“At no point during the campaign or since the inauguration has Trump articulated any kind of clear vision for how to improve health care. There is no unifying theme around his pronouncements, such as the promotion of a market-driven system. Instead, he makes vague statements about how the ACA is a disaster, without specifying with facts what he means with his criticisms, and then promises that he will deliver a better plan without describing in any way exactly how he will do it….
Instead of pushing McConnell to pass whatever can get 50 Republican votes in the Senate, Trump and his aides should regroup and do the hard work that should have been done months and even years ago to come up with a more plausible approach to health reform. The goal should be to develop a plan built more on market principles than on government control and regulation, and which can garner support from most Republicans, and some Democrats too. Such a plan would necessarily be more incremental than a plan written just by GOP members, and it would roll back less of the ACA than many Republicans would like to see occur. But it would also be far less controversial than the various versions of repeal and replace that have been assembled so far this year, and thus also more likely to survive when political control inevitably shifts again…. (A)

“Don’t tell President Trump, but cutting off extra Obamacare subsidies to insurers could actually improve – not ignite – the very insurance marketplaces he wants to undermine.
Weirdly enough, slightly more people – not fewer — could receive health insurance by 2020 were the president to terminate the controversial cost-sharing payments, otherwise known as CSRs, which compensate insurers for discounts they must offer their lowest-income customers.
That’s the rather unconventional conclusion the Congressional Budget Office came to last week after analyzing the effect on the Obamacare marketplaces should the president eliminate the monthly subsidy payments, as he’s repeatedly threatened to do over the past few weeks (to the chagrin of some Republicans in Congress). And perhaps this is one CBO report that the Trump administration could like. (B)

“When Senator Robert Menendez of New Jersey goes on trial on federal corruption charges in less than three weeks, far more than his own fate hinges on the outcome.
If Mr. Menendez, a Democrat, is convicted and then expelled from the United States Senate by early January, his replacement would be picked by Gov. Chris Christie, the Republican governor of New Jersey and an ally of President Trump.
That scenario — where Mr. Menendez’s interim replacement would more than likely be a Republican — would have immediate and far-reaching implications: The Republicans would be gifted a crucial extra vote just as the party remains a single vote shy in the Senate of advancing its bill to dismantle President Obama’s signature health care law. Those potential consequences only heighten the drama around the first federal bribery charges leveled against a sitting senator in a generation. (C)

“Unlike the double-digit percentage rate hikes individuals purchasing coverage under the Affordable Care Act will see next year, those with coverage at large employers will face single-digit increases, a new national survey of large employers shows….
Large employers face 5% health care cost increases for 2018, according to the National Business Group on Health annual Health Care Strategy and Plan Design Survey.
Though employer and worker premiums are still rising two to three times the rate of general inflation, the percentage increase won’t come close to the premium increases Americans are expected to face should they seek ACA-compliant coverage this fall for 2018. ACA-compliant Obamacare plans are submitting rate hikes of 25% or higher thanks in part to the Donald Trump White House’s inability to commit to signing off on cost-sharing reductions for low-income purchasers of subsidized Obamacare policies.
Employers say they are thankfully immune from the issues plaguing the ACA’s unstable individual market and its risk pools of sick patients whose costs far outweigh the number of healthy Americans signing up. To pay sick patient claims, premiums are jumping dramatically in the individual market.
But the employer market has remained stable.” (D)

“…Before I go into details, here are some bullet points of my findings.
For a broad spectrum of middle-aged persons in the middle class, premiums for even the cheapest bronze policy today are, in a majority of rating areas examined, so expensive that people are formally exempt from the individual mandate.
For people age 60 and earning about 450% of the federal poverty level, premiums today for the second lowest silver plan are unaffordable in a majority of rating areas studied. This is true using both metrics employed here to determine affordability.
In 2018, assuming premiums rise 20% as is frequently forecast, the situation becomes much worse for the middled-aged, middle class. Among persons age 50 and earning 500% of the federal poverty level, for example, people will be exempt from the individual mandate in 73% of rating areas studied. This is so because even the cheapest bronze policy will cost more than 8% of their income. And in about 30% of the rating areas, prices for the second lowest silver plan will be so high, that persons of this age and income will have to pay more than 1.5 times the amount they would have been required to pay for the same policy if they received even the smallest subsidy from the federal government. (E)

