Apropos of the discussion about Michigan and the role that medical centers may (or may not) play in revitalizing their surroundings, here's a piece about the Cleveland Clinic that questions its high value to the city of Cleveland, but the neglect of the people who actually live within sight of it. Politico
"There’s an uneasy relationship between the Clinic — the
second-biggest employer in Ohio and one of the greatest hospitals in the
world — and the community around it. Yes, the hospital is the pride of
Cleveland, and its leaders readily tout reports that the Clinic delivers
billions of dollars in value to the state. It’s even “attracting
companies that will come and grow up around us,” said Toby Cosgrove, the
longtime CEO, pointing to IBM’s decision to lease a building on the
edge of campus. “That will be great [for] jobs and economic infusion in
this area.”
"But it’s also a tax-exempt organization that, like many hospitals,
fought to preserve its not-for-profit status in the years leading up to
the Affordable Care Act. As a result, it doesn’t have to pay tens of
millions of dollars in taxes, but it is supposed to fulfill a loosely
defined commitment to reinvest in its community.
"That community is poor, unhealthy and — in the words of one national neighborhood-ranking website — “barely livable.”.....
"It’s the paradox at the heart of the Cleveland Clinic, as it lures
wealthy patients and expands into cities like London and Abu Dhabi. Its
stated mission is to save lives. But it can’t save the neighborhood that
continues to crumble around it."
Wow! Bravo Dan Diamond! As our population ages and wage inequality grows, there will be more stories like this: People dying in the shadow of state-of-the-art facilities.
ReplyDeleteSome years ago, when Lansing city officials were bending over backwards to keep one of the auto plants from leaving by offering tax breaks, the local paper did an in depth study of what the city would lose in revenues from those breaks.
As the article points out, nonprofs, like universities and hospitals, also have a corrosive effect on revenues. Snip:
Thanks to a loosely defined 50-year-old IRS regulation, the hospital is required to provide only “community benefit” in exchange for its tax exemption — no matter what those taxes would be worth. And in late 2013, three social advocacy groups concluded that the Clinic’s tax-exempt property in Cleveland was worth $1 billion, which meant the hospital was saving $35 million in annual property taxes alone. (The value of that property, and the forgone taxes, has only gone up since.) That money could go toward schools, roads and other city projects that desperately need funds, advocates say.
http://www.politico.com/interactives/2017/obamacare-non-profit-hospital-taxes/ with examples from Massachusetts, Pennsylvania, California, New York, Minnesota.
Delete"Revenue up, charity care down
"While operating revenue increased under Obamacare for not-for-profit hospitals like the Cleveland Clinic and UCLA Medical Center, the amount of charity health care they provided fell. For example, while UCLA saw operating revenue grow by more than $300 million between 2013 and 2015, charity care fell from almost $20 million to about $5 million."
The Cleveland Clinic is a more complex organization than just a world class medical center that sets in a poor neighborhood.
ReplyDeleteIt also competes with other hospitals (such as Lake Health) which provide inpatient and outpatient services to the region. Most of my doctors (many I have had for 20 years) are affiliated with Lake Health (formerly Lake Hospital which was originally a county hospital). I have also been to the Cleveland Clinic, both downtown and its regional center in Lake County.
There is a lot to be said for local health care by doctors who have known you for a long time, and are less likely to give you unneeded tests and unneeded treatments. Essentially I have a team of a primary physician, a cardiologist, a ENT specialist, a podiatrist, a neurologist, and a urologist with whom I vet almost everything relevant to my health. These people have come to know me well, respect my experience in the mental health system, and my scientific (rather than clinical) approach to health care.
I have been to the Clinic to see a cardiologist, several neurologists, a sleep doctor, and two specialists at the brain health center. Now three of these consultations were world class, and resulted in information valuable to me and my Lake County physicians. However none of the physicians developed much of relationship with me, and none of them were added to my team of physicians. They were all more focused on the problem than on the patient.
In some cases their focus was misleading. Because I snore they diagnosed me with sleep apnea and I spent several years trying to use a CPAP. In the meantime I lost weight and was retested for sleep apnea. It had disappeared (attributed to weight loss). But the scientist in me observed that the first test was done at the Cleveland Clinic in a flat bed, while the second test was done at Lake in a reclining bed. I bought myself an adjustable bed and I found I snore like I have severe sleep apnea when it is flat and I barely have a few minutes of snoring when its adjusted. Now you would think that standard medical procedure would be to do every sleep study in a adjustable bed, and adjust the bed to get rid of the snoring and see if the sleep apnea disappears. Surely a world class center should be doing that.
