Reacting to the Future of Primary Care

There is a provocative Perspective article in the November 13, 2008 issue of the New England Journal of Medicine. The basic question argued about is whether or not it is physically possible to provide primary care to the extent required to prevent illness and treat chronic disease effectively. There are so many things a primary care provider must do that she or he would need to work 18 hours every day. Whereas a specialist can focus on just one part of the body or one illness, a primary care provider must focus on everything from acute illness to preventive care to managing chronic illness -- and all in a 15-20 min patient visit. What do you think? No time to read the article? Check out the video.



As an example from my own practice, a 72 year old man has just been discharged from the hospital after being admitted for shortness of breath. He has chronic illness which include the following: diabetes, hypertension, coronary artery disease, sleep apnea, renal failure, severe arthritis, glaucoma and high cholesterol. He needs his list of medications from the hospital reconciled which what he was taking before he was admitted. In addition, he is due for his flu shot and other preventive interventions. Go. You have 20 minutes start to finish.

And, don't forget the follow up phone calls to pharmacy and specialists after the visit is over. Of course, now we have email too.

Is this an extreme example? Not really. Many adult patients suffering from chronic illness have more than one; way more than one.

As of 2008, health care providers get reimbursed based on the individual patient encounter. One visit equals one payment. Complexity of illness only plays a minor role in the amount of reimbursement, and all work done outside the exam room doesn't count. This is just as true for those providing health care without regard to the ability to pay, like community health centers, as it is for practices caring for a largely insured population. At health centers such as ours -- Erie Family Health Center -- we look for innovative ways to soak up the cost and we rely on winning competitive federal, state and local grants.

But our doctors, nurse practitioners, certified nurse midwives, physicians assistants, and dentists all have the same stress and challenge of trying to do everything, every day. We clearly need to invent something new.

END OF POST. THANK YOU FOR READING.

Election Landslide in Long Term Health Facility

I have the honor of providing health care to 2 ladies who reside in a local long term health care facility (aka nursing home). Ms Trawler (not her real name) used to be my patient when she lived in the community near our health center. About 10 years ago, she could no longer live by herself. All alone, except for a disinterested niece in the north suburbs, she began falling, forgetting to take her medications, and ended up in the hospital several times. With no one to look in on her and to help, she took advantage of Medicaid and entered the long term care facility.

Life there is not great for her. She rarely goes outside, and although she walks about with a walker, she is not very mobile. A couple of years ago the facility moved her away from her friends on the first floor, on up to the second floor; that was a million miles away from her delicate social circle. (...continued)


Her health care and her long term stay in the facility is funded by you and me. Medicaid picks up the tab for her daily room and board, her medications, and any special tests she may need. Thank you. This has been going on for almost 10 years. Ms Trawler thanks you too.

Her single room is shared with 3 other ladies in various stages of decline. They come and go, hooked and unhooked to various machines, but Ms Trawler stays. And keeps staying. With no privacy to speak of, she has permanently swallowed her pride a long time ago. One bathroom for all four.

So I asked her if she had been able to vote in the election last week.

Yes, of course. They wheeled us down to the basement and we all voted. We always vote.

Ms Trawler is an 83 year old white woman. She grew up in an all white neighborhood where newly arrived Italians lived side by side with immigrant Poles and other Eastern Europeans in Chicago's West Town Neighborhood. Later, Hispanics moved in. She always remarked at how much the neighborhood had changed.

Thus, it surprised me when she told me she had voted for Mr. Obama.

Why, I asked?

Well, he reminds me of why I voted for Jack Kennedy. His family reminds me of Jack Kennedy, his beautiful wife and those two adorable girls. And he's so smart. Everyone else there voted Obama too.

Her choice seemed color blind, from her dreary bed in a musty long term care facility in Chicago. A landslide there for Obama.

END OF POST. Thank you for reading.

Three Pumpkins Tell Stories

This years family pumpkins are allegorical. Al Gore (ahem) would be proud.

In "Let's All Hope It's Not Too Late", Michelle Gittler's map of the US is in the intensive care unit.