“Most enrollees in the marketplaces (84%) receive a tax credit to lower their premium and these enrollees will be protected from premium increases, though they may need to switch plans in order to take full advantage of the tax credit. The premium tax credit caps how much a person or family must spend on the benchmark plan in their area at a certain percentage of their income. For this reason, in 2017, a single adult making $30,000 per year would pay about $207 per month for the second-lowest-silver plan, regardless of the sticker price (unless their unsubsidized premium was less than $207 per month). If this person enrolls in the second lowest-cost silver plan is in 2018 as well, he or she will pay slightly less (the after-tax credit payment for a similar person in 2018 will be $201 per month, or a decrease of 2.9%). Enrollees can use their tax credits in any marketplace plan. So, because tax credits rise with the increase in benchmark premiums, enrollees are cushioned from the effect of premium hikes. (F)

“Senate Majority Leader Mitch McConnell (R-Ky.) acknowledged Monday that Congress’s next steps on healthcare are unclear after Republicans failed to repeal ObamaCare….
McConnell added that lawmakers were “going to see” what negotiations between Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), the top two members of the Senate’s healthcare committee, aimed at stabilizing the individual health insurance market could produce.
“We have … collapsing individual insurance markets around the country. Requests to continue to subsidize the insurance companies. It’s a pretty controversial subject to subsidize insurance companies without any reforms,” the GOP senator said.
He added that Democrats “have been pretty uninterested in any reforms,” but the two parties will need to try to negotiate when they get back to Washington next month.
“So when we get back after Labor Day we’ll have to sit down and talk to them and see … what the way forward might be,” he said.” (G)

“The Senate health committee will hold two hearings early next month on how the nation’s individual health insurance marketplaces can be stabilized, as party leaders grasp for a fresh path following the collapse of the Republican effort to repeal and replace much of former President Barack Obama’s health care law.
GOP and Democratic leaders are exploring whether they can craft a bipartisan but limited bill aimed at curbing rising premiums for people who buy their own insurance. In many markets, consumers are seeing steeply rising premiums and fewer insurers willing to sell policies.” (H)

“Democrats are ready to go on the health care offensive. And Sen. Brian Schatz (D-HI) may have a new plan for them to do it.
In an interview with Vox, Schatz revealed that he’s preparing a new bill that could grant more Americans the opportunity to enroll in Medicaid by giving states the option to offer a “buy-in” to the government program on Obamacare’s exchanges.
His proposal would expand the public health insurance program from one that covers only low-income Americans to one open to anyone seeking coverage, depending on what each state does. The idea is similar to the government-run “public option” that some Democrats advocated for during the battle over the Affordable Care Act’s passage.” (I)

The new (Republican) concept, sponsored by Senators Bill Cassidy and Lindsey Graham, would redirect current Obamacare spending to the states, giving each state legislature significant flexibility in how the dollars are spent, so long as it’s on healthcare.
The bill is an amendment to the Senate’s initial repeal bill, the Better Care Reconciliation Act, and it would also repeal the employer and individual mandates, but keep the rule requiring insurers to cover pre-existing conditions. It would cut subsidies and Medicaid expansion and direct the money to the states to use as they see fit.
Cassidy, a physician, says the plan returns power to the states. But the amendment wouldn’t necessarily benefit each state equally. Funding equations would be based on poverty, density and income, and as with any healthcare policy, some consumers would likely benefit from the Cassidy/Graham plan, and others would be worse off. (J)

“The relationship between President Trump and Senator Mitch McConnell, the majority leader, has disintegrated to the point that they have not spoken to each other in weeks, and Mr. McConnell has privately expressed uncertainty that Mr. Trump will be able to salvage his administration after a series of summer crises.” (K)

* http://www.businessinsider.com/trump-tried-to-trade-a-gop-healthcare-vote-for-a-ride-on-air-force-one-2017-8

