Physicians must organize for ethical medical care vs. the commodification of healthcare

October 26, 2017

You are not your patient’s doctor any more. You have been replaced. However, joining the corporate medicine bandwagon, turning a blind eye and following their unethical mandates can also jeopardize your career, and your patients’ lives.

The profession of dedicated healers of the sick has become a commodity. A commodity has traditionally been defined as “anything movable that can be bought and sold” and “an unfinished article of material substance, as opposed to a service.” By redefining medical services as physical articles, healthcare has been converted to something understandable to business managers and conducive to economic modeling. Insurance com­panies have redefined hospitals as “cost centers,” patients needing care as “covered lives,” and expenditures for care as “medical losses.” The goal of the insurance industry, then, is to keep the covered lives out of the cost centers to keep the medical loss ratios down.

William Andereck, M.D., summed up what patients experience under today’s system of commodified medi­cine in his essay Commodified Care:

Your company introduced a new health insurance program last spring and you were invited to select a physician from a list of doctors. You did your homework and asked friends and several health care workers for the most com­petent primary care physician. The name that kept coming up was Dr. Snipe, and so you made an appointment.

It took a while to get in, but on your initial visit, he seemed pleasant enough. He spent a lot of time talking to you and, when he examined you, he made you feel confident that you had chosen a physician that you could count on in the worst of illness. Dr. Snipe would be able to guide you through your next twenty years. When you mentioned to him the tight feeling you get in your neck and arm sometimes, his ears seemed to perk up.

When you left the office you were told to return in the morning for a treadmill test. The next day, you met Dr. Able, who introduced herself as your cardiologist. After the treadmill she told you that it showed signs of poor blood flow in the heart and recommended that you undergo a cardiac catheterization in a few days, by her colleague, Dr. Burns. The next morning the tightness returned and you called the emergency number on your insurance card. The on-call physician, Dr. Chan, told you to go the hospital immediately. There you were met by Dr. Davis and his emergency room team. Dr. Evans, the admitting cardiology resident, let it be known that he would be responsible for writing all the orders that directed your medical care when you were transferred to the coronary care unit. Dr. Fudd, the hospital’s intensivist introduced himself and his team, Drs. Gavin, Hubbard and Iota. After your heart was catheterized and Dr. Juster was unable to place numerous necessary stents, further catheterization was ruled out after consultation with the attending cardiologist, Dr. Kite. Therefore, you were referred to the Medical Center’s leading cardiac surgeon, Dr. Luce. He seemed totally competent and reassuring. Surgery was scheduled for the following morning.

There are several weeks when names and events float like leaves in the wind. Doctors like Nevermore, Potter and Travis seem to be in there somewhere, along with vague memories of respirators, IV tubes and innumerable smiling, unrecognizable faces. The next thing you clearly remember is the surgical ward with Dr. Weber as the resident managing your wound. As you got stronger, Dr. Xavier assumed your care in order to manage the multiple medical complications that had developed during your ICU stay. For the past four weeks you have gotten to know Dr. Yoste quite well, as she took care of you in the Skilled Nursing Facility. And now, as you are leaving, the nurse hands you a card listing your first post-hospital visit with your new cardiologist, Dr. Zulka.

Then you wonder, “What ever hap­pened to Dr. Snipe?”

Commodification is premised on the assumption that the whole can be completely broken down into its parts, which can themselves be precisely defined. Dr. Andereck illus­trated the concept by describing the experience of shopping for a turkey for his family’s Thanksgiving dinner:

“I imagined the noble bird of our forefathers’ time, standing proud, tail fanned, head held high, red waddle flapping defiantly. What I found on the shelf bore no resemblance to the creature I was seeking. Wrapped in plastic, on a yellow Styrofoam board was a very large, pale, glob of flesh. The neatly printed label advertised two large breasts, six wings and four legs, complete with drumsticks that would make a hog proud. I had found the commodified turkey. The turkey no longer contained the gizzards and giblets I loved as a youth, and certainly there was no heart. The turkey had become something else in its journey from the farmyard in Kansas to the meat counter at Albertson’s. Some essential items had been left on the slaughterhouse floor. The key to the dangers of commodified medicine was realized. It is not what the product is. It is what has been removed.”

To reverse this trend means challenging the rapidly consolidating economic power that now influences everything. Credentialing committees determine which doctors can practice at a given hospital, which therapies will be provided for any given disease process, the length of a patient’s hospital stay, or if they will even be admitted to the hospital at all.

Hospital corporations are buying up hospitals — sometimes two at a time, so they can close one and maintain the other as a monopoly. They are also buy­ing physicians’ practices from general prac­titioners to cardiologists to orthopedic sur­geons. In southwestern Idaho, over half the 1,400 doctors are employed by either the St. Luke’s Health System or its com­petition, the St. Alphonsus Regional Medical Center. Independent practitioners out­side of the larger systems in this medical battle­ground are increasingly denied referrals.

Boise’s situation reflects a growing national consolidation trend. Doctors who sold their prac­tices and signed on as employees have similar criti­cisms coun­trywide. In lawsuits and interviews, they de­scribe the growing pressure to meet financial goals of their employers — by performing unnecessary tests and procedures, ad­mit­ting patients who don’t require hospitalization or by denying necessary, but poorly-reimbursed procedures such as placing defibrillators in Medicaid patients, because they are “money-losing propositions.”

The AMA recently weighed in on the issue, warning doctors facing divided loyalties to always prioritize patient welfare, even if this is in conflict with the economic interests of the hospitals who employ them. However, without organization, doctors who object to the consequences their patients face if they follow corporate decisions to restrict care or schedule unnecessary tests, are easily replaced by colleagues more compliant with the “brave new world” of corporate medicine.

