Hospital Charity Care Debate Red Hot This Week

The debate about hospital charity care in Illinois continued to heat up this week. March 1st was the Governor's deadline for state and hospital negotiators to come up with a workable new definition of charity care.  I favor a broader definition for charity care which I call “community benefit.”  Now, the Chicago Tribune agrees. The Trib’s March 2nd editorial is right on target.

Here is an example of how the broader definition of charity care works with our health center’s long-standing collaboration with Northwestern Memorial Hospital.

Erie Family Health Center is a non-profit community agency that provides primary health care to over 37,000 low-income patients at 11 service locations on the West and Northwest Sides of Chicago, regardless of the ability to pay.

Over 98% of our patients live below twice the federal poverty level which is $44,000 per year for a family of four.  Over one third of our patients have no health insurance at all. Over two-thirds do not speak English as their primary language.  

Every year, thousands of specialist appointments, diagnostic tests, mammograms, surgeries, ER visits and hospital days are provided by Northwestern at no cost to our low-income uninsured patients. They are not turned away.

Northwestern’s collaboration with us extends way beyond the traditional and narrow definition of charity care.  

With Northwestern’s support patients receive needed services at our neighborhood locations: A community-based diabetes control program addresses an epidemic of diabetes with education and counseling, an eye care program prevents blindness in patients with diabetes or HIV/AIDS, and a breast cancer screening program (click for video)  identifies women in need of mammograms and links them to free tests.  We jointly established a community-based program to train the next generation of family physicians to serve in high needs neighborhoods – one of only 11 programs in the country and the only one in our state.

Our patients have many extreme barriers to accessing health care including transportation, cultural challenges and literacy.  By planning ahead and coordinating care at our community-based locations, costly emergency room visits are avoided and more uninsured patients stay healthy and out of the hospital. Isn’t this an efficient use of the charity care dollar?

The Big Brother of Influenza: Someone knows way before your doctor does

So far, this flu season has been pretty lame.  Unlike the H1N1 flu outbreak of 2009 -2010 which sent panicked citizens searching for a flu shot, this year, the trend is pretty typical.

Sporadic cases across the country. Business as usual.

But if things do heat up out there and the flu begins to hit big time, someone is going to know well before your doctor, even before the Centers for Disease Control and Prevention.

Who, Big Brother?   Google!

By "monitoring health seeking behavior in the form of queries to online search engines" google can predict a flu epidemic perhaps 2 weeks or more before it is reported by the CDC.  Google's monitoring of web inquiries is real time whereas the CDC relies on a reporting structure via state health departments. When people feel sick, they web search their symptoms and suggested treatments for the flu.  Google analyzes these search trends and can do it all over the world.  Although the CDC's statistical analysis and geo-mapping is the gold standard, it takes time.

On this chart from Google, the blue line represents search trends related to the flu and the orange line is actual flu cases as reported by the CDC.  Pretty impressive.

 Now add to this work being done at the community level by networks of health care providers such as the Alliance of Chicago Community Health Services and others who are collaborating with the CDC to monitor real time health care data right from the doctor's office as markers of flu outbreaks.  Let's say thousands of elderly visit their doctor in Chicago next week with a fever, cough and body aches and that temperature and symptom data is sent, real time, to the CDC.  The data is de-identified, to protect privacy.  The CDC then uses this information to immediately predict flu hot spots, do targeted virus identification tests, rush additional vaccine or plan to target increased supplies of medication.

If Google, the CDC and networks of health providers know all this information as nature actually takes its course, some might cry "Foul,  Big Brother again."  But I think it's a good thing. It's protects privacy and it's accurate.  So go ahead and get your flu shot if you haven't done so already, before Big Brother tells you it's too late.

Hospital Charity Care: Could it become the Cap and Trade of the health care industry?

A debate rages in Illinois about how much of its annual revenue a hospital must spend on charity care and still qualify for the tax abatement offered due to their non-profit status. In 2010, a downstate Illinois hospital in the Provena system lost its tax exempt status after allocating only about 0.7% of its annual revenue as charity care.