(A) Trump deserves much of the blame on health care, by James C. Capretta, http://www.aei.org/publication/trump-deserves-much-of-the-blame-on-health-care/
(B) The Health 202: Trump’s plan to harm Obamacare would actually help it, by Paige Winfield Cunningham, https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2017/08/22/the-health-202-trump-s-plan-to-harm-obamacare-would-actually-help-it/599b077f30fb0435b8208f43/?utm_term=.ad1c6e43d3c6
(C) At Senator Menendez’s Trial, Stakes Are High for Democrats, by By SHANE GOLDMACHER, https://www.nytimes.com/2017/08/17/nyregion/senator-robert-menendez-trial.html?smprod=nytcore-iphone&smid=nytcore-iphone-share&_r=0
(D) Employers Will Escape Obamacare-Sized Rate Hikes In 2018, by Bruce Japsen , https://www.forbes.com/sites/brucejapsen/2017/08/08/employers-will-escape-obamacare-sized-rate-hikes-in-2018/#107a0e8f30c5
(E) New Research Shows Many In Middle-Aged, Middle Class Can’t Afford ACA Policies in 2018, by Seth Chandler Seth Chandler, https://www.forbes.com/sites/theapothecary/2017/08/17/new-research-shows-many-in-middle-aged-middle-class-cant-afford-aca-policies-in-2018/#1c4cbc0c461f
(F) An Early Look at 2018 Premium Changes and Insurer Participation on ACA Exchanges, by Rabah Kamal, Cynthia Cox, Care Shoaibi, Brian Kaplun, Ashley Semanskee, and Larry Levitt, http://www.kff.org/health-reform/issue-brief/an-early-look-at-2018-premium-changes-and-insurer-participation-on-aca-exchanges/
(G) McConnell: Path on healthcare ‘murky’, by JORDAIN CARNEY, http://thehill.com/blogs/floor-action/senate/347373-mcconnell-path-on-healthcare-murky
(H) Senate panel plans 2 hearings on girding health insurance, by ALAN FRAM, http://abcnews.go.com/Health/wireStory/senate-panel-plans-hearings-girding-health-insurance-49356269
(I) Exclusive: Sen. Schatz’s new health care idea could be the Democratic Party’s future, updated by Sarah Kliff and Jeff Stein, https://www.vox.com/policy-and-politics/2017/8/22/16171160/schatz-health-care-medicaid
(J) New Obamacare Repeal Bill Returns Power to States, But Will It Pass?, by Alex Tolbert, http://www.huffingtonpost.com/entry/new-obamacare-repeal-bill-returns-power-to-states-but_us_599c269ce4b0ac90f2cba9bc
(K) McConnell, in Private, Doubts if Trump Can Save Presidency, by ALEXANDER BURNS and JONATHAN MARTIN, https://www.nytimes.com/2017/08/22/us/politics/mitch-mcconnell-trump.html?ribbon-ad-idx=4&rref=world&smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=0&module=ArrowsNav&contentCollection=Politics&action=swipe&region=FixedRight&pgtype=article

Recently after a doctor’s appointment I went to a nearby lab to have blood drawn for routine tests. I asked the phlebotomist to wash her hands to which she replied she already had. She had washed her hands in another room after the last patient, done some other work, come into the room, put gloves on, then went and used a shared computer*, before finally drawing blood. When I asked, she refused to wash her hands in front of me. So I refused to let her proceed. The same with the second tech. Finally the third washed her hands correctly in front of me.

“Most patients wouldn’t dare to ask their doctor to wash his or her hands..” It’s a simple enough request, but for patients and families who feel vulnerable, scared or uncomfortable in a hospital room, the subject can be too intimidating to even bring up with a doctor or nurse…” (A)

Some hospitals post signs in each examination room encouraging patients to be vigilant about doctor hand-washing; one even gives patients a card stating “Your care provider should clean their hands: 1) Before contact with you; 2) Before a procedure; 3) After a procedure; and 4) After contact with you.” (B)

Some background on Hospital Acquired Infections:

Hospital infections affect almost two million people in the United States every year, 100,000 of whom die. Up to 70 percent of these infections could be prevented if health care workers follow recommended protocols, which include hand hygiene. (C)

“…this sobering truth. When bacteria lurking on, for instance, a medical device, a bed rail, a bandage or a caregiver’s hands find their way into a patient’s body via a surgical wound, a catheter, a ventilator, or some invasive procedure, the disturbingly frequent result is a serious, sometimes devastating, infection.” (D)

“Hospital-acquired infections (HAI) cost $9.8 billion per year, with surgical site infections alone accounting for one-third of those costs, followed closely by ventilator-associated pneumonia at 31.6 percent….” (E)

“Hands are the most common vehicle for transmission of organisms and “hand hygiene” is the single most effective means of preventing the horizontal transmission of infections among hospital patients and health care personnel. “ (F) (G)

Protect yourself! Start by asking your doctor, nurse, phlebotomist, physical therapist and others –

DID YOU WASH YOUR HANDS? 