POC has handled multiple requests from member physicians who have been removed from their positions, taken off 
call schedules, reassigned or starved of
patient referrals after standing up to corporate medicine’s dictates. Legal rem­edies have been ineffective in resolving these matters except in ex­treme cases like that of Michael Fitzgibbons, M.D. where the Mathews Law Group won a $5.7 million judgment against Integrated Healthcare Holdings Incorporated (IHHI) for having hired someone to plant a gun in his car and slash the tires of his wife’s and daughter’s cars in retribution for his fight against IHHI.

Physicians themselves have now been reduced from professionals to mere commodities to be hired or fired. Physicians no longer have jurisdiction over prescribing therapies and procedures in the patient’s best interest, so essential to gaining the trust of patients. One POC member described the effect on the doctor-patient relationship as equivalent to having a third-party stranger in the exam room when you are asking the patient to undress for an exam.

he case of POC member Peter Navolanic, M.D., was a harbinger of things to come. In 2005 Sutter Connect took over the contract to manage his practice from East Bay Medical Resources. He was soon informed that his practice was losing money and the 401(k) plan was underfunded. After he terminated his relationship with them, Sutter Connect refused him access to the electronic and file copies of his practice’s medical records and billing information. Nine months later, with nearly $1,000,000 in unpaid claims and other losses, his practice was ruined.

One ICU director told POC of a situation where a credentialing committee questioned his credentials when he refused to cooperate with a “recommendation” made by the hospital’s “expert” to classify a blood sugar level of 200 as “out of control diabetes,” just to get more money.

Even executives who don’t play ball can be fired. Paul Meyer, a compliance officer for Florida-based Health Management, which operates 70 hospitals, said he was fired in 2011 in retaliation for questioning what he felt were improper admissions.

The economic transformation of medicine has paralleled that of other industries, with the growth of regional monopolies. The addition of bank capital allowed these regional medical care monopolies to expand and gain economic interest in hospital chains, clinics and diagnostic centers. Finance capital became a force in its own right, directing the development of medical resources to maximize profits. Doctors end up somewhere near the bottom of the chain.

Unorganized doctors are reduced to being medical workers, deprived of professional decision-making ability, rendering professional ethics secondary to business plans and leaving doctors without control of either their patient treatment plans or their own lives (many work under at-will contracts that can be terminated within 60 days.)

Without organization, doctors’ input concerning medical matters will continue to be ignored in plans to construct and operate medical facilities. To protect the 1.5 million people served by Stony Brook University’s burn unit, the late Harry Saroff, M.D., when in his 70’s, had to organize multiple rallies of doctors, patients and staff to save it from closure. Despite universal condemnation from psychiatrists and other physicians, Sutter Health, a non-profit hospital chain, projected to build 630 hospital beds in San Francisco without including a single mental health bed. An organized campaign by physicians played a major role in sending this plan back to the drawing board.

When doctors are organized, as has been demonstrated by intern and resident organizations and small groups of dedicated physicians across the country, patient care can be defended and preserved.

Doctors at numerous hospitals have noted that criticizing policies of their hospital or investor-owned physicians group is often difficult because, as employees without rights, they could be fired, with the hospital corporations blaming them for “poor performance.” Yet doctors are ethically bound to remedy harmful patient safety practices.

POC’s founding mission takes on new urgency every day. Per our State­ment of Principles, we are committed to “defending medical professionals who are facing impending loss of property, tenancy, ability, ethical practices and con­sti­tutional rights as professionals; through the inability to practice their profession to the mutual benefit of the community and pro­fession, in the face of governmental regulation and program.”

Huge corporate entities are currently accumulating capital and monopoy posi­tions at a rate far out pacing physicians’ ability to contain the damage to our health care system. Physicians have been left fighting one defensive battle after another as highlighted in the Spring 2013 issue of New Diagnosis.

In this context it is vital for physicians to learn a new profession, that of organ­izing. POC provides training on the job in physician organizing as well as classes on the pol­i­tics and economics of health care, teaching from history what does and does not work.

POC is designed to bring doctors to­gether as a skilled, professional, high­ly
trained workforce capable of defending the practice of medicine from the abuses and commodification so prevalent today. The efforts described in this publication have progressed as far as they have, because individuals have stepped forth to take the training and put in the time to learn on the job how to wage these fights.

POC calls on physicians to contact us today to find out about enrolling in our physician organizing training pro­grams, so you can learn how to help expand the movement to battle the ruthless consol­idation and perversion of our medical care system — and put an end to it in the in­terests of our patients and our profession.

Posted in Editorials: On the Commondification of Healthcare. |

MDs Unite with Community to Reinstate Medical Leadership of District Hospital

February 12, 2017

Corporate attempts to silence physicians fails

Physicians at Tulare Regional Medical Center rally to demand the administration reinstate the lawfully elected Medical Executive Committee. From left to right: Drs. Lonnie Smith, Prem Kamboj, Assit Shah, Isvan Potorke, Susan Haack, and Robert Orth

Physicians Organizing Committee (POC) members and other physician leaders from the Tulare Regional Medical Center (TRMC) organized with community residents this summer to win the first round in the battle to reinstate the illegally deposed Medical Executive Committee (MEC) and save their hospital. Defying a gag order imposed earlier this year by the hospital management corporation, Health Care Conglomerate Associates (HCCA), which threatened to revoke the admitting privileges of any physician who publicly criticized the hospital, the physicians organized a white coat rally on July 25 directly across the street from the hospital. The rally attracted a crowd of over 70 physicians, nurses, health district residents and community activists. Speaking from the platform of a flatbed truck with a sound system, POC TRMC member physicians took the lead and issued a call for reinstatement of the lawfully elected Medical Executive Committee. At a community forum the following week, physicians spoke passionately with over 100 residents in attendance about the patient care consequences of a hospital operating without an independent medical staff.