In September of this year, the State challenged the property tax exemptions of 3 more hospitals. State regulators use a narrow definition of charity care limiting the dollars they count to free clinical services provided to patients on hospital campuses and ignoring other significant community benefit such as funding community wellness and preventive programs, teaching, and research.

Now comes a proposal from the Illinois Department of Revenue -- a carrot and stick approach to encourage hospitals to provide more pure charity care in exchange for tax credits. If a hospital does more direct charity care, the more tax credits it gets. If it does less, the more taxes it pays. Perhaps the taxes paid could even be directed into funds to shore up the State's Medicaid program or go into an account to support community clinics.

To me it sounds like the power industry's carbon cap and trade program for carbon emissions.

Although the proposal is creative and could encourage laggard hospitals to pull their charity care weight, the first thing to do is to agree on what counts as charity care. Is it the narrow definition of providing free care for a patient in the hospital or an x-ray or scan? Or does it include the broader resources that hospitals provide as community benefit? The more taxes a hospital has to pay, the less community benefit it will want to provide.

Non-profit hospitals are not paying shareholders and investors. They are reinvesting in the community. As one of the only expanding industries in our sputtering economy, their new buildings and projects create jobs, massive durable goods and supply orders, and community investment.

Let's hope that in the effort to evaluate and redesign hospitals' commitments to community benefit, that we don't end up in the trauma unit with a shot to our own collective foot.

The Buzz About Health Care Reform and Community Health Centers

I have a new post on Erie Family Health Center's Beats per Minute Blog.

Where for art thou H1N1 (influenza)?

This blog post is re-purposed from Erie Family Health Center's Beats per Minute blog.

It just feels like the flu has gone away. Away from the headlines on TV, the web, radio. Away from the ERs and clinics. After H1N1 influenza ravished an unprepared America in the late spring of 2009 and again in the fall and early winter, it has basically disappeared. Should we let down our guard and stop worrying?

It’s true that most areas of the country are reporting either no or only sporadic (Illinois) flu activity. The most activity is in the South and in Maine. All of it is well below epidemic levels and it’s all H1N1, not other strains of flu virus that we sometimes call the “seasonal flu.”

H1N1 caused relatively mild illness for most people. Although this supposedly mild-mannered virus caused the deaths of thousands, it could have been much worse. The pandemic H1N1 of 1918 killed almost 500,000 in the US and at least 50 million world-wide. According to the Centers for Disease Control and Prevention, “from August 30, 2009 to March 6, 2010, 2,042 laboratory-confirmed influenza-associated deaths were reported to CDC” among them 277 children. Perhaps up to 14,000 actually died since not all patients had lab confirmed tests. By contrast, seasonal flu normally kills some 36,000 Americans annually and over 250,000 world-wide every year.

It may be a bit too early to declare that this year’s (2009-2010) regular old seasonal flu turned out to be none other than the lone H1N1, but that’s what it looks like. Very few other types of flu viruses are showing up in lab tests across the country.

But, H1N1 could come back, either soon, or next flu season. Young adults and children, pregnant women, as well as those with chronic illnesses are at higher risk get more severe flu symptoms.

That’s why the expert panel that makes recommendations to the CDC has decided to include the H1N1 virus in next year’s (2010-2011) seasonal flu vaccine, along with several other flu viruses, based on world-wide trends and predictions. Whereas this year there were two separate flu vaccines: H1N1 and the seasonal flu vaccine, next year they will be combined into a single seasonal flu shot, which is really a mixture of several different flu strains. The combination changes every year based upon worldwide flu trends. And the expert panel will now recommend that everyone, from young to old, be vaccinated unless there is a good reason not to.

Erie Family Health Center was a leader in providing H1N1 vaccinations this flu season, giving over 5,000 vaccines to children, more than 850 to pregnant women and over 700 to chronically ill adults. Erie opened its doors and made it easy for patients, relatives and others to walk in and get vaccinated.

Haven’t yet gotten an H1N1 shot? Should you still get one? Yes.