* “It turns out that your computer keyboard could put a host of potentially harmful bacteria — including E. coli and staph — quite literally at your fingertips.” (H) “A study… suggests that dangerous bacteria may be spread by health care workers’ clothing.” (I)

(A)    Why Hospitals Want Patients to Ask Doctors, ‘Have You Washed Your Hands?’ by Laura Landro  http://online.wsj.com/news/articles/SB10001424052702303918804579107202360565642?KEYWORDS=hospital&mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052702303918804579107202360565642.html%3FKEYWORDS%3Dhospital

(B)   It’s okay to ask your doctor: “Did you wash your hands?”, by Paul Taylor, http://healthydebate.ca/personal-health-navigator/okay-ask-doctor-wash-hands

(C)   Hand Washing Stops Infections, So Why Do Health Care Workers Skip It? ,  by Sanjay Saint, http://labblog.uofmhealth.org/industry-dx/hand-washing-stops-infections-so-why-do-health-care-workers-skip-it

(D)   What Zero Looks Like: Eliminating Hospital-Acquired Infections, http://www.ihi.org/resources/Pages/ImprovementStories/WhatZeroLooksLikeEliminatingHospitalAcquiredInfections.aspx

(E)    Hospital-acquired infections rack up $9.8B a year, by Julie Bird, http://www.fiercehealthcare.com/healthcare/hospital-acquired-infections-rack-up-9-8b-a-year

(F)    Guidelines for prevention of hospital acquired infections, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963198/

(G)  Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene, http://www.jstor.org/stable/10.1086/677145

(H)   How dirty is your Qwerty? by Dan Childs   http://abcnews.go.com/Health/Germs/story?id=4774746&page=1

(I)     Do white coats, scrubs, stethoscopes, cell phones and computer keyboards collect dangerous hospital germs?, by Joe Graedon, https://www.peoplespharmacy.com/2016/11/03/are-doctors-and-nurses-transporting-deadly-hospital-germs/

I just got an urgent cold call from a Financial Advisor recommending I buy warrants  in UBER since it is about to announce the opening of  a system of  “gig” urgi-care, UBER HEALTH.

You will be able to get a doctor to make a house call within ten minutes using a new UBER HEALTH APP. . If the doctor prescribes an MRI an imaging van will be sent to your house within one hour. Read by a radiologist somewhere in the ethernet.

There will be surge pricing and competition from LYFTparamedic.

Further research disclosed:

IBM WATSON DX will enable you to self-diagnose your health problems and treatment plans through secret proprietary algorithms, while the doctor is on the way.

APPLE MEDICAL SCHOOL will have virtual clinical rotations in medicine, pediatrics, surgery and obs/gyn, where students will deliver virtual babies.

WALMART HOSPITALS will become the anchor hospitals in many communities, right across from Walmart stores.

BLACKROCKdoc will employ 75% of physicians, with practice purchases funded by creating clinical derivatives.

AMAZONrx will dominate the mail order prescription medicine market.

MICROSOFTcare will capture 50% of the health insurance market driving Aetna, United and the Blue Cross plans out of business.

YAHOOlitigator will be do malpractice trolling akin to reverse mortgages.

To quote President Trump “nobody knew that healthcare could be so complicated”…

So I am going to sell all these stocks short.

About twenty years ago as President of LibertyHealth each of our hospitals (a medical school affiliated teaching hospital and two community hospitals) had an ICU. I was always concerned that sometimes patient acuity in one of the community hospital ICUs might have exceeded its capability and pushed for clear clinical threshholds for patient transfer to the teaching hospital ICU.
Which brings me to Congressman Scalise…
“A lone gunman who was said to be distraught over President Trump’s election opened fire on members of the Republican congressional baseball team at a practice field in this Washington suburb on Wednesday, using a rifle to shower the field with bullets that struck four people, including Steve Scalise, the majority whip of the House of Representatives.”
“His injuries are extensive, and he was in critical condition Wednesday night, MedStar Washington Hospital Center said in a statement. As the bullet traveled across his body, it broke bones, tore up internal organs and caused major internal bleeding.
Doctors operated immediately, but additional surgery is required, the hospital said.” (A)

Mr. Scalise underwent several surgeries last month, and his condition improved from critical to fair. However, hospital officials on Wednesday said he was moved back to the ICU. Mr. Scalise had another surgery Thursday to manage infection and is now in serious condition, according to the report.
Soon after his rehospitalization, attention shifted toward Washington Hospital Center’s publicly available grades for patient safety and care quality. The Leapfrog Group gave Washington Hospital Center a D in hospital safety ratings for 2016, and CMS’ Hospital Compare website shows the hospital earned 2 out of 5 stars in the most recent update.
“[I]nfections [at the hospital] are a pattern and a serious one,” Leapfrog Group CEO Leah Binder told USA Today. “They are significantly below the national average in four out of five areas that we have data, which suggests an inability to prevent infections.” (B)

a little old (2014)
“Staff at the region’s largest private hospital — MedStar Washington Hospital Center — have given it consistently low marks in key areas of patient safety over the past four years, according to results released Friday.
Although doctors’, nurses’ and administrators’ perception of patient safety has improved during that time — in some cases significantly — the hospital scores below the national average in seven out of 12 patient safety measures in key areas, including the overall perception of safety at the hospital and the ability of staff to report mistakes without fear of punishment.”