At the August 3 community forum, the doctors circulated a petition inspired by the Coalition to Save Tulare Hospital demanding the California Department of Public Health (CDPH) suspend the license of the hospital if they do not reinstate the lawfully elected Medical Executive Committee. The CDPH is responsible under state law to ensure hospitals, as a condition of licensure, have an independent, self-governing medical staff that selects and removes medical staff officers and adopts medical staff bylaws. The petition from the Coalition to Save Tulare Hospital – an organization of doctors, nurses, business owners, community activists and other health district residents – claims the hospital board violated this requirement when they chose to terminate the medical staff and its officers, and impose their own MEC and bylaws.

“They claimed the new bylaws gave them the right to censure us and revoke our admitting privileges if we criticized the hospital,” noted past Chief of Staff and POC member Lonnie Smith, M.D. “If we can’t vote for our medical leadership, we have no voice in how the hospital addresses quality of care issues.”

Rash of patient deaths add urgency

A rash of four tragic patient deaths in September added urgency to the doctors’ demand that the administration restore medical oversight of quality of care at the hospital by the lawful MEC without administrative interference.
These deaths occurred after HCCA had terminated 29 employees at the hospital that same week, including nurses, medical assistants and others with patient care responsibilities, along with key people in the hospital’s lab and pharmacy, including some of the most experienced staff who had been at the Tulare hospital for as long as 20, 30 and 40 years. These reductions resulted in staffing shortages in all affected departments, which statistically increases the incidence of negative patient outcomes.

Former Chief of Staff prevails over illegal attempt to silence him

On February 16, Abraham Betre, D.O., M.D., Chief of Staff at the time of the HCCA-led ouster of the lawfully elected MEC, applied for a temporary restraining order (TRO) to stop the administration from installing their own MEC. He warned that cases of improper care that the elected MEC was reviewing against three physicians on staff at the hospital would probably be dropped by the administration’s MEC, leaving patients vulnerable to substandard care. The three doctors named in Betre’s TRO as being under review, sued him for supposed invasion of privacy, intentional interference with prospective economic relations and unfair business practices. Although Tulare County Superior Judge David Mathis denied Dr. Betre’s request for a TRO, he stated in his decision that the suit against Betre was based on “speculative and unsupported allegations” and that it was an attempt to silence Betre, which is known as a SLAPP (Strategic Lawsuit Against Public Participation) suit, i.e. it was strictly retaliatory, not based in fact.

Ten Health District residents filed a lawsuit against the Tulare Local Health Care District Board, HCCA, Benny Benzeevi, M.D. and Rebecca Zulim, M.D., and the Hospital Board, which had allocated over $98,000 of health district funds to pursue a private civil case against Dr. Betre on behalf of Drs. Zulim, Kumar and Benzeevi, which the residents served in a surprise appearance during the public comment section of the monthly September 28 meeting of the TRHC District Board. At the meeting, Alberto Aguilar also served Parmod Kumar, M.D. with a notice of intent to circulate a petition to recall him from the board.

Community petitions Department of Public Health to intervene

The recent patient deaths underscore the urgency of the doctors’ demands for reinstatement of medical supervision of the hospital led by doctors elected by their peers, instead of doctors appointed by the administration for financial and political gain. The past five chiefs of staff of TRMC are participating in a petition campaign launched by the Coalition to Save TRMC demanding that the California Department of Public Health (DPH) take action, as the hospital continues to operate without an independent self-governing medical staff. In a call with Jean Chiang, District Manager of the California DPH in Bakersfield in September, POC Benefit staff member Nick Teslovich informed her that, “Our physician members in Tulare have asked to know what her agency intended to do about the illegal insertion of an illicit administration-appointed MEC at the hospital and its detrimental effect on patient care.” She said her office was aware of what was happening at the hospital, but this issue was not one of urgency.

Despite two site inspections by the federal Centers for Medicare and Medicaid Services (CMS) at the beginning of 2016 detailing problems at the hospital so serious as to cause the agency to threaten to revoke the hospital’s Medicare Provider Agreement, no action has been taken by CMS to correct the hospitals’ failing evaluation results and patients continue to suffer.

Community fleeced for bad care

In addition to questions of poor quality patient care, several presenters at the August community forum which included former hospital board members, a retired city manager, a nurse, physicians and those who had roles overseeing the hospital’s finances, objected to how HCCA had secured a contract which included exorbitant costs to the community. According to attorney Joseph Soares, speaking at the community forum, the hospital board is represented by Bruce Greene who is also HCCA CEO Benny Benzeevi’s personal attorney and the same attorney who drafted the contract for HCCA to manage the hospital. Soares showed how the Management Service Agreement (MSA) signed between the hospital board and HCCA on May 29, 2014, nets Benzeevi $3,000,000 per year with an automatic 6% increase and how wording in the contract indicates that HCCA had planned to terminate the MEC before HCCA even got the contract.

At the time of the contract negotiations, the firm of Dooley Pedersen represented TRMC. According to the Visalia Times-Delta, the firm claimed in a November 2015 settlement agreement that severed their relationship representing the hospital that Benzeevi and HCCA had interfered with their ability to fulfill their contract with TRMC. After terminating Dooley Pedersen as their legal counsel, the hospital board retained Bruce Greene of the firm Baker and Hostetler, LLP, who was also Benzeevi’s personal attorney.

