services is one of the largest cancer care providers in in Illinois with 5-year survival of Stage II breast, colon and lung cancers all significantly better than US averages.  Operative mortality for cardiac surgery is better than national  benchmarks despite serving a population more likely to be high risk to begin with.  

Another example is neonatology survival.  Despite caring for smaller premature infants, the Stroger neonatal ICU has a greater survival rate than the national average.

Additionally, the County-run CORE center cares for 31% of all known HIV patients in Chicago and 20% of all known HIV patients in Illinois.

We can't ignore what County is famous for:  trauma care.  Of 6 trauma centers in the Chicago region, the Stroger Trauma Unit sees 40% of all trauma cases.  If the patient comes in alive, there is a 95.5% chance that the trauma team will save their life.

When you include the entire ambulatory health care network of Cook County, almost 500,000 patient visits were accomplished in 2006.

Given the sheer size of the health care operation and the exemplary health outcomes odds are there should at least one "Top Doc"  at Stroger Hospital or within the Cook County system named by Chicago magazine and  Castle Connolly.

Yet, conspicuously, none of Chicago's "Top Docs" are at Stroger Hospital, or for that matter, in the entire Cook County Bureau of Health system. 

Perhaps the "Top Doc" selection methodology is skewed towards physicians who serve patients who have insurance and access to academic and private medical centers leaving safety net docs largely unrecognized.

I hope that next year's Chicago magazine report recognizes top docs for all.

______

*Stroger Hospital 2006 -- 124,880 visits in the main Emergency dept., 12,678 in the Pediatrics ED and 103,553 visits in the walk in urgent care Ambulatory Screening Clinic.

Cook County Bureau of Health is Not the Only One

Almost absent from the discussion about County budgets and safety net health care is the realization that community health centers are a big part of the picture.  In the Chicago metro area, community health centers (CHCs) take care of 500,000 individuals, regardless of their ability to pay; in Illinois, we care for almost 1,000,000;  in the US 16,000,000. 

According to the Illinois Primary Health Care Association, community health centers in in Illinois provide cost-effective care. Health care costs for CHCs are an average of 30% lower than other providers serving the safety net population.  CHCs save dollars spent on unnecessary emergency room care and through the lower use of specialty and in-patient hospital care. With 268 primary care sites in Illinois, over half of those in the Chicago metro area, CHCs are a decentralized solution to primary care delivery.

Cook County leadership should recognize the critical role played by CHCs.  By collaborating on health care services for the under-served, CHCs  save the County dollars while improving the overall quality of care.

Important collaborations between the Cook County Bureau of Health Services and CHCs already exist but are at risk of being cut due to the County's budget crisis.  CHCs may no longer be able to accept referrals to provide primary care to patients released  from County facilities such as Stroger Hospital's  ER if the County cannot provide specialty care for CHC patients in exchange. Ditto for County's provision of pharmacy services for those County patients enrolled for ongoing care at CHC who have the most complex of chronic illnesses.

Only visionaries in health care policy and planning who have a sharp financial accounting pencil currently see the tremendous potential synergy between CHCs and the Cook County Bureau of Health Services.  The Bureau is not the only one out there providing safety net health care and needs to stop acting like it is.

Who should run health care in Cook County?

Who should govern the Cook County Bureau of Health Services?

The current rubric gives the Cook County Board responsibility for oversight of public health and health care. We need experts who know how to run hopsitals and clinics. Most experts agree that the Cook County Board must relinquish oversight to an independent health commission. This is not new news. Earlier this year health experts, under the umbrella of Northwestern University's Feinberg School of Medicine came together and recommended this.

You can read the whole report from Northwestern University’s Feinberg School of Medicine about important priorities and directions that can be taken by Cook County Bureau of Health. The authors of this report should know. They are all veterans of the Cook County Bureau of Health Care system. They have worked there. They know the inside information. There are successful models from around the country that they draw upon in the recommendations section.


Not to be left out, Cook County Board President Stroger appointed his own Blue Ribbon Commission. Read the Blue Ribbon Commission Report to get a sense that we run health care in our County as if it was some feifdom from the middle ages. Time to turn it over to the experts in hospital management, public health systems and financial outcomes. We'll see if President Stroger has the political courage to follow these recommendations.

Death and Health Insurance

This column by Bob Herbert column by Bob Herbert in the NY Times got me thinking about the relationship between health insurance and what physicians write on death certificates. Does lack of health insurance increase the risk of death?

This letter was not published, but 2 by others took a different approach.

November 3, 2007

To the Editor:

Re “Worsening the Odds” (Op-Ed, Nov 3): Bob Herbert describes the unfortunate case of a 45 year old medically uninsured craftsman with progressive headaches who died of metastatic cancer to the brain. He suggests that lack of health insurance contributed to the cause of death.
At our inner-city community health center, 70% of the adults we serve lack health insurance. We commonly see preventable complications of disease.
In Illinois, physicians must enter the official cause of death on the death certificate. On the following two lines physicians may choose to add that the death was “Due to or as a consequence of …” Perhaps we should routinely write “lack of health insurance” or “inability to obtain preventive care” on these lines. By doing so, the role played by this important factor will become an official part of the public record.