Something more than jobs and health service is needed for the nearby residents of Cleveland. They need a local health care system more similar to what I have here in Lake County. But that health care system has to deal with an environment much different than Lake County, and so the people who serve it need to be from the local community.
The Gates need to invest some money in our local versions of Africa. Maybe a facility that would train physicians from poverty areas in this country and in Africa to work both in Africa and in our inner city communities combined with community interventions. Case Western Reserve University is located next door and has all the health education facilities needed.
We need to take the money from the Gates and the rich nonprofits rather than from the tax payers since we taxpayers are already contributing tax abatement to them (and other places like churches). I'll remember this the next time I get a phone call from the Clinics fund raising arm. (I have never contributed, just now I have a better excuse).
At the time most of these hospitals were founded, a hundred-plus years ago, the neighborhoods were probably stable and at least middle class. But as often happens to older neighborhoods, they deteriorate. That was true of the location of the two big teaching hospitals in Omaha, UNMC and Creighton University. Creighton is building a new medical facility farther away from the old inner city, but supposedly they will still have trauma and emergency services for the whole city.
ReplyDeleteI'm not sure how nonprofit is defined for hospitals, somebody is making a lot of money.
It is not clear from these reports, but it would be ironic if the number of charity cases fell because of the Affordable Care Act paying for treatment that the hospitals once gave as "charity." Now they offer neither charity or pay taxes! Something's out of whack.
ReplyDeleteThere is a big Catholic hospital here, Mercy, that my doctor was affiliated with, but it is what used to be the County hospital and is now University of California at Davis Medical Center that accepts Medicaid patients.
ReplyDeleteI worked for years at a different hospital downtown, Sutter Health. It's been in the news about its costs. I started working there part time when I was in college and later worked full time as an anesthesia aid in the surgery. Probably the best job I ever had.
One thing that is happening is that community hospitals are being purchased by these megahospitals. I'd be interested to know if this is good or bad.
ReplyDeleteFor me it's great because the Sparrow system owns the nearest hospital. My cardiologist takes appts there. There is also a great physical therapy facility. Since my insurance requires.I stay in the Sparrow system, I get good regional care.
Is this such a good deal for those with insurance that restricts them to another system? Do they have to drive outside their local area to get care? That seems terrible.
If you have insurance through work and your employer switches to another plan that's not in the system they had before, it can mean you have to switch doctors. This happened to my younger son and family. They had a doctor they really liked who was family practice, which appears to be a vanishing breed. But what finally happened is that a lot of the doctors became members of both systems, which seems to be working out, they were able to go back to their former doctor.
ReplyDeleteYes, I mentioned that to my husband, that we have more control over our choices with the ACA. I have always made sure to stay in the Sparrow system. Given that I have several health issues and three doctors, and they're all linked up to the same online chart for me, it would be a huge disruption in treatment to switch systems.
ReplyDeleteBernie was on the NewsHour tonight talking about health care legislation. Medicare at 55, plus power of govt programs to dicker with Pharma. http://www.pbs.org/newshour/bb/bernie-sanders-sees-bipartisan-middle-ground-health-care/
ReplyDeleteFrom a Medicaid pov the future seems pretty scary if the Repubs have their way.
ReplyDeleteA lot of Republican governors don't want them to mess around with Medicaid. Cutbacks would just make it harder for them to balance their budget.
DeleteYeah, like Susan Collins.
Delete3 GOP women were left out of the Senate's Obamacare Repeal effort. They just tanked it.
Delete"It’s notable that the three women who had the final say, vocal in their positions on health care policy, were all cut out of the Senate’s initial working group to draft the Obamacare repeal-and-replace bill — a group of 13 men."
Some community hospitals are doing well and some are not. Those who are not doing well tend to be purchased by the hospital systems. Sometimes they are redone, but sometimes they are closed. I suspect it all has to do with location.
ReplyDeleteOur Lake Health System has two hospitals in the county. One has to go out of the county to go to another hospital. Cleveland Clinic and University Hospitals have both tried to come into the Lake county market without much success. Physician care is very local; most doctors have several locations to be close to their patients. All of my Lake Health physicians are located within five miles, as is the hospital. I have to travel 15 miles to Cleveland Clinic doctors, and 30 miles to their downtown location.