TRMC is a District Hospital, built and financed through taxes levied upon homeowners in the local health care district and governed by a Health Care Board elected from among residents in the district. However, the May 29, 2014 contract states that the Board shall not interfere, directly or indirectly, with HCCA’s decisions; the Board Members cannot access the Hospital without HCCA’s approval and the Board can’t in any way criticize HCCA’s conduct. Soares concluded by asking, “Who is in control of TRMC?”

How did HCCA get the hospital contract?

According to local dentist Dr. Patricia Drilling, HCCA submitted their bid to manage the hospital in July 2013, after the closure of the bidding window. HCCA’s bid was accepted even though it was late. Drilling described how TRMC’s Request for Proposals to manage the hospital asked interested parties to submit records of facilities that they had owned or operated; proof of recent and long-term financial operating success; proof of financing to complete the hospital construction and their most recent audited financial statements. Sr. Drilling stated that HCCA was chosen despite having had no prior experience running hospitals, and with no financial background. HCCA had no record of their experience or financial practice because HCCA did not incorporate to exist as a corporation until two days after the Board chose their bid to run TRMC.

Claims of financial achievements questioned

According to an August 2, 2016 story in the Visalia Times-Delta, although Benzeevi claims to have achieved a significant turnaround in the hospital’s finances, “An examination of the TRMC monthly financial reports and annual audits shows two major factors in Benzeevi’s ‘real-life Cinderella story’.” The financial gains of the hospital are a result of two factors. First, the ACA increased supplemental payments to hospitals to augment the cost of caring for patients under Medi-Cal and Medicare; secondly, the HCCA that took over employment function at the hospital cancelled two hospital employee pension plans and a hospital retiree health plan valued over $1.3 million in 2014. The supplemental payments totaled more than $11.3 million in 2015 and for 2016 will total more than $15 million.

Hospital requests additional $55 million bond – Voters say ‘NO’

Although the original bond measure to upgrade the hospital with an as yet-to-be completed, seismically fit hospital, passed with an 85% approval rating in 2007, subsequent financial mismanagement detailed in a civil grand jury report “Tower of Shame”, together with HCCA’s refusal to provide an audit as to an accounting of the original $85 million, soured the community’s interest in the hospital’s current request for an additional $55 million this summer. Despite HCCA spending the equivalent of nearly $120 per vote in publicity funds promoting the measure, residents of the district rejected the special mail-in “Bond Measure I” in August by a 66 to 33% margin.

Hospital’s board incumbents vulnerable

Two of the hospital board members, Sherrie Bell and Laura Gadke who were backing Measure I, are up for re-election this year. Criticism of the board for its failure to provide transparency in regard to the original $85 million bond as well as the problems with poor patient care in the wake of the administration terminating the physician leadership at the hospital has community groups, such as the Alliance for Justice and Citizens for Hospital Accountability, backing candidates they hope will be more responsive to the medical needs of the community. According to Citizens for Hospital Accountability founder Deanne Martin-Soares, RN, who used to work as a nurse at TRMC, “I had problems with the hospital for a while, but when they terminated the MEC they had gone too far and I had to get active.”

Alberto Aguilar, a member of the Bond Oversight Committee created to oversee the $85 million bond stated, “We want the financing for the new hospital, but we want a transparent board with accountability.” At the August 2 community forum, Aguilar presented copies of his multiple, but futile, requests to the Hospital Board for an audit of the $85 million bond. He said at the last meeting of the Bond Oversight Committee, the hospital board presented the committee with a three-page report they claimed to suffice as an audit, that concluded however, with the statement, “We are not engaged to, and did not, conduct an audit.” The committee refused to accept this as an audit.

While the suit against the hospital to reinstate the lawfully elected MEC moves slowly forward, POC members in Tulare continue to reach out to the California Department of Public Health and Centers for Medicare and Medicaid Services for action on the quality of care issues, while coordinating with community activists who are working to take back control of the hospital by replacing two of the five board members who are running for reelection this fall and recalling a third in hopes of creating a hospital board that can eventually get a different operator for the hospital.

“We have demonstrated time and time again that we can defeat bad actors on the medical scene, but until we achieve long term change in the root of the problem that enables the likes of a Sutter, HCCA, Columbia HCA, Prime Health and other profiteers to proliferate in the health care sector, the problem won’t stop,” said POC President, Geoffrey Wilson. “This precedent cannot be allowed to stand and by organizing the doctors together with the community we can win.” Physicians facing similar problems should call POC at (415) 434-9335 and ask for David.

Posted in Medical Staff Self-Governance: Tulare |

Legal Victory Buys Time for Rural Northern California Hospital

February 5, 2017

MDs who oppose Sutter’s profiteering face retaliation
After a nearly two-year legal battle, Beverly Hussey reached a settlement in November 2015 in her suit to stop Sutter Coast Hospital (SCH) from cutting the number of patient beds in half, in violation of the terms under which her late husband donated the land in Crescent City, California that the hospital was built on.

Hussey Suit Details

Beverly Hussey, widow of the late Francis “Sonny” Hussey, who donated his land to Sutter Coast Hospital, first filed suit in February 2014, claiming the hospital Board of Directors’ vote to change the hospital designation from an acute care hospital to a Critical Access facility breached the Declaration of Covenants, Conditions, and Restrictions executed in 1988, when the land was donated. The suit also accused three hospital board members, who are employees of Sutter Health, of violating the obligations of a charitable trust by not recusing themselves from votes through which they stood to gain personally.