Cook County Bureau of Health Cuts Now to Spend More Later

The Cook County Bureau of Health is trying to close a budget deficit. Currently the round peg of $835M in health system expenditures has to fit into the square hole of a $730M target. An historic closing of County-run community clinics combined with one of the largest layoffs of doctors and nurse practitioners has created repercussions across the region. The problem? No strategic plan, no governance by health care experts.

Meanwhile, the response by Cook County managers is to strangle prevention efforts and to cut resources that allow people to get health care close to home, at a neighborhood clinic. Let's keep the emergency department free to see true emergencies instead of clogging it up with folks who just need a refill on their diabeted medication.

Paradoxically, cutting back on neighborhood-based care will put more stress on the system by forcing patient to stand in line for routine services at Stroger Hospital. Or worse, wait until they are too sick and end up with costly hospitalization.

Can someone do the math?

Cutting off a system for community to hospital referrals saves money and time. So why cut it?

Testimony of
Lee Francis, MD, MPH
Interim CEO, Erie Family Health Center
May 23, 2007

Erie Family Health Center is a federally qualified health center celebrating its 50th year. With 8 service locations ranging from North Lawndale, West Town, Humboldt Park, and Logan Square all the way to Albany Park, we provide over 120,000 patient visits annually to over 30,000 patients. On a budget of $20M we employ 260 health care workers. Although we are located in Chicago, approximately 10% of our patients come from Suburban Cook County, the rest from the City.

On March 27, 2007 Dr. Robert Simon, Interim Chief, Cook County Bureau of Health Services, notified community health centers participating in the cooperative computerized specialty referral system called IRIS that our patients would no longer be able to access services for specialty consultations and testing effective April 16, 2007. He stated that a task force had been formed to evaluate the issue and would report back to him in 1-1.5 months. After over a month of requests through various high level channels, Dr. Simon finally met with us last week and some sort of work group with our input was formed. The first meeting will be in early June. Meanwhile patients go without services. We are asked to refer them to the ER for simple and complex problems alike that are best sorted out directly between primary care doctor and specialist.

Shortly after IRIS was cut off, I saw Sra. C. in my clinic. She has terrible diabetes and sees the diabetes and kidney specialists at Fantus Clinic. Her colon cancer was diagnosed and cured by the skilled surgeons at the hospital. She attends the eye clinic because she has diabetic eye disease and the ear nose and throat clinic because she has lost much of her hearing. She complained of chest pain and I felt that she needed a stress test. Stroger Hospital is her health care provider of choice. She chooses. Yet, for the first time in over 10 years, since the Stroger ER first referred her to me, I could not link her with an appointment for a stress test. Here’s the kicker – she has both Medicare and Medicaid, and she is choosing the County for her health care. Should I send her to the ASC so another doctor, who doesn’t know her, can decide if she needs a stress test or not? Or to another hospital who is more eager to bill for the service?

This decision has left thousands of Cook County residents out in the cold – residents who have a right to Bureau services.

IRIS is part of the Neighborhood Referral Program, a system with almost 20 years history. It creates a successful exchange relationship between tertiary care hospital and its specialty clinics and neighborhood health centers such as ours which specialize in primary care.

In 2006, Erie made 2,907 referrals for services on the Stroger Hospital campus, 84% of which were scheduled for service. Seven percent of patients referred actually had good solid health insurance. In exchange, Erie has accepted over 400 new patients per year from Stroger ER and the ASC walk in clinic – taken them under our wing and provided them affordable, high quality comprehensive primary care services – regardless of their ability to pay. We have been doing this for over 10 years; we have accepted over 4,000 into our system. Multiply these numbers by 10 or 20 to get an idea of the number of patients unloaded from the Stroger campus and able to receive care in their communities. We are talking 40,000 – 80,000 people who are being helped right in their own neighborhoods.

When we accept patients through NRP, we accept the financial burden. Each visit costs us $153. Our Federal grant accounts for only 23% of our income. Medicaid and Medicare pay about $120 per visit, only 60% of what the County receives per Medicaid visit. We fundraise the rest. If the patient is uninsured, we ask for a reasonable fee of $30 per visit. The average patient currently pays about $18, or 60% of our self-pay fee. We ask a small fee of $4 for medications we supply. We know how to compassionately collect self-pay fees, we know how to bill Medicaid and Medicare and other payers. We even accept Visa and Master Card!

Dr. Simon has stated that community health center use of the IRIS system costs the County $20M per year. No one has any idea where this number comes from. Community clinics account for only 16% of IRIS referrals. If this 16% costs $20M then, the other 84% of usage from Bureau clinics must cost $105M for a total cost of the IRIS system of $125M. Please ask Dr. Simon to show on paper how the IRIS system, for all users, costs a total of $125M per year out of a total expense line of approximately $853M (total per Dr. Simon).

More important: What is the “cost of waste” of not having such a system? What is the additional cost of thousands of new emergency room and ASC visits at over $200 per visit. What about preventable heart attacks, cancers, strokes at tens of thousands of dollars each? From the standpoint of the public good, this question deserves an answer from the financial experts at the Bureau.

We requested that the IRIS system be turned back on while we work together as partners to evaluate the system and increase efficiencies. So far the answer has been “no”. We all agree that we can and must improve efficiencies in the system. At least turn on the most vital parts of the system and restore access to the most needed services.