The CDC is now encouraging everyone to get vaccinated. This could give you a head start even if the flu season is over for this spring, since H1N1 may come back before the 2010-2011 seasonal vaccine is available next fall. Supplies of H1N1 vaccine are still available, but ironically, the 2009-2010 seasonal flu vaccine (which does not contain H1N1) is still in short supply.

Flu prevention business is a tricky one. Every year, we are reminded to wash our hands, cover our cough while public health experts try to outguess Mother Nature by predicting the best vaccine. We know that the TV weatherperson has a difficult time with telling us if it is going to rain or snow or be sunny tomorrow and predicting the patters of a virus is even more complex. H1N1 is still smoldering in certain parts of the country. We should be worried and prepared for the flu if and when it decides to return.

For weekly updates on the flu, visit flu.gov.

END OF POST. Thank you for reading.

Your Piece of the Health Care Pie: How much would you pay?

This post is re-purposed from Erie Family Health Center's Beats per Minute blog, with permission.


Would you pay $1.94 per day in health insurance for the privilege of unlimited access to comprehensive preventive and primary care services at the level of quality provided by Erie Family Health Center? It sounds like a pretty good deal.

Health care reform pie is on a lifeline in Washington, DC, and cost is of high concern. Meanwhile, around the country, at over 1,200 health centers like Erie, data staff hit the send button this week and uploaded information for 2009 on the 20 million medically disadvantaged people cared for at community health centers. The fix is in, and the data show that health centers provide very cost effective primary care and preventive services.

I’d like to show some of Erie’s results as example. (read more)


Over 33,000 patients now access primary care services at Erie. Perhaps an indication of our economic times, the number is up 10% from a year ago. And patient visits climbed accordingly, to 142,000 in 2009, up 7% in 2009 from 2008.

Our annual report to the feds allows us to calculate the average cost to provide a year of health center services to an Erie patient: $700 per year, or $59 per month, or $1.94 per day. This includes unlimited doctor visits, laboratory services, counseling, case management, oral health care, delivering your baby, 24/7 answering service and coordination of care with our hospital partners. Erie competes for federal grant dollars to help support the 34% of our patients who are uninsured. The annual cost to the feds per uninsured Erie patient is $360 – less than a dollar a day.

If you like a bargain, you are thinking – good deal!

A recent report by Lo Sasso and Bryck in the journal Health Affairs predicted that for every $500,000 additional funds a health center receives, 540 additional patients can be served -- $925 per patient per year, $2.50 per day. Erie is doing better than the national average.

But health the health care pie is really divided into three slices. The first slice is primary and preventive care like Erie provides, a good deal as we see. The second is both basic and sophisticated outpatient testing such as x-rays, mammograms, CT scans and MRIs, to which Erie arranges affordable and deeply discounted linkages with partners. The third is the most expensive – hospitalization, surgery, rehabilitation, and Erie provides linkages as well. And I’m not even going to touch the issue of long term care (a whole other pie).

It’s that first slice of pie, $1.94 per patient per day, which has the most potential to prevent over use of the other two slices. The other two slices are super expensive, their costs are rising, and they are breaking our health care system.

As negotiators try to resurrect health care reform in Washington, they should keep an eye on health centers as a cost-effective and expandable slice of the health care pie. We are ready to do more. END OF POST...Thanks for reading.

Health Care Reform: Where will the newly insured seek health care?

I have a new post on Erie Family Health Center's new blog: Beats per Minute. Enjoy the cross post. I have added Beats per Minute to my blog roll on this page.

Erie Family Health Center in the New York Times!

Proud of this article about Erie Family Health Center's Humboldt Park location which appeared in the New York Times 12/4/09.

Treating a Community's Health Needs That Reform May Not Fix

Chicago News Cooperative reporter James Warren hit the nail on the head. Thanks, Jim!

The Chicago News Cooperative is a new non-profit started with seed money from the John D. and Catherine T. MacArthur Foundation. It will feed 2 pages of Chicago news in locally printed editions of the New York Times on Fridays and Sundays and will supply high quality local news to other clients in print and over the airwaves.