June, 2017
“Like many other hospitals across the country, MedStar Washington Hospital Center has been experiencing the financial impact of numerous changes in health care,” the statement from MedStar said. That has included the nationwide nursing shortage that forced the health system to use agency nurses to fill critical positions, as well as “inflationary pressures” that have driven up costs of pharmaceuticals and medical supplies.
MedStar officials also pointed to investments in the last year that have required additional staff, such as the creation of a Sepsis Response Team and the Behavioral Emergency Response Team, that have impacted the budget. The health system saw positive effects from those investments, such as reductions in hospital-acquired infections, and it intends to leave those teams intact, officials said. (C)

So I would be digging deeper…..but understand this can be quite frustrating
The U.S. News analysis of hospitals includes data from nearly 5,000 centers across multiple clinical specialties, procedures and conditions. Scores are based on a variety of patient outcome and care-related factors, such as patient safety and nurse staffing. Hospitals are ranked nationally in specialties and regionally in states and major metro areas. U.S. News assigns a rating to hospitals in a handful of common procedures and conditions, including hip replacement and COPD. This hospital achieved the highest rating possible in 5 procedures or conditions.
To see the U.S. News rankings of MWHC highlight and click on http://health.usnews.com/best-hospitals/area/dc/medstar-washington-hospital-center-6330120

The information on Hospital Compare:
Helps you make decisions about where you get your health care
Encourages hospitals to improve the quality of care they provide
In an emergency, you should go to the nearest hospital. When you can plan ahead, discuss the information you find here with your health care provider to decide which hospital will best meet your health care needs.
To see Hospital Compare’s ratings of MWHC highlight and click on https://www.medicare.gov/hospitalcompare/profile.html#profTab=0&ID=090011&loc=WASHINGTON%2C%20DC&lat=38.8951118&lng=-77.0363658&name=MEDSTAR%20WASHINGTON%20HOSPITAL%20CENTER&Distn=3.3

Completed by more than 1,800 hospitals annually, the flagship Leapfrog Hospital Survey collects safety, quality, and resource use information you can’t find anywhere else. We report on the issues that matter to patients and purchasers—from maternity care and surgical outcomes, to handwashing policies and nursing standards.
To see Leapfrog’s report on MWHC highlight and click on
http://www.thehoya.com/medstar-safety-ranks-low/
http://www.hospitalsafetygrade.org/h/washington-hospital-center
http://www.leapfroggroup.org/hospitals/search/list/location/Washington%2C%20DC%2C%20United%20States/10

An independent, not-for-profit organization, The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.
To see JCAHO’s most recent accreditation report for MWMC highlight and click on
file:///C:/Users/Jonathan/AppData/Local/Packages/Microsoft.MicrosoftEdge_8wekyb3d8bbwe/TempState/Downloads/6308qr.pdf

whew! That’s hard work

Maybe we need to designate levels of ICUs just as we do for trauma centers and perinatal centers.
Here’s one example:

LEVELS OF INTENSIVE CARE UNITS (D)
LEVEL 1: should be capable of providing immediate resuscitation and short-term cardiorespiratory support for critically ill patients; will also have a major role in monitoring and prevention of complications in “at risk” medical and surgical patients; must be capable of providing mechanical ventilation and simple invasive cardiovascular monitoring for a period of at least several hours
LEVEL II: should be capable of providing a high standard of general intensive care, including complex multi-system life support, which supports the hospital’s delineated responsibilities; minimum of 6 beds
LEVEL III: a tertiary referral unit for intensive care patients should be capable of providing comprehensive critical care including complex multi-system life support for an indefinite period; should have a demonstrated commitment to academic education and research; All patients admitted to the unit must be referred for management to the attending intensive care specialist; all consultants are FCICMs; may have over 50 beds, should include pods of 8-15 beds
PICU: as for a Level III unit, but dedicated to the care of pateints under the age of 16 years

(A) Steve Scalise Among 4 Shot at Baseball Field; Suspect Is Dead, by Michael D. Shear et al, https://www.nytimes.com/2017/06/14/us/steve-scalise-congress-shot-alexandria-virginia.html
(B) Medstar hospital’s poor safety ratings get limelight as it treats Rep. Steve Scalise, by Mackenzie Bean, http://www.beckershospitalreview.com/quality/medstar-hospital-s-poor-safety-ratings-get-limelight-as-it-treats-rep-steve-scalise.html
(C) MedStar Washington Hospital Center gets low marks from staff on key safety issues, by Lena H. Sun, https://www.washingtonpost.com/local/medstar-washington-hospital-center-gets-low-marks-from-staff-on-key-safety-issues/2014/07/18/94f3643e-0e95-11e4-b8e5-d0de80767fc2_story.html?utm_term=.d762fccecd67
(D) ICU Design and Staffing, https://lifeinthefastlane.com/ccc/icu-design-and-staffing/

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

A little background….

