Showing posts with label hospitals. Show all posts
Showing posts with label hospitals. Show all posts

Sunday, September 23, 2007

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.

----
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."

Saturday, August 11, 2007

What goes around comes around


It's not just "a small world" we live on -- it's a small "us" we are part of: there is, really just one of "us" here, with plants, animals, and people of all types including those with a "j" as the fourth letter of their middle name, or other irrelevant distinctions, such as "race" or "ethnicity" or administrative governmental unit of origin.

It turns out, viruses and bacteria don't really care about those distinctions that we take as so important. When bad things are let thrive, they come for all of us.

That would be true even if we had all come here from different planets, due to the intense "system effects" that mean anything affects everything, and vice-versa.

It's even more true since we were all born here on Earth, as were our parents, and our grandparents, etc. on backwards. (aside from my 2nd grade gym teacher, who I think was from Mars.)

So, we need to be very careful of the glee we take when someone "else" has managed to shoot a hole in the bottom of "their end" of our lifeboat -- and more so if we were involved in handing them the loaded gun.

This basic physical truth is one basis behind the various religions' description of the Golden Rule - some variant of "Do unto others as you would have them do unto you". Or we have the Christian Scriptures, where Jesus says (see other versions)
KJV: And the King shall answer and say unto them, Verily I say unto you, Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me. (Matthew 25:40).

Or, Islam's Book of Sincerity -'The believer will not truly believe until he wishes for his brother that which he wishes for himself.'

So, in today's papers we see some of that effect coming into play.

First, the home mortgage market. I wrote about the present disaster that is unfolding on us now back when there was still time to do something:
Honey, We're losing the house - Dec 7, 2006 (Pearl Harbor Day).
The Mortgage Trap Begins Closing - Dec 11, 2006
How does that help me? - Average American -- May 22, 2007
Rising Rates and the Soon to be Homeless - June 15, 2007
More on Foreclosures for the Baltimore Sun - June 15, 2007
So, what started as a large scale scam to dupe poor people into buying homes they couldn't afford and then close the trap on them has now turned into an international incident roiling stock markets around the globe. Now even rich people are being affected! Here's something from this morning:

In a Spiraling Credit Crisis, Large Mortgages Grow Costly.
New York Times
August 11, 2007

When an investment banker set out to buy a $1.5 million home on Long Island last month, his mortgage broker quoted an interest rate of 8 percent. Three days later, when the buyer said he would take the loan, the mortgage banker had bad news: the new rate was 13 percent.

“I have been in the business 20 years and I have never seen” such a big swing in interest rates, said the broker, Bob Moulton, president of the Americana Mortgage Group in Manhasset, N.Y.

“There is a lot of fear in the markets,” he added. “When there is fear, people have a tendency to overreact.” ...

For months after problems appeared in the subprime mortgage market — loans to customers with less-than-sterling credit — government officials and others voiced confidence that the problem could be contained to such loans. But now it has spread to other kinds of mortgages, and credit markets and stock markets around the world are showing the effects.

Those with poor credit, whether companies or individuals, are finding it much harder to borrow, if they can at all. It appears that many homeowners who want to refinance their mortgages — often because their old mortgages are about to require sharply higher monthly payments — will be unable to do so.

Some economists are trimming their growth outlook for the this year, fearing that businesses and consumers will curtail spending.

“You find surprising linkages that you never would have expected,” said Richard Bookstaber, a former hedge fund manager and author of a new book, “A Demon of Our Own Design: Markets, Hedge Funds and the Perils of Financial Innovation.”

... There were reports that a surprisingly large number of loans made in 2006 were defaulting only months after the loans were made.

There have been sudden changes in the mortgage market before, but this one may be both more severe and more damaging than those in the past.

I Investors made the mistake of assuming that housing prices would continue to rise, said Dwight M. Jaffee, a real estate finance professor at the University of California, Berkeley. “I can’t believe these sophisticated guys made this mistake,” he said. “But I would remind you that lots of investors bought dot-com stocks.”