According to Mrs. Hussey’s attorney, Majed Dakak, “Since Mrs. Hussey’s case was resolved through a last-minute settlement, several important accusations were never tried.”
Sutter demanded the settlement be sealed, so the exact terms of the agreement remain confidential, but Del Norte County District Attorney Dale Trigg has subpoenaed evidence from the case, in pursuit of potential criminal and civil charges against Sutter Coast (see sidebar Hussey Suit Details).
According to former Sutter Coast Chief of Staff Kevin Caldwell, M.D., who has served the Northern California coastal community of Crescent City for over 30 years, “Given the history of falsehoods and broken promises Sutter has made to this community, no agreement — sealed or not — is a guarantee that the hospital will not be downsized. When millions of dollars are available, Sutter has demonstrated the ability to lie and distort the truth with impunity.”

Unsettling settlement leaves issues unresolved

One salient unresolved point from Mrs. Hussey’s suit is the fact that the hospital was operating without a chief financial officer, in violation of section 5213 of the California Corporations Code, for the two-and-a-half-year period during which they were trying to move hospital ownership out of Del Norte County to Sutter’s regional multi-hospital corporation. This was the only period of financial loss in the hospital’s 30-year history.
Sutter also paid the Camden Group hundreds of thousands of dollars to conduct a study corroborating Sutter’s claimed losses. Sutter used these purported losses to justify its plan to downsize Sutter Coast to a Critical Access facility. Ultimately, the County Board of Supervisors and City Council of Crescent City discredited the Camden study findings in a unanimous 10–0 vote.

Sutter Coast didn’t hire a CFO until challenged on two fronts

When former hospital Chief of Staff Greg Duncan, M.D. obtained Sutter Coast’s Medicare renewal application through a Freedom of Information Act Request, he found that Sutter Health had stated that it owned Sutter Coast Hospital, and that Sutter Coast had a CFO, neither of which was true. After Medicare questioned Sutter’s statements, Sutter revised the application. According to the Centers for Medicare and Medicaid Services, fraudulent statements on Medicare applications may result in fines of up to $500,000.
Secondly, Dr. Duncan brought his concerns about the lack of a CFO to auditors from Ernst and Young, who confirmed Sutter Coast did not have a CFO. Shortly thereafter, a CFO was appointed, and the truth about Sutter’s claimed “losses” was revealed in the local newspaper — the “losses” were, in fact, profits of $11.8 million in 2014 with similar expected profits in 2015.

Falsehoods and fraud

Reports of past losses by former Sutter Coast CEO Linda Horn were also proven fraudulent. “She attempted to rewrite history and confuse the public, by falsely claiming the hospital had lost money in 2009 and 2010, when in fact Sutter Coast sent over $7 million in profits to Sutter Health during that time,” said Duncan.
The Hussey lawsuit also documented that three executives of Sutter Health (which manages Sutter Coast) sit on the Sutter Coast board and voted to transfer ownership of Sutter Coast to Sutter’s regional corporation. The Sutter Health executives also voted for critical access, which Sutter estimates will bring an additional $5 million annual income to Sutter Health. These executives receive bonuses tied to the financial performance of the hospital. By not recusing themselves from these votes, they “violated the duty of a charitable trust to avoid self-dealing,” according to the suit (see sidebar The Price of Price Gouging).

The Price of Price Gouging…
Letter by Velma Rinehart to the The Daily Triplicate

As I sit and eat my Cheerios, I’m staring at a hospital bill for $8,487.49 for a condition I still have. That astronomical amount does not include the anesthesiologist, labs, or the surgeon’s fees. Curiosity forced me to call Surgery Center of Southern Oregon to compare costs. They would have charged — get this — $900 for the use of their hospital room. Yes, I would much rather pay a $90 co-pay instead of just over $1,000.
How can Sutter call itself a nonprofit? I’ve heard the CEO makes a six-figure salary. Is that where all our co-pays go?
Crescent City folks aren’t rich, yet our hospital charges us too much.
If this continues, Crescent City will lose its old-timers like me with steady income and those who work hard for the money they earn.

While physicians and others have been waging a three-year battle against Sutter Health’s attempt to take ownership of and downsize the hospital by fraudulently claiming multi-million dollar financial losses to portray Sutter Coast
as a poor, struggling rural hospital in need of higher Medicare payments to survive, the Hussey suit bought the time needed to prove that Sutter Coast has been lying about losses while sending millions in profit to Sutter Health. Critical Access would further enrich Sutter Health, while increasing out-of-pocket costs to local seniors and forcing all patients to be transferred whenever the twenty-five-bed Critical Access cap was reached.

Two year reprieve at the most

“Although the actual wording of the sealed Hussey settlement is not available to the public, even a best-case scenario would only bar Sutter from applying for Critical Access status for the remainder of the term of the land donation, which gives us only until the end of 2018,” said POC Membership Coordinator Brian Tseng.
“There is no time to lose,” noted Kevin Caldwell, M.D. “Those of us dedicated to the health of our community will continue to organize public presentations and town hall meetings and release written statements to educate both the community and responsible government officials as to what is at stake here. As POC members, we will continue to avail ourselves of the support that POC membership has provided.”
Although current Sutter Coast CEO Mitch Hanna announced the hospital is no longer pursuing Critical Access status, he also stated, “We may again consider Critical Access in the near or distant future to honor our community commitment to preserve the long-term viability of Sutter Coast.” (The Daily Triplicate, March 23, 2015)
It wasn’t until the February 23, 2016 SCH medical staff meeting that CEO Hanna announced they had finally complied with the request from the California Department of Public Health Licensing and Certification Division to submit a written retraction of their CAH application, filed over two years ago.
If Sutter Health does attempt to resume its pursuit of Critical Access status and transfer of ownership plans, the Del Norte Healthcare District has retained an attorney to prepare for retaining control of the hospital via eminent domain, by which the Healthcare District could compel Sutter to sell them the hospital, thus stopping the harm that Sutter’s actions would bring to the community.