Two Weeks in Business School: Top Ten Take Home Points

After 2 weeks at the UCLA Anderson School of Management Johnson and Johnson Health Care Executive Program what did I learn? This is a program for leaders of community-based health care organizations. You compete to get in and then you work hard with 41 colleagues from around the country for 2 weeks: classroom work for 8 hrs a day as well as additional time devoted to development of a Community Health Improvement Project (CHIP).

Here are my top 10 take-aways in a tongue and cheek format. (A la David Letterman's Top Ten, start from the bottom and read up.) Behind each point below is a story, a lecture, a problem to solve, a challenge to face.

1	During your time at UCLA -- you have visited your own future. Take time to visit your own future. Visit, inquire, investigate agencies and programs which are leaders and innovators.
2	A CHIP is a many faceted tool: It's a tool for your future. Use the tool over and over again to create SMART goals, goals which are Specific, Measurable, Achievable, Reproducible, and Time Bound.
3	The faculty director is a groovy guy. And not only him, the entire faculty at UCLA. Excellent teachers. Leaders in their fields.
4	In any process, find the bottleneck. Shift it to the economic bottleneck. The economic bottleneck may be what is generating your revenue (think: the physician face to face component of the total health center visit -- you can't get rid of that!). In terms of process management and work flows, if you spend time fixing other aspects before the bottleneck you're wasting your time.
5	Fly coach. If you won't fly coach, there's Amtrak and Greyhound. Appearance matters.
6	Dust off your Shakespeare. Practice your eeees and ahhhs. Community health leaders must have a public presence and prepare for it.
7	IF cost effectiveness analysis is "Doing the right thing, " and cost benefit analysisis is "Doing the thing right." Then what is doing the right thing right? Clearly that is cost effective benefit analysis. Try to understand both and if you can't, get someone who does to help you.
8	Regarding your EHR (electronic health record system): The initial goal is not "best practice." Instead focus on "no bad practices." The main message here -- get one and GET IT ON.
9	Being a leader is like a big juicy peach. I think this is somewhat related to a big hairy audacious idea, except with fuz. Have clarity as a leader.
10	Build a leadership molecule: Vision and culture, operations, systems. They must overlap. If your leadership team has members with talents in these three areas you have a better chance for success.

Below: The famous on-line CHIP tool.

And, thoughts from class.

Immediate Demand: Federal Dollars to Stimulate Community Health Care, Jobs

In a previous blog post, I wrote about how federal stimulus dollars will flow to community health centers.

Now, we have some more details. Through the American Recovery and Investment Act of 2009, the US Department of Health and Human Services will soon distribute $337.9M to 1,128 community health centers in 50 states, Puerto Rico and other territories.

Named, Immediate Demand for Services (IDS) funds, these dollars are meant to assist health centers in providing primary health care services to a large number of people who have lost jobs and therefore their health care coverage. Currently 8.5% of workers are unemployed in the US. (Read more...)


With these dollars, health centers propose to serve 2.1 million new patients over the next 2 years. Half of the new patients will lack health insurance, and the majority of the other half will likely be dependent of state and federal programs such as Medicaid, which insures the lowest income Americans, including most low income children.

Nationally, community health centers serve almost 18 million individuals regardless of the ability to pay. IDS funds will promote an 11% increase in community health center enrollment over 2 years according to estimates.

Health centers provide economical health care services. The per patient federal outlay through these stimulus dollars is only $159.62. Health centers will likely look to other sources to meet the needs of supporting services to these patients on a long term basis.

Health centers also propose to create or retain 6,400 jobs in primary health care over the next 2 years: health care practitioners and support staff.

More about Illinois:  36 community health centers in Illinois will share $15M in Increased Demand for Services funds over 2 years.  An estimated 66,000 patients will be added in Illinois, a 6.6% growth rate over 2 years,  and 50% will be uninsured.  Approximately 270 jobs will be added or retained. Illinois community health centers currently serve 1 million statewide. 