He added, “When you are an investor, and everybody else is doing the same thing and making money, you often forget to ask the hard question.”

And that is how a problem that began with Wall Street excesses that provided easy credit to borrowers — and made it possible for people to pay more for homes — has now turned around and severely damaged the very housing market that it helped for so long.

Not everyone had evil intentions, although predatory practices certainly worsened the problem. We have yet another case of what Jay Forrester called (50 years ago) "The law of unintended consequences", although at this point in our history I don't think these can be called "unexpected consequences" -- aside from the expectations of the structurally blind who have been deceived by their own myths.

In fact, this area of self-induced blindness is fascinating, and scary, and relevant to understanding why so many personal, management, and governmental level policy decisions look so stupid in the morning. Or, as the cartoon strip Calvin says: "How come dumb ideas seem so smart when you're doing them?" And in turn, that is akin to my favorite Snoopy cartoon:
Did you ever notice
that if you think about something at 2 AM
and then again at noon the next day
you get two different answers?
I was trained as an instrument pilot, and we were carefully taught how to read each instrument so we could navigate when you couldn't see out the window. One item in the tool kit was curious - a 3 inch disk covered with suction cups, suitable for holding soap in the bathroom. "What's this for?" I asked. Well, it turns out that is to save you from the alternative, which is smashing the face of an instrument on the cockpit panel so you stop paying attention to the blasted thing when it has decided to lie to you convincingly -- you can stick this over the instrument so you don't see it anymore.

Because, it turns out, all our instruments, and senses, lie to us. It's only by comparing notes that we can detect that one of them is "acting up". It's invisible by itself, in isolation, as are the tricks our own minds play on us. As Calvin says, - why do these things look so smart at the time? This is a serious question and worth reflecting on.

But cockpit instruments, computer readouts, or the minds of Calvin, Snoopy, or you or me, all can lie to us in the most convincing way. Most of the time they are right, some of the time we know the results look "funny", and some of the time they are very wrong but still look perfectly right. The altimeter tells us we're climbing when we're descending and about to crash.

That's what "consultation" is for. We need independent confirmation by others, preferably others who are not subordinate to us or trying to please us, or selected as friends because they always seem "agreeable" - ie, agree with us whether we're right or not. One of the strengths of "diversity" is that a diverse group doesn't share the same blind spots. So when that hand goes up, even though that person is "obviously wrong", we need to pay attention, because maybe our "obviously" unit is broken. It happens a lot, it turns out, to all of us.

I have an entire book titled " Why do smart people do dumb things?". It's a good thought. Getting caught up in the herd stampede is often one of the wrong things to do, even though we've been genetically selected from those who did listen when the herd detected a predator coming that we had missed. The impulse to go with the herd is "hard-wired" into our DNA now, and hard to even detect, let alone block.

This is well known in stage magic, which my dad taught me. Even if some guy in the third row sees what you're doing, if no one around him believes him, he will actually "un-see it", and by a few minutes later will have forgotten he ever thought he saw it, even though the videotape shows him seeing it, and asking people around him if they saw "it".

Well, I said at the front that there were two items where what went around came around - or where efforts to discriminate against and exploit poor people turned out to come back and bite us. My point is, those aren't unusual events, and don't require "God to see what we did." -- those are "system effects" in a small world.

Throwing out the concept "God" and being "scientific" does not remove our ultimate accountability for our own actions. We are still in our own prop-wash, and need to adjust to that fact of life. We are not finally free to exploit our neighbors or even distant lands with impunity, and no "terrorist" or "God" is required to bring the deeds of our hands back into our lives, often with amplification.

The bogus mortgage scam is one. The other is the concept that we can deny some people health care, and "get a way with it" or even "be further ahead because of it." Obviously, that is the unspoken assumption -- that the fate of "them" over "there" is completely distinct from the fate of "us" over "here."

The lessons of small-world systems thinking is "Not!". We're in the same lifeboat, and look identical to invading viruses and bacteria, that we have much more to fear from than "immigrants". In the US alone, it's now estimated that over 75 million people go without "health insurance" each year.