            

Meanwhile, in Hannah Francis's "Mirrror", John McCain gazes at George W. Bush in the mirror -- 8 years of the same thing.

... and Laila Francis's "The Pig and the Lipstick"  is "kinda about Palin and Biden."

Happy 2008 Elections everyone!

Less Access (Again!) for Women to Deliver Babies in Chicago

I heard last night from my counterpart at a sister community health center in Chicago which uses Lincoln Park Hospital (the former Grant Hospital) as their hospital to deliver babies. The CEO of Lincoln Park had contacted him to say that the hospital was abruptly stopping maternity services effective immediately.

The Chicago Tribune reported on Thursday October 9, 2008 that the hospital was for sale and at risk of closing.

For almost a year, Lincoln Park has been reaching out to community health centers in an attempt to increase maternal services utilization by attracting Medicaid insured women. This is a potential money-maker for community hospitals.

Our sister agency, on a Friday night, had to scramble to find a place to safely deliver their babies. As community health centers, we take care of patients regardless of their ability to pay. As a result, those most affected by this abrupt move are expectant mothers living in poverty and covered by Medicaid.


Over the past year or so several North Side hospitals have limited or closed their maternity services. Weiss Hospital closed its maternity services (with plenty of advance notice), Advocate Illinois Masonic Hospital has no room at the inn for more normal-risk Medicaid deliveries, neither does Swedish Hospital. There is definitely an unhealthy pattern here.

One of the drivers of hospitals getting out of the baby delivering business may be malpractice costs. But that's a whole different subject.

The current situation raises the question: if you are a pregnant woman, living in poverty, on the North Side or Northwest Side of Chicago, and you are insured by Medicaid, where will you go to deliver your baby? Where will your doctor be able to attend to your birth with you?

Because of this very same dilemma, Erie Family Health Center will now start delivering babies at Norwegian American Hospital (moving almost 500 deliveries per year from Advocate Illinois Masonic Hospital). We will continue our long-term relationship with Northwestern’s Prentice Women’s Hospital where we deliver over 1,100 babies per year.  END OF POST. THANK YOU FOR READING.

Sunday Parkways in Chicago: I think it's a hit!

I had some fun riding boulevards closed to car traffic today as part of Chicago's first ever Sunday Parkways in Chicago.   Today, boulevards were closed to everything but human powered traffic in Logan Square, Humboldt Park,  and Garfield Park area.  Hundreds of neighborhood folks came out to just ride their bikes, walk, rollerblade and even ride their razor scooters. When you think about it, this is really a public health intervention. In one sense, neighborhood park space was increased several fold and on a day when people have free time to use it; calories burned, heart rates up and stress reduced.


Sunday Parkways is patterned after similar ones in Bogota, Columbia, and Guadalajara, Mexico where the events are called Ciclovias. Here in North America, Ottawa, Ontario, Portland, Oregon and Cleveland, Ohio all have events like Sunday Parkways.

I loved seeing so many families out today with little kids on tiny two wheelers. Without traffic and with traffic minders at every intersection, it's much safer than the annual Boulevard Ride.

While on the road today, I heard rhythms at the Humboldt Park Boat House and checked out the art work happening at the Garfield Park Conservatory.   But mostly it was some cool relatively fresh Sunday morning air that made it all worth while.

I'm looking forward to the next Sunday Parkway event on October 26, 2008.

While on the ride I met the founder of an online social community for Chicago cyclists.  Check out the chainlink.

Medically Uninsured Paradoxically Decrease

The reports are in regarding the number of uninsured residents in Illinois and in the US. In 2007, the year of the latest statistics, the number actually went down!

Yes, down.

In Illinois, 13.4% of our fellow friends and neighbors (1.7 million) were uninsured in 2007, down from 14% in 2006. Nationwide, 15.3% were uninsured in 2007 (45.7 million), down from 15.8% in 2006.

