Docs in charge
Putting the control of a health system back in the hands of the physicians -- as Carilion Health System in Roanoke, Va., intends to do -- makes perfectly good business logic ("Putting on a clinic in Va.," June 26, p. 6).
Decisionmaking in most large health systems moves at glacial speed and rarely has support from a majority of the medical staff. Without physician leaders at the helm, there cannot be an alignment of goals; with that said the community should have input at the board level. The political characteristics of a voluntary medical staff will transform into a collective collaborative voice so long as rules and systems are in place that create equity, fairness and consistent decisionmaking.
Had the industry moved in this direction a decade ago we would not have the many for-profit niche players that now plague the industry. David Disbrow Administrator Pain Management Center Cleveland Clinic Foundation Transparency is everyone's job
Pain Management Center
Cleveland Clinic Foundation
Transparency is everyone's job
I agree generally with Richard Clarke's opinions about transparency, but I would have preferred to see more emphasis on insurance companies' important role as a provider of information for consumers ("The real price of transparency," June 19, p. 34).
While providers work diligently to answer patients' questions and provide cost estimates for needed healthcare services, going to a specific provider for this information only gives the consumer information about one provider. Insurance companies, on the other hand, are in a position to provide cost-estimation tools and consultation that would allow patients to compare one provider with another based upon the consumer's specific insurance plan coverage and the insurance company's contracted rates.
Providing cost estimates to patients is not a controversial issue for hospitals. Most hospitals readily assist patients and supply the best information they have regarding the cost of anticipated healthcare services. The issue is whether or not "public posting" of prices is of benefit to consumers. However, posting a price does not provide the complete financial picture to an insured consumer because it may differ from the insurance company's negotiated price. Likewise, the posted price may not reflect applicable discounts to any individual uninsured consumer.
Ultimately, any movement toward greater transparency should result in meaningful information for a broad base of consumers-most of whom have insurance. Elaine Anderson Senior vice president and chief compliance officer Texas Health Resources Arlington
Senior vice president and
chief compliance officer
Texas Health Resources
Something else that Thomas Frist Jr. and his dad should get credit for is creating a whole new breed of hospital administrators who could balance the complex business side of healthcare with patients' demand for good, compassionate care ("Father figures," June 19, p. 6).
I worked at HCA's Henrico Doctors' Hospital in Richmond, Va., and at an HCA division for 13 years as a marketing director before making the jump to operations six years ago. Frist and his dad never spoke about smart business management without also emphasizing the need for quality, patient-centered care. From bottom line to patient satisfaction, they insisted on a balance of both from their hospital chief executive officers.
The elder Frist once told me that he and his son started the company because he was tired of his patients not getting good care when they were in the hospital. I found this commitment to both disciplines of hospital management to be very much in demand when I began interviewing for CEO positions at not-for-profit hospitals.
I learned well, thanks in part to the Frists. John Mitchell President and chief executive officer Grays Harbor Community Hospital Aberdeen, Wash.
President and chief executive officer
Grays Harbor Community Hospital
Right on the JCAHO
Congratulations to Neil McLaughlin for his editorial on the Joint Commission on Accreditation of Healthcare Organizations ("A JCAHO for patients," June 12, p. 19). He echoes the perspective of a great number of healthcare executives and providers. The JCAHO has not been a "patients' thing" for many years.
As McLaughlin writes, the JCAHO needs a radical restructuring. I would add that oversight on some level is also part of that equation. In an article in your June 5 edition, Dennis O'Leary states that if he were going into the hospital, "I would bring someone with me and have them stay the night, and I would always be asking questions" ("O'Leary's legacy," p. 8). He adds that he knows he would be vulnerable as a patient and needs to protect himself against caregivers who might "unintentionally harm me."
This comment comes from the head of an organization charged by a federal agency to oversee the safety of the public and improve the well-being of the U.S. healthcare system. It seems that even O'Leary might not recognize the mission of his own organization or is woefully admitting that it is inept when it comes to overseeing the nation's healthcare providers.
McLaughlin is also right that the Joint Commission has a wonderful opportunity in O'Leary's departure to peel back the camouflage and return to the perspective that matters -- the patient's. But can that be accomplished without some kind of oversight of the JCAHO if it remains the sole organization with deeming status from the CMS? Perhaps the door should be opened to allow more competition to the JCAHO, giving providers a choice in determining their credentialing body. Choice creates an incentive for the JCAHO to develop a more independent credentialing body and less need to exude the bully-on-the-block mentality.
In consideration of complete disclosure, my company competes with the Joint Commission in a niche business of the healthcare industry, but the playing field is anything but level. I have a personal agenda here as I would like to see the JCAHO have to tighten the integrity belt like the rest of us. But even on that personal level, it still comes back to being a "patients' thing." If you need any more members of the choir, just sign me up! Colleen Mills Chief executive officer Staffing Accreditation Standards Wichita Falls, Texas
Chief executive officer
Staffing Accreditation Standards
Wichita Falls, TexasKudos
Thanks to Jessica Zigmond for her recent articles on rural hospitals. Her work has been balanced, informative and well-written. We've recommended and referenced your articles to rural health providers and small hospitals throughout the country. Keep up the good work! Terry Hill Executive director Rural Health Resource Center Duluth, Minn.