I was appointed President and CEO of Jersey City Medical Center (JCMC) in 1989, one year after JCMC had been converted to not-for-profit governance after a long and colorful history as a public hospital (including bankruptcy protection from 1982 to 1985). JCMC was and still is Hudson County’s (500,000+ residents) regional referral center “safety-net” hospital.

“As defined by the Institute of Medicine, the health care safety net comprises hospitals and other providers that organize and deliver a significant level of health care and other health-related services to patients with no insurance or with Medicaid. Often referred to as providers of last resort, safety-net hospitals (SNHs) have historically assumed a major role in the provision of comprehensive services to medically and socially vulnerable populations.” (A)

When I started New Jersey Hospitals were reimbursed through an all-payor state rate-setting system for Medicare, Medicaid, and commercial insurance, which assured hospital financial stability if managed effectively.
This was coupled with a robust Certificate of Need (CN) process which rationed approval of certain tertiary care services to assure access to them throughout the state, rather than based on a hospital’s fiscal situation, since approved CNs garnered additional reimbursement in reimbursement rates.

Already the sole designated paramedic provider for the County, together rate-setting and CN allowed JCMC: to apply for and be designated as a Regional Perinatal Center (1992), Level Two Trauma Center ((1994), and Medical Coordination Center for Emergency Preparedness (2003); and build a total replacement hospital on a new site (CN approved in 1986, hospital opened in 2004) where an Open Heart Surgery CN (approved in 1999) was started. JCMC became a state approved Children’s Hospital in 2000. Along the way JCMC became LibertyHealth adding two community hospitals, Greenville and Meadowlands (which in 1996 opened a CN designated inpatient rehabilitation unit). In 1997 JCMC became a major teaching affiliate of Mount Sinai School of Medicine (now Icahn School of Medicine at Mount Sinai).

All as a safety-net hospital.

Why am I writing all this?

“Hospitals that primarily serve low-income patients could collectively lose $40 billion in funding over the next decade if the Affordable Care Act is repealed and not replaced by something comparable, according to a new analysis by America’s Essential Hospitals.
That amount represents lost coverage and cuts to Medicaid and Medicare disproportionate share hospital (DSH) funding from 2018 through 2026. The ACA called for those cuts because hospitals would have theoretically needed that funding less as more people gained coverage on the marketplaces and through Medicaid expansion.” (B)

“People with health insurance tend to think of safety-net hospitals the way airline travelers think of the bus: as a cheaper service they would use only if they had to. But without these essential hospitals — which specialize in the care of our country’s most medically and financially vulnerable, particularly the uninsured — our entire health care system would be in danger.” …
For uninsured patients, lifesaving surgeries and treatments, along with a limited recovery period, are often covered through Emergency Medicaid funds. But patients who don’t fit neatly into our medical system for reasons of health or finances or their social situation — the “medical misfits” that any one of us can become under the wrong circumstances — need far more long-term support. This is often where safety-net hospitals step in. “(C)

“Despite promises to the contrary, it will leave millions of people without health coverage, and others with only bare bones plans that will be insufficient to properly address their needs. As the nation’s medical schools and teaching hospitals see every day, people without sufficient coverage often delay getting the care they need. This can turn a manageable condition into a life-threatening and expensive emergency.” (D)

“In short, Democrats are focused on trying to maximize the number of people who have decent health insurance, and are willing to accept whatever tax increases and arrangements with health insurers and other private interests are needed to make that happen. They seek the broadest possible availability of health care, whatever the cost and political trade-offs it takes to achieve it.
Republicans are focused on trying to minimize taxes, especially on investment income, and keeping federal subsidies for health care to a minimum. They are willing to accept the wrenching consequences that attaining those goals might have for Americans’ insurance coverage, betting that lower taxes and smaller government will fuel a more vibrant economy.” (E)