Does this mean things are getting better? Maybe. Maybe not. A look at US Census data by Physicians for a National Health Program analysts shows that most of the improvement in health insurance coverage is due to expansions of Medicaid (government coverage for those living in poverty or near poverty) and Medicare (government coverage for senior citizens). Employer provided coverage actually declined another half a percent.

This is mixed news for health centers such as ours. On the one hand, more of the low-income community residents we serve can qualify for Medicaid, especially women and children. On the other hand, working adults are less likely to receive insurance from their employers and are caught in limbo, with incomes too high to qualify for Medicaid.

We have made great strides in bringing health care coverage to almost all children in Illinois. The biggest challenge is covering grown-ups. I certainly have my eyes on the successes the Massachusetts system is experiencing (see the New York Times editorial on this).

NBC Olympics Coverage Slights Silver, Bronze and non-Americans

Doesn't anyone care about silver and bronze or even 4th place in the Olympics? Certainly not NBC, which consistently ignores many competitors achieving less than gold and those who hail from other countries. Perhaps NBC host Bob Costas should be banned for 24 hrs (or permanently) for saying the word "gold".

One example of NBC eyes focused only on the gold prize was coverage of the women's 10 meter platform diving. In edited replay prime time coverage NBC showed only divers from USA, Canada and China. Guess what? Mexico, yes, Mexico, took 4th and 5th place. The US diver finished 9th.

Given the large Mexican-American population in the US (as of 2006 28.3 million US residents were considered Mexican-American, 9% of the US population, and the fastest growing segment) you'd think NBC would key in to that. Certainly the advertisers on NBC do that (Chevy’s pick-up truck commercial ends with a Mexican-American gentlemen saying in Spanish, “Este es mi truque.” This is my truck.) Perhaps the Mexican team's swimming suits weren't cute enough to show on TV.

It happened again for the men’s 10 meter platform diving event 2 days later. After the semi-final round with a Mexican diver in 9th place and Cuban divers in 11th and 15th places. The US diver was in 5th place. And in the finals round the Cuban diver wasn't shown even though he was in second place after the first round. He later dropped out of medial contention.

A thoughtful colleague of mine from work reacted in the following way on a Facebook posting: “I watched the diving finals with my daughters. We anticipated that NBC would show at least a couple of dives by the two Mexican ladies that had received bronze in the synchronized diving competition earlier in the week. We were very disappointed. I didn't know how to explain it to my girls. For one brief moment I started to question the world's perception of the positive influence of Latinas. Then I remembered what the Latina Women of Erie accomplish each and every day. It's more than gold, silver or bronze. It's priceless.”

I’ll let her have the last word. (End of post.)

Word on Street: Evanston Northwestern Health Care Looks South

The word on the street is that Evanston Northwestern Health Care (ENH) which runs Evanston Hospital, Glenbrook Hospital and Highland Park Hospital is looking for a new academic affiliate. Will it say good bye to Northwestern Feinberg School of Medicine and hello to a new partner? Even as ENH plans to buy Rush North Shore Hospital it is in negotiations with Rosalind Franklin University of Medicine and Science in North Chicago (formerly Chicago Medical School) for a possible new Academic affiliation.

Northwestern Med's Dean Larry Jameson has expressed the wish that ENH contribute more dollars to the med school to support research and teaching reinforcing the suspicion at the downtown campus of Northwestern Med that ENH gets the cache of the Northwestern name without contributing much in the way of funds back to the med school. Unfair cries Dr. Jameson.

It won't be long, I predict, before the University of Chicago Medical School is in the game. ENH may be looking south rather than north. More later.  

p.s.  Where is Glenbrook Hospital?  Not in Glenbrook -- no such place.  It's in Glenview, IL.

END OF POST

Northwestern Memorial Hospital Plants Flag in Sand - El Norte

Northwestern Memorial Hospital made public the purchase of a 10 acre parcel of land in the north west suburbs, the Chicago Tribune reported today. The location is Northbrook near Interstate 294.