Actually "insurance" is a bogus concept and not necessary to the equation, and only muddies the water with middle-men concepts and fragmented thinking. So let's be clear. About a third of the US population has primary care health problems that could be taken care of, that should be, but aren't, each year. This number is rising, inexorably.

God may or may not "see", but viruses and bacteria and other bad things can detect "lunch" when they see it, as well as predatory corporations like Tobacco or Alcohol can. And, given air travel, our own "backyard" now includes most of the globe. Diseases that find a portal into our world through the poverty in India or China can result in deaths from disease here in the USA in under 48 hours. It's a very small world to viruses as well, who get to ride international flights, first-class for free.

But when they get here, where will they gain a foothold? Hmm. Maybe they can start in the sections of our towns where we let people get ill or die, more or less abandoned, because "there's nothing we can do?"

A while back I reported on the lady who died slowly, screaming in pain, on the floor of the King hospital in LA. , while everyone stepped over her and the janitor mopped up the blood she was vomiting. We do have a culture capable of doing that, of not seeing, on so many scales.
( A Patient Dies in Los Angeles - System Views. May 20 2007)

Well, the scale has just moved up one more level in LA, as that hospital failed inspection and was closed this week - removing the only hospital for miles around for poor people in that area, replacing poor care with none at all.

Los Angeles Hospital to Close after Failing Tests and Losing Financing.
New York Times
Aug 11, 2007
Jennifer Steinhauer and Regan Morris

Excerpts:

LOS ANGELES, Aug. 10 — Martin Luther King Jr.-Harbor Hospital, built in the aftermath of the Watts riots and one of the few hospitals serving the poorest residents of South Los Angeles, is headed for closing after federal regulators found Friday that it was unable to meet minimum standards for patient care.

At a news conference Friday, county officials said the hospital would probably close within two weeks, after patients were moved to other hospitals. All 911 calls will direct ambulances to one of the nine other hospitals in South Los Angeles. An urgent care center will operate on the site 16 hours a day.

he loss of the hospital for residents of the Watts/Willowbrook area of Los Angeles.

“They are going to be left without a safety net for health care,” said Janice Hahn, a Los Angeles city councilwoman whose district includes Watts. “There will be no trauma care, no emergency care and a lack of the basic services this community needs and deserves.”

Nearly since its opening 35 years ago in Willowbrook in South Los Angeles, the center has been a symbol of both the political neglect of South Los Angeles and its struggle to emerge from blight.

It pointed to many successes — it was once a teaching hospital for the nearby Charles R. Drew University of Medicine and Science and featured a respected neurosurgery unit — and in a neighborhood riddled with gang violence and myriad health problems common to poor urban areas, it was a safety net, though an increasingly imperfect one, for the poor and uninsured. The nearest public center is several miles away, which, in an area with many poor residents without cars, means nearly inaccessible.

Debates over the hospital’s future have always been tangled in racial politics. “It is actually quite tragic that this hospital that came into existence with such high expectations now dies because of the culture of incompetence,” said Joe R. Hicks, vice president of Community Advocates Inc., a Los Angeles research group. “It suffered what has often been called the soft bigotry of low expectations, because the Board of Supervisors were aware that the hospital was being nicknamed killer king by people who lived in the neighborhood and they continued to hide the ball.”

Others echoed the criticism. “The Board of Supervisors failed to put enough money and personnel into the hospital,” said Earl Ofari Hutchinson, a Los Angeles political commentator. “And now,” he said, “we are asking the question we always ask: Where are all these people going to go?”

What's the thought here - that "these people" should just die quietly and not bother "us"?
Regardless, I'm struck by the quote referring to the "soft bigotry of low expectations", that saw problems and just kept on doing nothing , or maybe never actually really "saw"the problems, but just kept on stepping over the writhing body on the floor.

That was true of the ER staff there that night, and of the management of the hospital, and the oversight Board, and of the State of California, and of the whole United States. We continue to just keep on "stepping over the body" as if it's not there or not our concern.