(A) https://www.hcup-us.ahrq.gov/reports/statbriefs/sb213-Safety-Net-Hospitals-2014.pdf
(B) http://www.modernhealthcare.com/article/20170209/NEWS/170209902
(C) https://www.nytimes.com/2017/05/26/opinion/sunday/safety-net-hospitals-health-care.html
(D) http://www.beckershospitalreview.com/hospital-management-administration/9-organizations-react-to-senate-gop-healthcare-bill.html
(E) https://www.nytimes.com/2017/06/23/upshot/the-health-debate-shows-what-both-parties-care-about-most.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

From 1967 to 1970, during the Vietnam War, I served first as a 2nd Lieutenant and Chief Administrative Officer of the 4th Casualty Staging Flight attached to Wilford Hall USAF Medical Center, Lackland AFB in San Antonio, Texas. We received combat casualties still in battlefield bandages, often within 24 hours of injury, and either admitted them to Wilford Hall or further transported them to hospitals near home.

Here’s what hospital care looked like during the Revolutionary War period.

“When the Revolutionary War began its actual skirmishes in 1776, early attempts to prepare for the medical needs related to War were made in the City of New York. During the spring and summer of 1776, Samuel Loudon was publishing his newspaper the New York Packet, in which he included numerous articles and announcements regarding the Continental Army. On July 29, for example, came the following announcement written by Thomas Carnes, Stewart and Quartermaster to the General Hospital of King’s College, New York. Anticipating an increase demand for medically trained staff, he filed the following request for volunteers:
“GENERAL HOSPITAL New-York, July 29, 1776 Wanted immediately in the General Hospital, a number of women who can be recommended for their honesty, to act in the capacity of nurses: and a number of faithful men for the same purpose…King’s College, New York” (A)

“One of the most famous surgeons, and the first, was Cornelius Osborn. He was recruited in the Spring of 1776 and had little training even as a physician. The Continental Congress was even concerned about the well-being of the troops and the militia. They passed several ordinances and helped establish the order for the several field Hospitals during the War. The hospitals served about 20,000 men in the fight. Each hospital was required for each surgery to have at least one physician or surgeon, and one assistant, which was usually and apprentice of some sort. Each hospitals staff numbers varied on how many wounded it served and the severity of the wounds….
Most of the deaths in the Revolutionary War were from infection and illness rather than actual combat. The common practice if a limb was badly infected of fractured was amputate it. Where most amputees died of gangrene a result of not properly cleaning instruments after surgeries. Only 35% of amputees actually survived surgery. There was no pain killers quite developed back then. So at most the patient were given alcohol and a stick to bite down on while the surgeon worked. Two assistant would hold him down, a good surgeon could perform the entire process in a mere 45 seconds, after which the patient usually went into shock and fainted. This allowed the surgeon to stich up the wound, and prepare for the next amputation. Another way they decided to clean wounds, disease, or infection was by applying mercury directly to the cut of injured space, and letting it run through the blood stream which usually resulted in death.” (B)

“To seek treatment for any serious ailment, a soldier would have had to go to a hospital of sorts. Military regiments had a surgeon on staff to care for the men, so the soldier’s first stop would be with the surgeon. During battles, the surgeon could be found in a makeshift or “flying” hospital that consisted of a tent, an operating table, and some medical equipment. If the surgeon could not treat the soldier, he might be sent to a hospital. Many regimental hospitals were in nearby houses, while general hospitals for more in-depth treatment were sometimes set up in barns, churches, or other public buildings. The conditions were often cramped, which resulted in the rapid spread of contagious illnesses and infections….
Woe to the soldier who required surgery after being wounded on the battlefield! The conditions in “flying” hospitals were deplorable. Not only was the operating room simply a table in a tent, but there was little thought given to keeping the table and tools clean. In fact, wounds were sometimes cleaned using plain water from a bucket, and the used water would be saved to clean out the next soldier’s wounds as well. (C)