Lake Health is constantly building new facilities. They built a new hospital near me, replacing an old and outdated one with a state of the art facility. They also build an outpatient surgery pavilion near me. Several years ago when my local fitness center was remodeled, Lake Hospital located a rehab center there. The physical therapists can use the equipment if you are a member. And next year they are opening a state of the art fitness center of their own near me. They say all their trainers will be certified and everything will be done under medical supervision. That sounds attractive. My health insurance includes Silver Sneakers, the AARP Medicare supplement benefit which allows me to use several local fitness centers without charge. It will be interesting to see if Lake's new center accepts Silver Sneakers.
So Lake Health system must be making a lot of money. I am surrounded with their new facilities and their physicians. They giving the world class people in Cleveland a run for their money. It may help that Lake county is the third wealthiest county in the state, an "island" off the coast of Cleveland!
I saw Silver Sneakers on the PT bulletin board and wondered what that was.
DeleteAsked my PT about it,but she said, You're not ready for that right now, go get a neoprene knee sleeve, an ice bag, and don't do any kneeling. She said my stationary bike (my bike to nowhere) is OK. Good to know about that AARP benefit.
Overall, I think there is big money to be made in keeping us oldsters up and moving. Probably good preventive care, but that needs to start with younger people.
Silver Sneakers has group programs as well as giving access to fitness centers where the group programs are held.
DeleteI tried the group once when they had a demonstration. Made my sciatica worse for two weeks. I have a bunch of exercises from my PT that keep it in control. The Silver Sneakers exercises most have gone in the opposite direction. Which is why I like the idea of medical supervision of fitness centers. I have gotten the Lake PT people who are at my fitness center to carefully watch and approve all the exercise equipment that I use.
I think that once one gets to a certain level of disability, e.g. problems with balance, sciatic pain, etc. one should probably see a PT once a month for the rest of one's life. Use the time to check out everything, review all current exercises, and add any new needed ones.
Unfortunately the Medicare Advantage plans drastically limit PT. My retirement benefits had me in one for several years. It took me about three years to get the benefits I should have gotten in six months. Extremely pennywise but pound foolish.
PT is something that requires both a very thoughtful patient and a very thoughtful therapist. Without both a lot of time and money can be wasted.
I've had rounds of PT with the same therapist at the same office (located on the top floor of a local gym). Medicare/AARP pay for it (with doctor's prescription). The key is the therapist who is a genius at listening to what's aching and then describing the body parts in play and showing me how to get them in line. She's great.
DeleteThe place is also great. One big room with about ten tables, always busy. Lots of young PTs who seem especially solicitous of the very elderly (not there yet myself!).
Good PT may be better than the semii-annual physical that produces the prescription for the PT. Is that because the PT listens carefully and the MD is too busy reading your file on his computer?
The insightful author on this is Ellen Langer and her books
DeleteMindfulness
that introduces the general idea, and Counterclockwise that applies it to the general disability of getting older.
Langer is a social psychologist like myself and approaches things as a scientist. Mindfulness is careful observation of the behavior of yourself (or the patient) in relationship to changes in their environment, and their results.
Langer criticizes clinical practice because it deals with averages and correlations that may not apply to the particular person. Actually this goes back to the original idea that clinical psychologists should be PhDs that is researchers even with a N=1.
While it is important for the therapist to observe the relationship between what the patient is describing and their environment, I think it is equally important for all of us to develop skills about the relationship between our behavior, our environment and good outcomes. That is what Langer calls mindfulness.
The opposite of mindfulness is mindlessness, behavior that is done with inattention to what is going on. PTs can give a lot of mindless exercises, that are done mindlessly by patients. In my experience good PTs listen carefully, give far fewer exercises that are far more likely to be practiced, and to produce better results.
The problem with physicians is that they are focused upon applying general solutions to particular problems rather than upon the uniqueness of each patient. Increasing this is codified by insurance companies, etc.
When I see a physician I usually bring a one page summary of my current and past problems to try to get them to focus on the particulars of my situation rather than their canned diagnoses and solutions. A lot of hurried physicians seem to appreciate this. Perhaps they are merely being tolerant of my scientist background. An academic colleague from years ago remarked that every time she saw a doctor she lost 100 points from her IQ.
Margaret and Jack, yes, same kind of PT set up here. I also agree PT and a nutritionist visit might be better than yearly check ups. Matt Almighty, the head therapist came and looked at my knee, hip, and back. Doc had waived it off as arthritis, but he fiddled, poked, and prodded, and said he thought it was (near as I can tell from his explanation) a tendonitis problem. So I am wearing a knee brace and icing to reduce swelling. These kids know that I am a high surgical risk, and they are doing their damndest to find ways to get me fixed up without that. They know I don't expect to be pain-free, but getting a solid eight hours without being wakened by burning, shooting, or aching pain would be nice.