Meanwhile patients suffer

Although Sutter Health claims not to be pursuing Critical Access at this time, physicians have reported negative impacts on their patients from the downsizing Sutter Coast has already engaged in to attempt to show a patient census low enough to justify downsizing to Critical Access status.
This February 2016, Sutter Coast staff reported that when a patient needed a cesarean operation, Sutter Coast falsely claimed there were no beds in the hospital. There were beds, but hospital administration has refused to staff them, which supports Sutter’s effort to show patient census numbers are low enough to qualify for extra funding.
“Sutter Coast has already cut staff to the point that patients are being transferred, at the patient’s expense, to other hospitals,” says Greg Duncan, M.D., Chief of Surgery at SCH. “Patients are being flown to other hospitals, surgeries are being cancelled, emergency room waits have risen and, frustrated by the lack of care, more patients have left the emergency room without being seen.”
According to data from the Office of Statewide Health Planning and Development (OSHPD), Sutter Coast transferred out a record 872 patients in 2014: 671 ER transfers and 201 transfers from the inpatient ward, compared to 271 ER transfers in 2006, before Sutter began trying to downsize to Critical Access status.
After being told the hospital was “full,” a cancer patient with a leg infection was flown from Sutter Coast to Medford, Oregon, when in truth; beds were available at Sutter Coast. Another patient with a childhood kidney disorder was transferred by air ambulance to Redding, California, for the same treatment she could have received at Sutter Coast. She was unable to afford the $1200 airfare for the trip home, so the Redding hospital wanted to discharge her to a homeless shelter. A local cab driver came to the rescue.  He drove 260 miles over the mountains in a snow storm, picked up the patient and brought her home.

Doctors who stand up are 
economically targeted
After urologist Mark Davis, M.D. opposed Sutter’s corporate plans, Sutter began subsidizing a competing urologist, in a market that Sutter determined had no need for a second urologist. Sutter Coast CEO Hanna claimed Sutter was not required to demonstrate community need in recruiting decisions. Dr. Davis was forced to leave town. One week later, a young girl could not get treatment for a large painful kidney stone. Why? Sutter’s new urologist had taken an eight-week leave of absence, leaving Sutter Coast with no urology coverage. The girl had to be taken to Gold Beach, 60 miles away in Oregon for treatment.

Impact of Critical Access

Although the past and current Sutter Coast CEOs Eugene Suksi, Linda Horn, and now Mitch Hanna have maintained that a Critical Access hospital will provide the same care as the current acute care hospital, research on Critical Access hospitals proves otherwise. A nationwide study in 2011 found patients treated at Critical Access hospitals had higher mortality rates for heart attack, heart failure and pneumonia (lead author Karen Joynt, M.D., M.P.H. Journal of the American Medical Association).
Additionally, patients pay as much as 300 percent more in co-pays at Critical Access hospitals according to a December 25, 2015 Wall Street Journal article “Comparing Costs for Outpatient Care.” According to the Carpenters Health and Welfare Trust Fund for California, Sutter’s price gouging cost them $5,000,000 in 2012 alone. Sutter patients have received bills with charges as high as $10,000 an hour for operating room time, not including medications, surgeon and anesthesiology fees.

In addition to the risk of complications due to delayed emergency care, patients transferred out of Sutter Coast are billed upwards of $50,000 for air ambulance flights to hospitals from Portland, Oregon, to the Bay Area. By reducing their beds from forty-nine to below twenty-five, Sutter stands to gain an extra $5 million a year in Medicare reimbursements by qualifying as a Critical Access Hospital. (See sidebar Impact of Critical Access).
According to eye surgeon Larry Eninger, M.D., past Chief of Staff at Sutter Coast Hospital and member of the hospital Conflict Resolution Committee, the main obstacle to resolving the conflict is the local Hospital Board. The Hospital Board is appointed by Sutter Health, with the exception of the chief of staff. The Conflict Resolution Committee was formed when hospital physicians opposed the hospital board’s secret vote to transfer hospital ownership out of the local community. In his letter of resignation from the committee, Eninger wrote, “It is our Board’s responsibility to protect the interests of Sutter Coast Hospital, and by virtue of the hospital’s charter, the local community. Whether by ego, ignorance, ineptness, laziness, cowardice or combination thereof, our local Board has failed miserably in that responsibility.”
“Our Sutter Coast Hospital Board is at odds with our community, fighting us on behalf of Sutter Health. Until the majority of our Board is once-again composed of community-focused individuals who are capable of independent thought, our efforts on the Conflict Resolution Committee are a waste of time.”
According to POC President Geoffrey Wilson, “Opposition to the increasing corporatization and commodification of healthcare is now playing itself out in ethics committees, medical executive committees and hospital board rooms across the country. These are some of the new battlefields in the movement for change in health care where all possible influence and support from the community must be brought to bear. Learning how to fight and win for patient care in these arenas is crucial to being a doctor in the 21st century.” Physicians seeking to learn organizing skills should call POC at 415-434-9335.

Posted in Medical Staff Self-Governance: Crescent City |

Government Failure Continues to Roil Mental Health Professionals and the Community

In 2002, the California Legislature passed AB1421, which authorized counties to implement Assisted Outpatient Therapy (AOT), also known as Laura’s Law. San Francisco launched its program in November 2015. The law mandates early intervention by mental health professionals and wraparound services, such as intensive case management, housing, job training and regular contact with a mental health professional to provide long-term stability to those who have a serious mental illness.