The challenge for community health centers will be to sustain these new patients after the stimulus funds end in 2 years. (END OF POST.  Thank you for reading.)

If you see something, say something.

On a recent trip to Washington, DC, I could have caused an emergency response to a strange, unclaimed suitcase. With the national terrorism threat level elevated at YELLOW and the airport threat set even higher at ORANGE,  I'm sure the average citizen and security personnel alike are on the lookout for strange packages and unattended luggage.

While boarding the Metro at the National Airport stop last week, I inadvertently left my knapsack on the train platform, boarded he train with my suitcase, and headed into town.  By the next stop, ironically, the Pentagon stop, I noticed my error.  

Envisioning SWAT teams and bomb sniffing dogs surrounding my rucksack, heart in throat, I boarded the next train back to the airport.  For sure, the airport would be locked down, I'd be arrested and shipped off to Guantanamo Bay.  

Back on the platform, I spotted my laptop containing backpack; not a siren or black booted officer in sight.  I nonchalantly claimed my property.  National crisis averted.

If you see something, say something.

Of Hospitals and Safety-Nets

Crain’s Chicago Business recently pointed out in “Wealthy hospitals owe their heath to ‘safety nets’.” (Crain’s Feb 9) out that Chicago area hospitals cannot operate in isolation when it comes to serving the health care “safety net” population.

Hospitals and policy-makers cannot ignore the fact that the safety net health care system involves much more than acute care academic and community hospitals. The network of federally qualified health centers (FQHCs) and other clinics such as the Cook County system and free clinics should be important partners. FQHCs provide comprehensive primary care to over 500,000 individuals in the Chicago metro area and to almost one million in Illinois regardless of the ability to pay. They keep ill patients out of the hospital emergency room and help to reduce costs in health care system. They manage a high burden of complex chronic maladies such as diabetes, asthma and high blood pressure.

Perhaps existing expanding hospitals should partner more with FQHCs and others so that emergency rooms are not the first point of care for so many safety net heath care patients.

Such is the case with several hospitals already, including Northwestern Memorial Hospital, which was mentioned in the Our View editorial. Northwestern works with two FQHCs on the North and North West Sides of Chicago to enhance diabetes care, improve mammogram screening rates, and to increase access to hospital-based diagnostic testing and inpatient admissions. Efforts have focused on attacking specific diseases and measuring the outcomes in a results-oriented approach.

There is no question that hospitals and government need to do more in partnership to address challenges of the heath care safety net. Strengthening partnerships with community-based health care providers is part of the solution.(End of post. Thank you for reading.)

Retail Store Clinics Fill Nice Niche Above Your Waist -- But Stop Short

Word last week that CVS will cut some of its in-store MinuteClinics, opening some of them only in flu season got me thinking about the pros and cons of these types of clinics. In addition to CVS, Walmart and Walgreens also have clinics in their stores for a total of about 1,100 locations nation-wide.

These clinics are good for a spur of the moment need but do they really help address the need of the uninsured and those who are really diagnosed with something long term? The answer is more no than yes.

First, the advantages.

In-store clinics offer the basics such as basic physicals, checks for diabetes, cholesterol, and high blood pressure. Some offer help you to quit smoking (you’ll be buying your anti-craving pills and nicotine gum in their pharmacy, of course). They also provide shots for flu and pneumonia prevention and the basic childhood vaccinations. Their web sites provide the full lists of services offered.

Additionally, the clinics probably help keep people who have simple problems such as strep throat, ear aches, bladder infections, rashes, ear wax, the flu, a cold, pink eye, sprains and other acute minor problems from clogging up busy emergency rooms. Think you may be pregnant? Come on in for a test.

They are relatively affordable. The average charges are around $60 - $80 for the common conditions listed above or for a check up such as a school physical, sports physical or health screening. Additional charges may apply. For example, the price of shots is added on to your visit charge in some cases and if you need a prescription filled, you still have to buy it (at the in-sore pharmacy, of course, and pick up some shampoo, deodorant and toothpaste while you’re at it).