DeleteI'd like to go to PT. The docs had advice for the knees ... elliptical machine, swimming, recumbent bike ... but if you can't drive and don't have much cash, it's hard to access that stuff.
ReplyDeleteI think PT should be offered in home! I like my exercise Nike. It was very cheap (used) and folds up.
DeleteIt's an exercise bike?
DeleteOh, duh. Yes. I need proofread better.
Deleteunagidon here.
ReplyDeleteHospitals like Cleveland Clinic don't really care what kind of neighborhood they are in since their whole business model is to draw in people from far away. And the amount of charity they are to provide is probably not set in the statute that gives them tax exempt status. Regarding their support of the community infrastructure, they will have no responsibilities. Sometimes a case will arise like Hyde Park in Chicago, which was kept relatively stable compared to the impoverished ghettos surrounding it because the University of Chicago bought up various properties in the neighborhood themselves.
Regarding Cleveland Clinic's provision of healthcare to paying patients in the neighborhood, there is the matter of how insurance companies treat hospitals like this. Teaching and university hospitals attract the most difficult cases and many of the best doctors. So they are usually (not always, but usually) the most expensive hospitals in a city. These hospitals not only charge high prices, but because they take complex cases they are in high demand in any case. So even when they are in an insurance network (and often they are not; Mayo Clinic was not in network for United Healthcare for decades) the discount the insurance company gets is small. Insurance companies will take this discount because they know that people will use the hospital anyway, in network or not. But once such a hospital is in network, the insurance company has a problem. A place that charges top dollar for a complex cancer case will also charge top dollar to treat a common ear infection. Local primary care becomes massively expensive. What insurance companies will often do, then, is apply what is called an "area factor" to the neighborhood around the hospital. The area factor is a premium multiplier. This means that anyone who lives close to the hospital is going to pay a lot more for their insurance. The insurer will claim that this area factor is meant to cover the expensive price differential for the hospital. But in fact, it's meant to discourage the locals from buying insurance there at all.
And yes, the ACA has caused a decline in charity care, as one would probably expect.
Finally, big expensive hospitals are buying smaller hospitals, including community hospitals, all over the place (since they rake in the big bucks and can afford to). What then often happens is that the big expensive hospital substitutes its prices and low discount contracts with the cheaper pre-acquisition rates. It then slaps on its higher profile name on the front of the building, while otherwise leaving the entire staff intact. And you end up paying much more.
How do you assess their non-profit status? They don't pay dividends to stockholders. They don't pay property or sales taxes to cities and states. The "profits" go to.....???
DeleteIn theory, the taxes they don't pay zero out the charity care they provide. So non-profits constitute a sort of private sector charity. It's the kind of model one sees Republicans rolling out all the time, where some kind of support for the indigent is paid for by "tax credits" and therefore isn't technically paid for by the direct levy of taxes.
DeleteThe "excess earnings" (which is the genteel way of saying "profit" in that world) become part of a reserve. This is why your local non-profit hospital can go around gobbling up other non-profit hospitals. But this is assuming that excess earnings are listed at all and not buried in the accounts.
The point is, non-profits can be very profitable indeed.
The Cleveland Clinic wants that Convenience Corridor (or whatever it's called) to facilitate parking and traffic around undesirable neighborhoods. So they certainly SHOULD contribute to city infrastructure. (If you want to see a city ruined by roads built to accommodate business, go to Flint and see how the freeway arteries feeding workers to auto plants, now defunct, carved up neighborhoods and lowered property values.)
DeleteMy local hospital has the Sparrow name, but, so far, not the Sparrow prices. It is still cheaper (overall 30 percent) to get things done at the little hospital, where they are friendly, competent, and no waiting. Some of my caregivers are my former students. I can't say enough nice things about the place. And I wonder when sticker prices will creep up.
But, yes, big hospitals charge more for routine procedures. I was disgusted when I saw my bone marrow biopsy cost $900. Then I googled around and saw that Johns Hopkins charges $6,000.
Unagidon is right about nonprofits. All the money has to go back to the enterprise, and that leaves a lot of leeway. It can be spent on bonuses for execs, pay raises, service expansion, physical plant improvements. There are thousands if creative ways to hide excess income in ways that will benefit the org and its execs and not the community it serves.
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