At that IS of concern, because the larger scale analog to the hospital closing is the whole health care system of the USA collapsing under its own weight, like some bridge in Minnesota.

Blindness is contagious, like the measles. We have to learn how to be blind to the pain of others, but then, once we master that, we can apply that blindness to being blind across the board.

Maybe, that's not the best strategy for keeping the plane in the air. We made this mess, and we can clean it up, but first we have to come to grips with national-scale denial that there is a very serious problem.

Sunday, May 20, 2007

A Patient dies in Los Angeles - Systems Views


The LA Times reconstructed the scene today from the videotape and interviews.
Parked in the emergency room lobby in a wheelchair after police left, she fell to the floor. She lay on the linoleum, writhing in pain, for 45 minutes, as staffers worked at their desks and numerous patients looked on.

Aside from one patient who briefly checked on her condition, no one helped her. A janitor cleaned the floor around her as if she were a piece of furniture. A closed-circuit camera captured everyone's apparent indifference....

Alerted to the "disturbance" in the lobby, police stepped in — by running Rodriguez's record. They found an outstanding warrant and prepared to take her to jail. She died before she could be put into a squad car.

How Rodriguez came to die at a public hospital, without help from the many people around her, is now the subject of much public hand-wringing.
Questions are being asked of "How could this happen?"
Rodriguez's son, Edmundo, 25, said he still couldn't understand why his mother died. "It's more than negligence. I can't even think of the word."
And blame is being focused on the last person in what always proves to be a very long chain of contributing events:

David Janssen, the county's chief administrative officer,... said that the preliminary investigation suggests that the fault primarily rests with the nurse who resigned. "I think it's a tragic, tragic incident, but it's not a systemic one."
But, while legal issues of blame proceed, from the bleachers we can start an analysis of the "system factors" that all came together in this tragic result. And, as with many previous studies in errors, odds are very high that there are many more distant factors that were are work here. It is important to delve into the always-surpising world of "How could this happen?"

You can read the Times article, and start with as much information as I have, but I'll try to put it into a "systems thinking framework."

First, though, let's abandon the idea that the nurse is "to blame." Yes, she may have made an error in judgement - but that's a type of problem humans have that is fully predictable, and the collection of other people around her should have caught that and reversed that error before harm occurred. So, remove the nurse entirely from your mental picture of the scene, and just look at what else was going on, as we change the "zoom" setting on the lens and back out to larger and larger contexts.

First, an entire room of other people, patients and staff, was apparently paralyzed. We need to ask how that sort of thing happens. This brings to mind the Kitty Genovese stabbing and slow death in New York City, where hundreds of people watched from their apartments and did nothing, not even call 911. It brings to mind Stanley Milgram's famous experiments, where subjects, told by a person in a white coat to deliver electric shocks to another person, continued to do so far past the point where the other person screamed and finally went silent. It brings to mind not only "It's not my job" but also "... and the last time I intervened I was punished and told if I did it again, I'd be fired."

It seems that everyone in the room, staff and patients, had been conditioned to observe an unfolding tragedy, and sit passively by and do nothing. Hmm. Sounds like the sort of operant conditioning and behavior modification that 20 years of watching television might create.

Actually, it also sounds like a lot of people were in a burned out, depressed, helpless, hopeless state and maybe had given up trying to change the world around them, and this was just one of a hundred things around them daily that was going wrong.

It appears that the patient was Latina, overweight, and had no health insurance or regular family doctor. We might investigate bias, bias, and an entire nation that seems to stand by indifferently while 50 million residents of the US with no "coverage" try to get adequate primary medical care by swamping emergency departments. This problem is very well publicized, but the American public is too busy with other problems right now to focus on that.

On a mid-range scale, it seems that California or Los Angeles is standing by, not helping, while another hospital that attempts to help the poor sinks into debt and finally drowns.
The LA Times article points out:
The incident has brought renewed attention to King-Harbor, a long-troubled hospital formerly known as King/Drew....Over the last 3 1/2 years, King-Harbor has reeled from crisis to crisis.