This brings to light an interesting battle of the giants of health care in northern Illinois. Advocate is moving to acquire Condell Medical Center in Libertyville, IL, apparently beating out Lake Forest Hospital for the prize. Evanston Northwestern Health Care (ENHC) is to acquire Rush North Shore in Skokie. Not too long ago ENHC, which acquired Highland Park Hospital in 2000, was allowed to keep it in a ruling by the FTC that examined the "anti-competitive" nature of that acquisition.

Before we know it there will be juggling in med school affiliations. The Chicago Tribune suggests today that Rosalind Franklin University (the former Chicago Med) might get into bed with ENHC leaving Northwestern University Feinberg School of Medicine to find another affiliate.

Stay tuned.

END OF POST

Chicago Area Hospital Profits Spawn Debate: What is community benefit?

When Crain's Chicago Business published the 2007 net profits for Chicago Area Hospitals people once again began to ask how much profit can a non-profit have?  Most of the hospitals are non-profit corporations and therefore they receive special dispensation when it comes to real estate taxes.  They don't pay; they provide community benefit in lieu of taxes.  A legitimate debate rages regarding what constitutes community benefit. But first, let's look at the magnitude of the profits for the top 3.

Northwestern Memorial Hospital leads with $142.9M net profit on $1,125.5M (yes, that's $1.125 billion) total revenue, University of Chicago Medical Center next with $140.7M on $1,077.5M total revenue (yes, that's billion again), Rush University Medical Center is next with $120.7M profit on total revenue of $842.1M. Let's assume what I think to be true: these profits are after the hospitals deduct from their operating statements the following -- money spent on charity care, bad debt, funds donated to their respective medical schools for research and teaching, and allowances for insufficient payments from Medicaid and Medicare.

Enter Illinois Attorney General Lisa Madigan who proposes that the only legitimate expense hospitals can count as community benefit is charity care. The other categories listed above don't count. Moreover, the Attorney General's goal for charity care expenses alone should be 8% of total hospital revenue.

Charity care dollars are those spent to hospitalize or otherwise care for a patient who is uninsured and will end up paying little to nothing out of pocket. Bad debt is money that insurance companies and patients should have paid and did not. This would include a patient from the gold coast who just doesn't pay or an insured patient who owes co-payment and cannot or does not pay. Academic medical centers tend to support their affiliated medical schools with donations for research and teaching, a case of one non-profit donating to another. Finally, neither Medicaid or Medicaid reimburse hospitals for the full cost of care. The gap between what government funded insurance pays and what the hospital's cost is considered donated care by most hospitals. Which of these should constitute community benefit? Hospitals would argue all. The Attorney General argues that only charity care counts.

What about hospital donations to their academically affiliated medical schools for research and teaching? If a medical school uses the money and finds a new treatment or a cure for breast cancer, isn't that community benefit? We all benefit, yet the definition of charity care is not met. What about the difference between what Medicare or Medicaid pays and what costs the hospital incurs (not the total charges, just the cost of the service)? This is more of a gray area in my view to be resolved by effective policy making by Congress and the Centers for Medicaid and Medicare. Until policy-making resolves this issue, I think hospitals can legitimately argue that they are providing charity care to many Medicaid and Medicare patients. Bad debt? Another gray area, but those that can pay and refuse should not be counted as charity care cases.

That still leaves the question of what to do with the profits.  When a hospital invests in its infrastructure, builds new buildings and purchases new scanners and equipment, they use profit and donations to pay for it and argue that this too is community benefit.

Much of this debate should play out much more publicly than it has so far.  Recent articles in the Wall Street Journal and Chicago Tribune seem to give less than a fair shake to the hospitals' arguments.  I'm all in favor of charity care since our health center's patients benefit from it.  But I'm also in favor of curing breast cancer, diabetes and training stellar students to become great doctors.  

Let's have more of an open debate. And let's use the profits wisely benefit those who need care the most. END OF POST

Epidemic of Gun Violence Hits Chicago Again

Recent reports of shootings in Chicago affecting Chicago Public School students, gang bangers, bystanders and others once again seem routine in newspaper headlines and in TV and radio spots. 