False Promise

“So far, Laura’s Law has been a false promise, for all the same reasons we have a crisis in mental illness on the streets in the first place,” said POC Administrative Assistant Virginia Spiegel, LCSW who also sits on San Francisco’s Mental Health Board. She criticized the SF Department of Public Health’s latest failure to provide the range of services and support for the severely mentally ill mandated through AOT under State Welfare and Institutions Code 5348. “Like many other programs, the failure to put adequate money into the required treatment facilities made it just another ‘good idea’ gone awry in the face of what it would really take, not only to provide services to the severely mental ill, but to address the underlying problems that manifest in mental illness or exacerbate it,” said Spiegel.
Angelica Almeida, director of San Francisco’s AOT program, stated in a March 2016 interview with POC that since eligibility criteria for the law are strict, only 49 people have been referred for AOT since the county launched the program in November 2015. Of those, only 26 were eligible to receive AOT’s wrap-around services, including housing. Twelve of those voluntarily accepted services.
If the person meets criteria, but refuses voluntary participation, the San Francisco Department of Public Health personnel who first evaluate the case can either petition the court for a hearing or the DPH can continue to reach out to the person to get them to voluntarily accept treatment. If the case goes to court, a special AOT judge can mandate a full range of treatments including intensive case management, housing, job training and regular contact with a mental health professional or deny the petition.  However, no petitions were ever filed for the remaining fourteen, despite their having been hospitalized or incarcerated because of their mental illness twice in the past three years or involved in one or more acts of serious and violent behavior toward themselves or others within the last 48 months.
Barbara Garcia, M.P.A., SF’s Director of Public Health, posted in July 2014 on the agency’s website that “based on national data, it is expected that fewer than 100 individuals in San Francisco will meet criteria for the [AOT] program.”

No Housing

However, based on figures from the 2015 Homeless Point-in-Time Count and Survey compiled by the nonprofit social-research firm Applied Survey Research, approximately 1,700 out of 6,700 homeless people on the streets of San Francisco are suffering from a severe mental illness. If individuals are ordered into treatment through the court system established as part of the AOT legislation, the treatment plans are mandated to provide access to housing, one of San Francisco’s most sought after and fought over commodities. “This creates a disincentive to enroll people, because there is such a dearth of available housing,” noted psychiatrist Gil Viella, M.D., formerly with San Francisco’s Citywide Services, an agency tasked with finding housing to stabilize patients after release from psychiatric emergency holds or locking wards.
Almeida claimed, “Even without a court order, AOT helps voluntary participants use money received from other programs to access housing and find housing they can afford.”
San Francisco rents rose 12.3 percent in 2014 – four times the national average, such that the median rental rate for a two-bedroom apartment is now $3,350. Building developers cater to employees who work for companies like Google, Apple, Genentech, Twitter, Firefox, and who can better afford inflated housing prices.
Since 2010, SF has lost over 7,000 housing units available to low-income individuals and those with severe mental health conditions. On the one hand institutions like the Academy of Art University have been buying rent-controlled units to use as dorms for their 15,000+ students, while foreign language schools and other educational institutions such as the Make School, have been taking up affordable housing units by contracting with the city’s single-room occupancy hotels for dorm space.
Developers are required to contribute only 12 percent of their project’s cost to affordable housing, according to the City’s charter. Jane Kim, Aaron Peskin, and other San Francisco supervisors have placed a charter amendment on the June ballot to increase this requirement.
The U.S. Department of Housing and Urban Development’s HOME Investment Partnerships Program cut San Francisco’s funding allocation for affordable housing construction and down-payment assistance from $15.7 million in 2008 to $4.2 million in 2015.
After Governor Brown shut down California’s multibillion-dollar redevelopment initiative in 2011, San Francisco, which had been spending most of its redevelopment money on affordable housing, was hit hard. Around $50 million per year disappeared, resulting in severe cuts in SF’s affordable housing market.

No Beds, Either

“Our entire city is awash with people needing mental health services. The services and the facilities needed to provide for them are insufficient all the way down the line – from decent affordable housing, board-and-care homes, sub-acute treatment, adult diversion units to intervene before a psychiatric crisis and locking wards for the severely mentally ill in crisis. We’re getting reports from psychiatrists and case managers who are quitting their practices due to the hopelessness of accessing appropriate services for their clients.”
Meanwhile the City and County of San Francisco gives away $37.9 million a year in tax breaks and direct subsidies to the non tax-paying, non-profit hospitals like Kaiser and Sutter Health’s four-hospital California Pacific Medical Center (CPMC) division, which provide scant mental health services. Sutter/CPMC has not replaced any of the 52 acute inpatient psych beds they cut from their St. Luke’s and Davies facilities and Kaiser maintains no acute inpatient beds in San Francisco.
These corporate giveaways are in addition to the $34 million “Twitter Tax Break” the county gave in the form of payroll tax exemptions to tech firms to keep them from moving elsewhere.
Based on the most urgent unmet psychiatric needs, Physician’s Advocacy and Information Task Force (PAITF) is pursuing the demands it submitted to the County Board of Supervisors in March of 2013 that Sutter/CPMC create a 38-bed unit to replace the beds they closed to include 10 acute and 12 sub acute psychiatric beds, 8 medical detox beds and 8 non medical detox/stabilization beds and that Kaiser fund the construction of a 100-unit supportive housing complex.
Currently, the county is allowing Sutter to build two new hospitals without a single psych bed in either one and doesn’t charge Kaiser for the emergency psych visits of Kaiser patients to the county’s Psychiatric Emergency Services PES unit.
San Francisco County closed 66 of 87 acute psych beds from 2008 to 2011. John Rouse, M.D., veteran psychiatrist at SF General Hospital (SFGH) currently working in the remaining adult inpatient psychiatric wards, noted that only 10 of the 37 patients in his unit have been designated as “acute” by the in-house utilization review staff who report to the California Department of Public Health “Some of those deemed by the auditors as not being sick enough to satisfy the Medi-Cal criteria are, however, rejected by the community based locked sub-acute treatment (LSAT) facilities as being ‘too acute,’” noted Rouse.
One of Dr. Rouse’s patients has been in SFGH’s acute psych ward for 205 days waiting for an LSAT bed, while the county gets zero reimbursement from the state.
The majority of the other 27 of the 37 patients in the hospital’s locking wards are waiting for a bed in an LSAT, of which the City has cut 150 in the last four years, leaving the county with just 203 out-of-county contracted beds and 20 to 30 at the county’s Behavioral Health Center.
“As a result of the state refusing to pay for patients being treated in the county’s acute locking wards – many with suicidal, homicidal, or other psychotic ideation or actions – SFGH has had to absorb millions of dollars in uncompensated care,” noted POC membership coordinator Brian Tseng.
In addition the demands to the Board of Supervisors, the Task Force will also submit Dr. Rouse’s proposal to convert one of the county’s shuttered acute psych units into an LSAT, to the County Department of Health. “It makes no sense to have a completely functional unit sit empty when there is such a tremendous need,” noted Rouse.