Based on serious patient-care lapses, it has lost its national accreditation and federal funding. Hundreds of staff members have been disciplined and services cut.

Janssen said he was concerned that the incident would divert attention from preparing the hospital for a crucial review in six weeks that is to determine whether it can regain federal funding.

If the hospital fails, it could be forced to close.
Then what? Then what will the people in this neighborhood do for primary and emergency medical care? Drive 45 minutes to Beverly Hills? The same problem of inner city hospitals closing is visible across the US. They want to move out to the rich suburbs and focus on care for rich people with great health "coverage." Or, they have no choice, because of the perverse "unintended side effects" of demanding that they must provide emergency services to anyone who shows up, whether they can pay or not - and a national health care system that means 50 million people can't pay. The public hospitals and all the caring staff in them are being burned out, gutted, and deleted.

One of the roles of the field of "Public Health" is to hold up such uncomfortable mirrors, stop focusing entirely on how to repair gunshot wounds in the Emergency Room, or how to get faster ambulance dispatch, and start asking why so many people are getting shot in the first place.

Yes, in this case a nurse resigned. But, in many ways, it appears that she was a victim too, and likely a person who went into nursing because she really wanted to help, and tried to help, and just finally ran out of the ability to cope with the job that society had created for her. Day after day, night after night, social tragedies that could at best be patched and sent back out into the world to be damaged again and return again. I doubt that she started as a mean or uncaring person. How many hours had she been on duty? How was she coping with the fact that even this job looked like it would evaporate soon? What else was going on that she needed to attend to?

No, I don't think that removing this single person will "fix" this problem and stop such things from ever happening again in this hospital or in Los Angeles or in the USA.

How can people just look the other way? It's baffling.

But, now that we've all seen this larger issue squirming in pain on the floor, and feel helpless to do anything about it, it must be time to shake our heads in disbelief at "those people", and go see what else is on TV.

I'm not trying to be mean - only to illustrate that this problem of being overwhelmed with other people's problems is not some local thing that only happens in this hospital ER in LA. That doesn't make it less of a problem - it makes it more of a problem.

When a whole nation says "there's nothing we can do..." it's right, but it's wrong.


Article: Tale of last 90 minutes of Woman's Life,
By Charles Ornstein
Los Angeles Times
May 20, 2007

The Future of Emergency Care in the US Health System
Institute of Medicine, June 2006

Crisis Seen in Nation's ER Care
The Washington Post (registration required)
June 15, 2006
Emergency medical care in the United States is on the verge of collapse, with the nation's declining number of emergency rooms dangerously overcrowded and often unable to provide the expertise needed to treat seriously ill people in a safe and efficient manner
Emergency Medical System in Crisis, USA
Medical News Today

Emergency Care - A system in crisis
Journal Watch

Kellerman AL. Crisis in the emergency department. N Engl J Med 2006 Sep 28; 355:1300-3.

Photo credit: In the Emergency Room by ebilflindas

Sunday, February 04, 2007

South Dakota hospital gets $400 million gift

Global competition for pediatrics business increases:

From today's New York Times
Hopes Soar after Record Hospital Gift of $400 Million

by Stephanie Strom

excerpt:

Now, T. Denny Sanford, a low-key billionaire who made his home and fortune here, will help sustain the state’s economic boom with a $400 million gift to the Sioux Valley Hospitals and Health System, the state’s largest employer. Hospital officials hope the gift — the largest ever to a hospital, according to the Center for Philanthropy at Indiana University — will help transform Sioux Valley Hospitals, which will change its name to Sanford Health, into a national institution that will eclipse Johns Hopkins and the Mayo Clinic.

“He told me he doesn’t want this to be just another Mayo,” said Kelby K. Krabbenhoft, Sioux Valley’s chief executive.

It has four stated goals: to build five pediatric clinics around the country; to expand research, especially in pediatrics; to build a health care campus with more than 20 separate facilities, and to identify a promising line of medical research and follow it to a cure, much the same way John D. Rockefeller’s money found a cure for yellow fever and Bill Gates is searching for a cure for H.I.V./AIDS.