Financial woes jeopardize LA Hositals

From the Los Angeles Times

Financial woes jeopardize area hospitals

Nearly two dozen are at risk. Losing even a few would mean greater strain on the region's healthcare network.

By Daniel Costello and Susannah Rosenblatt
Los Angeles Times Staff Writers

September 23, 2007

excerpts:

Nearly two dozen private hospitals in Los Angeles and Orange counties, accounting for up to 15% of beds in the region, are in dire financial straits and in danger of bankruptcy or closure, according to hospital administrators, industry experts and state data.

The troublesome development follows the closure of community clinics and hospitals in recent years that has left the healthcare system seriously overburdened.

If even a few other hospitals close or reduce costly critical-care services, it could mean longer ambulance rides to hospitals, additional delays in emergency rooms and less access to care, especially for poor and uninsured people.

Among the hospitals in poor financial health, according to industry analysts, are Downey Regional Medical Center, Centinela Freeman Health System in Inglewood, Brotman Medical Center in Culver City, Century City Doctors Hospital and four Orange County hospitals owned by Santa Ana-based Integrated Healthcare Holdings Inc. including Chapman Medical Center in Orange and Western Medical Center in Santa Ana, one of three trauma centers in the county.

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The financial woes result from a multitude of developments:

* An increasing load of uninsured and low-income patients has resulted from overcrowding and the shutdown of public facilities. The number of uninsured patients visiting private hospitals, particularly in poor areas, has increased by one-third in Los Angeles County since 2002. California's Medi-Cal program for the poor reimburses hospitals at one of the lowest rates in the country.

* The closure of Martin Luther King Jr.-Harbor Hospital in Willowbrook last month left half a dozen nearby hospitals to absorb most of the 47,000 patients who used the public hospital's emergency room last year.

* Smaller community hospitals are drawing fewer patients as a few larger facilities attract a growing share of doctors and insured patients.

* As insurers have consolidated in recent years, they've squeezed many smaller facilities. Private insurance companies generally pay higher rates to larger hospitals with greater bargaining power.

* New, stricter state mandates on nursing ratios have raised labor costs, and a 2013 deadline to retrofit all hospitals to better withstand a major earthquake is estimated to be costing medical facilities $110 billion statewide.

Since 1996, more than 70 community hospitals have closed across the state, with a disproportionate share -- more than 50 -- in Southern California. Regionally, 14 emergency rooms have closed in the last five years, including 10 in Los Angeles County.

That's why experts say a new wave of closures would be so destabilizing.

"In many areas, you have had enormous consolidation, and there's very little breathing room left," said Kirby Bosley, director of California healthcare consulting for Watson Wyatt, a company that advises employers on health plans.

Many agree, however, that it's been years since so many hospitals have been in such dire financial straits at the same time.
In a few years' time, it's inevitable our community's already horrendous statistics of heart disease, cancer and diabetes will rise even more," she said.

The most immediate concern is how to best address the fallout from the closure of King-Harbor, which was shut down last month when the federal Medicare and Medicaid agency pulled half the hospital's funding after nearly four years of failed attempts to reform the troubled institution.

"Regardless of what everybody's trying to do, there's not enough money," said Carol Meyer, director of governmental affairs for the L.A. County Department of Health Services.

"We're talking about a system that is already in crisis," she said. "I think this is a tipping point for a couple of hospitals in the immediate area."

It's all in the wrist

Most of us aren't Einstein. People aren't born fluent in reasoning.

There are holes, gaps, blind-spots in our reasoning and perception. Magicians, con-artists, and some advertisers make good use of those to fool us.

(picture credit: That picture is the work of researcher Gregory T Huang, from New Scientist's 31 March 2007 issue at newscientist.com, subscription required.)

This makes it hard for us to make good decisions, especially social decisions.

Here is a made up example that illustrates a common problem that doesn't even have a name-- at least I don't know what it's called.

Suppose I walk into 10 rooms and shoot a person in each room, killing them. That would clearly be homicide.
Suppose instead I lock each of them in their room, seal all the doors and windows and cracks, and they die of suffocation. It's still homicide, but getting fuzzier and harder to see.
Now suppose instead of those methods, I release 1000 mosquitoes into each room, and let's say that 900 is sufficient to kill someone by each drinking one drop of their blood. The numbers may be off but you get the idea. At the end of the day, the poeple are all dead, due to my actions, and it is still homicide, but with a bioweaopon, I guess you'd call it.