Convenience is probably the major advantage, with hours 7 days a week and no appointment necessary. Evening hours are available which is good for working families and kids who are in school.

The clinics are staffed by advanced practice nurses (nurse practitioners) and physicians assistants. Both classes of  these professionals are uniquely qualified to provide the services the clinics offer.

This is all good. It’s hard to argue against making acute care, screening and prevention more conveniently available.

However, the clinics do fall short, especially in the area of comprehensiveness, the ability to diagnose and treat complicated chronic illness and the promotion of continuity of care rather than episodic care. Patients registering at an in-store clinic should lower expectations. (Read more.....)


These are basically “above the waist” clinics, unless you have athlete’s foot. They do treat that. Below the waist? Find another option.

In-store clinics are set up to skim off the easy diagnoses and treat them, leaving the complex medical issues to other health care providers. For example, babies younger than 18 months, women and men with possible or overtsexually transmitted diseases, HIV testing, women needing pap tests for cervical cancer breast exams with a connection to a mammogram are not served. If you have a gynecologic problem you may be out of luck. Colon cancer screening with a take home test? Not on the list. Family planning? Not advertised on the list. And if you actually have diabetes, high blood pressure, heart disease, asthma, arthritis, a pinched nerve, or any chronic condition, you will be referred to your primary care provider – if you have one. If you don’t and you have no insurance, to where will you be referred?

Although there are 1,100 in-store clinic locations around the country, a quick survey of the ones located in the Chicago area show that they generally avoid areas with the highest concentrations of poverty and the uninsured. By contrast, community health centers have over 7,000 locations nation-wide, located in the most highly impacted communities, and provide services regardless of ability to pay. Unfortunately, many community health centers struggle with rapid access as they are overwhelmed with uninsured and low-income patients trying to get in, and few probably offer Sunday hours, although most offer evening and Saturday hours and 24-hour answering services for telephone advice.

The fee at in-store clinics seems reasonable, but can be a barrier. At our health center, many low-income, uninsured patients struggle to pay their flat $30 fee per visit and, as a result, we collect an average of $21 per visit. We never decline services based on the ability to pay. In-store clinics will not slide your fee down based on your income and will not accept a payment less than the full charge.

I am a big fan of the talents and skills of advanced practice nurses and physicians assistants. In Illinois, these professionals may practice without a physician on-site. Our health center uses this model in some of our school-based health centers. Advanced practice nurses and physician’s assistants in Illinois must have a collaborating physician. At in-store clinics, the collaborating physician will never be on site and available to lay eyes and hands on, an advantage we have at our health center’s comprehensive care locations. It is more difficult to collaborate with a physician when the physician is off site.

Overall, I’m glad the in-store clinics are out there. They fill a specific niche. But a smart health care consumer should realize their limitations. Policy makers should pay attention to the growing need to manage chronic care and to provide quick access to complex medical problem solving for safety-net populations. Big box clinics are an “above the waist” entrepreneurial approach but not a solution to the care of the uninsured.

What do you think?
END OF POSTING – THANK YOU FOR READING

Federal Stimulus Dollars Flow to Community Health Centers

Federal stimulus dollars have been directed by Congress to community health centers. Health Centers are economic engines that provide hundreds of thousands of health care jobs nation wide as well as stimulus to the economy through purchasing of supplies and equipment.

The American Investment and Recovery Act of 2009 includes (read more):


$2 billion for community health centers. There are over 1,000 community health centers nation wide with over 7,000 service sites. For example, Erie Family Health Center is 1 community health center with 8 service locations.

Included in the $2 billion mentioned above:

$340 million has just been announced for health centers to immediately increase the number of uninsured patients served by hiring more health care workers, increasing hours of operation, and increasing existing health center services. Applications are due on March 16th to compete for these funds.

$155 million has been already awarded to community health centers who applied to launch new sites last year and were not funded. In Illinois, the following community health centers just received $1.3 million each to add a new service site: Lawndale Christian Health Center (Chicago), Lake County Health Department/Community Health Center, Community Health and Emergency Services (Carbondale), and Friend Family Health Center (Chicago, and affiliate of the University of Chicago).