What's going on?  Chicago Tribune columnist Eric Zorn complained that the only protest in favor of improved safety  from the general public was the innocent sound of crickets chirping in the night.  In other words, nothing.

Most view firearm violence as a crime issue, one for law and order to deal with.  Certainly that is true.  But, gun violence also follows the basic patterns of disease and we can use epidemiology to study disease patterns and causes.  Epidemiology is basically body counting; either sick bodies or bodies that have passed away.  The patterns tell us what's going on whether it is flu, cancer, heart disease, asthma or firearm deaths or injury.

Health care providers can help stamp out the vector of death and injury from guns since, like malaria and the mosquito, the vector is basically a gun.  Not the gun your uncle and brother use to go hunting on the weekend or for sports shooting at the local range.  In many cases, it's the one that's in the home. 

As part of the medical interview, health providers, whether in the emergency room or in primary care clinics need to ask if a gun is kept in the home.  If it is, is it locked away safely or is it kept unlocked and perhaps even loaded?

Epidemiology tells us that a firearm kept in the home increases the risk of a homicide occurring in the home by almost 3 times  and suicide by 5 times compared to homes where no gun is kept.  Although most gun deaths in Chicago are homicides, more than half of the gun deaths nation wide are suicides.

Doctors, nurses, nurse practitioners should ask patients if they keep a gun in the home and if they do advise to lock it safely and unloaded or get rid of it.  We do lock poisonous chemicals  in the kitchen cabinet to keep it away from kids, don't we?

END OF POST

Smooth Go-Live For Electronic Health Record at Erie Humboldt Park

Smooth sailing and cool heads characterized the go-live for Erie Humboldt Park's electronic health record system.

Erie successfully launched it’s Alliance-hosted Electronic Health Record (EHR) system at Erie Humboldt Park on Thursday April 24, 2008. This is Erie's second large site to go live. Erie West Town turned on its electronic health record in August 2006.

The Alliance of Chicago Community Health Services, LLC was formed by 4 community health centers (Erie Family Health Center, Heartland Heatlth Outreach, Howard Brown Health Center and Near North Health Services) to improve the delivery of quality health care to underserved patient populations. The mission is to share resources and to integrate services thereby enhancing quality and economies of scale.

The centerpiece of the Alliance's mission to improve health care quality is to provide a centralized hosting model for a robust electronic health record system. The system has been customized to meet the needs of underserved patient populations with disproportinate shares of diseases such as HIV, diabetes, heart disease, asthma late entry into prenatal care and obesity.

Alliance partners use General Electric's Centricity EMR.

Erie Humboldt Park is a large site with 21 exam rooms. Approximately 35,000 patient visits are conducted there annually.

There is no easy flick of a switch to launch an EHR even if you have done it at another site within your own organization before. EMR products are not ready to go out of the box such as a software product you might puchace for your home computer. The essentials include a well organized internal implementation team with a sponsor who is an executive within the organization and an information technology team that knows what it is doing. The Alliance provided the professionals who can design the implementation, train the endusers and host the service.

Superior technical support, training and overall design and help support was provided by the Alliance throughout the process.

With the addition of Erie Humboldt Park to the electronic health record system, Erie’s 2 largest sites will provide over 80,000 patient visits annually in the electronic environment.

The Alliance-hosted EHR is on target to cover over 100,000 individual patients through over 350,000 anual patient visits in Chicago alone with its EHR. Aliance has expanded its services to host the EHR at heath centers from San Francisco, to North Carolina.

I'll post some photos soon.

Adelante!

END OF POST

UIC School of Public Health Features Erie Family Health Center (and me)

My alma mater for public health is the School of Public Health at the Unversity of Illinois Chicago. A recent on line article features Erie Family Health Center and says nice things about me.

A quote from the article:

“Here in our own backyard, 1.3 million Chicago-area residents are uninsured, and one out of three of the city’s uninsured is Hispanic,” Francis said. “At Erie, we know from experience that ‘one out of three’ isn’t just a statistic. It’s a life that’s being compromised by a lack of access to medical care.”