Mandates Ignored

Supportive housing units like the Richardson Apartments on Gough and Fulton Streets and the Rene Cazenave Apartments at 25 Essex Street in San Francisco demonstrate what can be done.  Although insignificant compared to the overall need, these 120-bed purpose-built apartments have stoves that turn off when you walk away from them, and walls made with diatomaceous earth to kill fleas and bed bugs. The apartment complexes each have case managers and an on-site clinic to help residents maintain stable lives. They are projected to save the county $2.4 million per year in ambulance, emergency room, jail and psychiatric treatment each year.
The total cost for these two facilities was approximately $87 million, but there are funds available for more.  California’s Mental Health Services Act (MHSA) generates approximately $1 billion per year, $75 million of which is mandated to go towards the capital costs of permanent supportive housing people with serious mental illness and their families that are homeless or at risk of homelessness and $40 million for operating subsidies in these developments  Despite the mandate, MHSA claims to have allocated only $255 million for total housing dollars since the program began in 2004, and the California Housing Finance Agency can account for only $41.8 million of MHSA money having been spent on supportive housing during the same time period.
According to MentalHealthIllnessPolicy.Org, “$1-2 billion was intentionally diverted to social service programs masquerading as mental illness programs, while $2.5 billion of the Full Service Partnership funds were spent without oversight and $23 million went to organizations directly associated with oversight commissioners.” The site lists over $7 million that went to organizations like Disability Right California, California Network of Mental Health Clients and Mental Health America’s California and San Francisco chapters who used the money to lobby against the adaptation of AOT programs, in effect  “working to prevent the seriously mentally ill from receiving treatment until after they become violent.”

Nonprofit hospitals and HMOs not helpful

Despite federal mandates for insurance companies to provide mental health services on a par with medical and surgical treatments, only 2 of 26 insurance companies in California were even close to compliance according to a recent finding by the state insurance commissioner.
Without access to proper care, the severely mentally ill often end up trapped in a cycle of living on the street, getting arrested and going to jail or PES. They then get released to programs that fail to treat their mental health problems and they end up back on the streets or in jail. The number of mentally ill people in Californian prisons has doubled since 2000. According to a recent report from the National Sheriff’s Association and the Treatment Advocacy Center, ten times as many mentally ill people are in prison and jail in the United States than are in mental health treatment facilities.
Kaiser Permanente was fined $4 million in 2013 by the Department of Managed Health Care for “serious” and “systemic” violations of California law: falsifying patients’ appointment records, forcing patients to endure illegally long waits for care, and failing to provide psychiatric services that are on par with primary care health services. Nearly 1400 Kaiser mental health workers voted to strike in October 2014 as staffing levels were still deemed severely inadequate by those clinicians.

Take back public resources from corporate pockets

“Even if fully implemented, AOT will not diminish the population of mentally ill people living on the street unless we stem the tide of shell-shocked vets returning from foreign wars and shell-shocked workers losing their pensions, homes and healthcare in this worker-hostile collapsing economy,” noted Nick Munoz, POC staff member.
According to Samuel Patterson, Commander of American Legion Post 198, “Returning vets from Iraq, Afghanistan and other US military operations are coming back with PTSD and other psychological damage to the point that 22 veterans are committing suicide per day with tens of thousands of others suffering from serious mental illness, some self-medicating with drugs and ending up homeless on the streets.”
“We need a complete reversal in the priorities for housing, access to care, case management and other needs of the mentally-ill that would only be possible if we end the private theft of public resources,” said Munoz. Psychiatrists and other mental health professionals interested in participating on POC’s Physicians Advocacy and Information and Task Force and fighting to reverse those policies should contact POC membership coordinator Brian Tseng at (415) 434-9335.

Posted in Mental Health |

POC Celebrates 33 Years of Fighting to Uphold the Ethics of the Medical Profession

On Saturday October 17, 2015, Physicians Organizing Committee, in collaboration with Commander Samuel Patterson, Jr. of American Legion Post 198 celebrated our 33rd anniversary. The event held at the San Francisco War Memorial Building included members, veterans, and friends of the association to celebrate POC’s ongoing campaign to expand access to acute and outpatient mental health services as well as full hospital services for low-income and needy populations.

Posted in 33th Anniversary Celebration, Mental Health |