$1.5 billion for construction, renovation, equipment and health information technology systems at the community health center level. We do not yet know how community health centers will be able to compete for these funds. Buildings such as Erie Family Health Center's, Humboldt Park location  (Chicago, pictured above) are in need of state of the art upgrades.

Community health centers are cost effective providers of primary health care. Health centers provide primary care for 17 million individuals in the US, over 1 million in Illinois and over 500,000 in the Chicago metro area. Currently at least 45.7 million Americans are uninsured. This does not count the underinsured and those who are not residents of the US but who are workers and their family members who need health care.

Farewell Governor Blagojevich

It was just announced that the Illinois Senate has removed Governor Rod Blagojevich from office. I guess I will see him jogging by my house more frequently than usual.

He and I probably share something in common (besides a passion for getting health care services to those in need). Chances are we both read a popular 1970s book, Culture of Narcissism, by Christopher Lasch. Elements of narcissism permeated our culture according to Lasch. Reading it as a college freshman I was, like, what? But now it makes more sense, especially if we look at our ex-Gov in light of a personality disorder which Lash thought was shared by American society.

Perhaps, our ex-Gov has Narcissistic Personality Disorder (diagnosis 301.81 in the DSM IV).

"A pervasive pattern of grandiosity, need for admiration, and lack of empathy beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following:

• has a grandiose sense of self-importance...exaggerates achievements and talents
• is preoccupied with fantasies of unlimited success, power, brilliance...
• believes the he is special and unique
• requires excessive admiration
• has a sense of entitlement
• takes advantage of others to achieve his or her own ends...is interpersonally exploitative
• lacks empathy
• shows arrogant haughty behaviors or attitudes"

Well, either Mr. Blagojevich is a product of the Culture of Narcissism, or he suffers from the above diagnosis. Or both. You decide.

Paging Dr. Gupta for Surgeon General? Yes!

The buzz in the mainstream press is that Dr. Sanjay Gupta (left), CNN chief medical correspondent, is tops on the list to be the next Surgeon General. Although some of my colleagues in the trenches of community and public health are offended by the selection of someone outside of the public health field, I think it is a brilliant choice. Because of his international media stardom (he was named as one of People Magazines 50 sexiest men alive in 2003 and a pop culture icon by USA today in 2004) he has the opportunity to influence the public health more than any Surgeon General in memory, even more than white bearded Dr. C. Evertt Koop (right), the quintessential public health leader we remember from the Reagan administration.

The Surgeon General heads the U.S. Public Health Service with the job of being the "nation's chief health educator by providing Americans the best scientific information available on how to improve their health and reduce the risk of illness and injury. " The most recent Surgeon General, Dr. Richard Carmona, resigned in 2007 and later testified to Congress about restrictions placed upon his message by the Bush administration. The current acting Surgeon General is Rear Admiral Steven K. Galson, M.D., M.P.H., a career commissioned officer of the U.S. Public Health Service.

Dr. Gupta is a brilliant choice for the next Surgeon General.

Imagine the chief public health officer reaching out to everyone younger than a baby boomer via social networks and electronic media such as Facebook, MySpace, Twitter, and via the blogosphere and YouTube (just to name a few).  And for those of all ages, think about the natural talent he has for communicating via television where previous Surgeons General have looked awkward and have delivered messages as if they were cardboard cutouts of a person frozen at a podium. Dr. Gupta has the opportunity to bring public health messaging to an entirely new level by leveraging his talent as a media specialist. And, as a practicing neurosurgeon already with many public health credentials, he has the panache to man the bully pulpit like no other.  If he is nominated and confirmed, leveraging the incredible assets of the U.S. Public Health Service via innovative media outlets should be his focus.

Also, don't you think he'll look super great in that uniform?

END OF POST. THANK YOU FOR READING. WOULD YOU LIKE TO COMMENT ON THIS POST?

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.