Now suppose instead that I and 9 buddies each release 100 mosquitoes into each of 10 rooms, so the total is still 1000 per room. The people in the rooms still end up dying, but now no one person has released enough harm to any one person that it was fatal.

In this case, is anyone "guilty" of anything? Under American law, I suspect they are guilty only if someone can prove conspiracy.

Now suppose 10 people who don't know each other and never talk each release 100 mosquitos into each room for different reasons. All ten people in the rooms die.

Suddenly, now, no "crime" remains on the table. The "criminal action" has "gone away", and yet, the victims are all still dead at the end of the day.

Finally, suppose that 1000 mosquitoes are only enough to kill one in 10 people, if that one is unusually sensitive. Most people, 9 out of 10, can easily handle 1000 mosquito bites, say.

So, the 10 perpetrators each release 1000 mosquitos , 100 per room, and only 1 person, predictably, always dies, but we don't know in advance which one of the ten it will be. And let's say that happens every day for a year, so at the end of the year 365 people are dead.

Is anyone guilty of anything?

Here's the problem. On a collective scale, if you stand way back, there is a clear causal relationship between the mosquito release and the deaths. If you get up close, the relationship seems to go away - at least its now become so fuzzy that no jury would convict any individual mosquito-breeder for releasing a sub-lethal dose of 100 mosquitoes that demonstrably, in zero cases, by itself, would ever be fatal.

This becomes like the picture of, uh, Einstein (if you stand close) and Marilyn Monroe (if you stand far away) that I posted at the top and repost here:


If you back up 20 feed (7 meters) and look at that picture, it's the actress Marilyn Monroe.
If you sit at your computer, it's a picture of Alfred Einstein, the scientist.

Anyway, the problem described is an analogy to many of the problems Public Health has to deal with, and problems that large cities or nations have to deal with on a regular basis.

There is a hole, a gap, a blind-spot in our reasoning and perception, for this kind of distributed action that "goes away" when seen close up, but is clearly there when seen from "far away."

Or, in the case of the poor people who are stuck in urban ghettos, this kind of problem is very real when they are the ones dying, and the frustration is very real when they can't figure out how to make their case that the killing should stop.

Worse, it's not just the jury that won't convict anyone - it's that the perpetrators may individually each feel sincerely that they are not doing any significant harm and they can't figure out what the fuss is about. Sadly, the dim perception of a possible problem to a possible hypothetical victim has far less weight than the very clear perception of very clear profit from some enterprise such as selling cigarettes, or liquor, or guns, or predatory check-cashing, or predatory home-mortgages, etc.

In the suburbs, these don't add up to a lethal concentration, and the reported problems from the slums are interpreted as "something wrong with the people who chose to live there."

From the slums, the question is "Why do they keep doing this to us?"

Outrage, violence, or riots are ineffective at making the case. They generate a lot of attention, but then no one (from outside) can see what everyone (inside) is so excitedly pointing at.

On an international scale, I have to wonder how much of the violent resistance to the US and perception of the US as "the great Satan" is similar -- a protest over policies and actions that arrive diffusely but are experienced in concentrated form by the victims.

We need, as a planet, as humanity, better tools and better words for this sort of thing, so we can discuss it intelligently. This is one kind of "system effect" with profound implications and "unintended consequences" of the worst kind.

It is not unknowable. The problem is very clear, mathematically. It is easy to simulate it and show the effect, and, like the Einstein/Monroe picture, show how different it looks from each viewing location (inside and outside, in that case.)

After studying this, I think this effect is remarkably widespread, because it evades our perception. It causes management and labor to battle. It causes commerce and the poor to be in conflict. It causes the US and poor nations to be in conflict.

It seems like we should make a priority funding project to get researchers in such things to figure out how to make this visible, tangible, perceivable to everyone so we can resolve the abuse/oppression/exploitation cases that are accidental and inadvertent and unintentional.

Intentional abuse is a different story, but Systems Thinking shows that many problems are actually unintentional and completely unrealized and effectively impossible to view in the direct sense we normally see things. So, let's lower the conflict temperature by resolving the unintentional ones first, that we may all agree on if we all could simply see.