Rural Health Resource Center
The complexity of charity ...
T he recent discussion over what constitutes "community benefit" is interesting but worrisome ("Charitable intentions," June 5, p. 6). I went through what our answers would have been to the Internal Revenue Service compliance questionnaire, even though my system was not among those sent letters. I was interested to see what might be required of us if we were queried. I also reviewed the new Catholic Health Association/VHA commun-ity-benefit guidelines. I respect the current efforts and thank those who have worked to create the current proposals. But a formulaic approach misses a lot of "benefits."
The CHA suggests that Medicare shortfalls and bad debt should not be counted as part of community benefit. I beg to differ. Where I work, at Adena Health System, we provide services to five of the 10 poorest counties in Ohio. Not everyone qualifies for medical assistance from the federal or state governments, but that doesn't mean that all of those who don't can afford to pay their medical bills. While we extend our charitable assistance to individuals above the poverty line, this still fails to meet the total need for the community we serve. Since every provider's markup on cost is different, the only way to measure the real loss on providing care is to use cost. Thus the cost of providing care to uninsured patients needs to be measured net of any reimbursement received and the shortfall recognized as a benefit to the community.
If you are unwilling to accept all of the bad debt as a benefit, then any excess over an average level of loss might be considered. But to assume that an accounting treatment of an account balance prohibits the loss from being included in a report on the value a healthcare system provides misses the important point that we do not extend credit and take all persons without regard to their ability to pay.
I think that healthcare lost an important credential when it permitted accountants to move bad debts from a deduction from gross revenue to an expense. Generally, hospitals are not "credit extenders" as commercial enterprises are.
The situation is similar for Medicare. It doesn't pay the full cost of care for all patients. Depending on your service mix, a provider may provide care at less than cost, regardless of their efficiency in providing services. At my system we have a medical-service-oriented patient mix. It was no surprise to me, and should not have been to anyone else, that certain services provided an opportunity to reap a profit from Medicare. It is also not surprising that providers currently enjoying a mix weighted toward surgery would want to postpone the proposed change to severity-adjusted DRGs. Again, I think that the shortfall should be included in any calculation of "community benefit."
Adena employs approximately 75 full-time physicians in order to provide service and access for patients. We would not be able to recruit and retain these physicians without compensation that was competitive at a national level. This requires some level of subsidy. Without the losses incurred on that side of the system, we would not be able to provide specialty services. While we are doing well financially and intend to strengthen our services provided to the community, without a strong commitment to our mission, the area we serve would be without some essential services. Is that important? Only in areas like south central Ohio where public transportation is practically nonexistent.
Adena is a survivor among inpatient psychiatric service providers. As other systems reduce or eliminate this service, Adena has reaffirmed that this is a need that should be met locally. Self-pay patients pay virtually nothing toward their care and local mental-health services manage their limited funds by directing some patients to us.
I know that Adena is not alone is this. There are systems, such as Appalachian Regional Healthcare in Lexington, Ky., that also cover poor sections of the county. But rich or poor, it is important to recognize that not all communities are created equal and that the value of a local provider is often greater than the sum of some general ledger accounts. Ralph Sorrell Sr. Chief financial officer Adena Health System Chillicothe, Ohio
Ralph Sorrell Sr.
Chief financial officer
Adena Health System
... can't be overstated
I am utterly astounded and dismayed with the lack of understanding and naivete revealed in your article on charity care by notables such as the president of the Catholic Health Association, VHA officials, a professor of healthcare management at Harvard and member of the Medicare Payment Advisory Commission, and a senior investigator for the Public Health Institute, not to mention your reporter.
I would have thought that people in these positions would have a little more insight into the community benefit provided by hospitals all across this country. Since they do not, here are a few simple facts.
Bad debt and charity care both amount to care being rendered to patients without payment. Anyone remotely familiar with hospital operations would understand that there is no easy way to distinguish between bad debt and charity. For the most part those unlucky patients who are not insured and cannot pay their hospital bills are charity-care beneficiaries, whether they are identified upfront as such or not. You know they can't afford to pay, or you find that out soon after the matter is turned over to a collection agency because they have not responded. To simply say that the latter are patients who could pay but choose not to underscores a complete ignorance of the plight of the uninsured and poor.
Medicare doesn't pay all hospitals the same even though it is a federal program! There, the big secret is out. To suggest that if Medicare payment rates are below cost it means the hospital is inefficient betrays an amazing lack of awareness of Medicare payment programs.
While I would agree that there is much wrong with healthcare financing mechanisms and that the cost of healthcare is a growing concern for every part of the healthcare system, there is no doubt that the typical not-for-profit hospital is providing a great deal of benefit to its community. Walter Winkler Chief financial officer Keokuk (Iowa) Area Hospital
Chief financial officer
Keokuk (Iowa) Area Hospital
What do you think?
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