Hospitalization was a serious problem during the American Revolutionary War. Plans were made quite early to care for the wounded and sick, but at the best they were meager and inadequate. However on April 11, 1777 Dr. William Shippen Jr., of Philadelphia was chosen Director General of all the military hospitals for the army. Consequently the reorganization of hospital conditions took place.
Four hospital districts were created: Easter, Northern, Southern and Middle. The wage scale was as follows: Director General’s pay $6.00 a day and 9 rations; District Deputy Director $5.00 a day and 6 rations; Senior Surgeon $4.00 a day and 6 rations; Junior Surgeon $2.00 and 4 rations; Surgeon mate $1.00 and 2 rations.
After the battle of Brandywine, September 11, 1777, hospitals were established at Bethlehem, Allentown, Easton and Ephrata. After the battle of Germantown, October 4, 1777, emergency hospitals were organized at Evansburg, Trappe, Falkner Swamp and Skippack. Hospitals at Litiz and Reading were also continued. By December 1777, new hospitals were opened at Rheimstown, Warwick and Shaeferstown. Yellow Springs (now Chester Springs) an important hospital was organized under the direction of Dr. Samuel Kennedy. At Lionville, Uwchlan Quaker Meeting House was also made a hospital for a time. Apothecary General Craigie’s shop, Carlisle, was the source of hospital drugs….
It seems there was carelessness in making necessary health reports, consequently Washington ordered on January 2, 1778: “Every Monday morning regimental surgeons are to make returns to the Surgeon Gen’l. or in his absence to one of the senior surgeions, present in camp or otherwise under the immediate care of the regimental surgeons specifying the mens names Comps. Regts. and diseases.” [Weedon’s Valley Forge Orderly Book, p. 175]
January 13, 1778. “The Flying Hospitals are to be 15 feet wide and 25 feet long in the clear and the story at least 9 feet high to be covered with boards or shingles only without any dirt, windows made on each side and a chimney at one end. Two such hospitals are to be made for each brigade at or near the center and if the ground permits of it not more than 100 yards distance from the brigade.” [Weedon’s Valley Forge Orderly Book, p. 191] The Commander-in-Chief always solicitous about the comfort of his soldiers issued the following order January 15, 1778: “The Qr. Mr. Genl. is positively ordered to provide straw for the use of the troops and the surgeons to see that the sick when they are removed to huts assigned for the hospital are plentifully supplied with this article.” [Weedon’s Valley Forge Orderly Book, pp. 192-199-204-216] “ (D)

(A) https://brianaltonenmph.com/6-history-of-medicine-and-pharmacy/hudson-valley-medical-history/revolutionary-war-doctor/
(B) https://prezi.com/uwl_a877t2ia/hospitals-and-medicine-during-the-revolutionary-war/
(C) http://www.dosespot.com/medicine-in-the-revolutionary-war
(D) http://www.ushistory.org/valleyforge/served/surgeons.html

“The drug industry was more than willing to meet the need of increased opioid administration and more than willing to advance its usage…..
Adding to this pressure to overprescribe powerful analgesics was the decision by Medicare to adjust payments to hospitals according to their Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. This naïve thought put medical treatment on par with any other commodity. But, medicine is different—often patients have an erroneous view of what is in their best interest. Thus, they may be dissatisfied with appropriate medical decisions. In response, many hospitals have fostered a hotel-like approach to please patients.
This practice has led to patients being discharged with a plethora of powerful analgesics to assure hospitals receive excellent scores.
These series of missteps by the medical establishment, the government and public desire has led, in our nation, to drug overdoses (primarily opioids) as the leading cause of accidental deaths.” (A)

“In a recent letter to the Health and Human Services inspector general, Johnson noted that opioid problems appeared much worse from 2013 to 2015 in states that expanded Medicaid under the Affordable Care Act than those that didn’t, based on Census data and statistics from the Centers for Disease Control and Prevention…
Overall, overdose deaths per million residents increased twice as fast in Medicaid expansion states than in non-expansion states.
Correlation doesn’t automatically equal causation, but Johnson provides reason to think it exists in this case. Based on police comments, he reports someone with a Medicaid card can obtain up to 240 oxycodone pills for as little as a $1 co-pay. Those pills can then be resold for $4,000 on the black market.
It’s not unreasonable to think some people will exploit the system for fast cash, especially since others (taxpayers) foot almost all up-front costs.” (B)

“We need a plan. Now that the President has labeled this as a national health emergency, we need to act on this momentum to effectively combat this crisis….
Addiction is an illness, and we must start treating those struggling with substance abuse like patients.
Part of this approach must include improving access and use of treatment and recovery services, offering support to people who have become addicted, and using research data to prevent high-risk populations from ever encountering opioids. And we need more post-treatment rehabilitation programming that reintegrates recovering patients into society.
And importantly, we need to focus on prevention and improve education and training for the physicians and healthcare professionals who are on the front lines of this crisis. Similarly, we all need to understand the dangers of opioid abuse and the risk of addiction and overdose.
Federal money should go towards funding innovative solutions– (C)

STRATEGIES
“Following on the heels of last week, advocates, social service providers and people with a history of drug use staged a protest on Thursday at the office of Governor Andrew Cuomo to raise the visibility of the epidemic of overdose raging across the state and demand bolder political action.
Protestors called on the Governor to: 1) guarantee universal access to sterile syringes, naloxone, buprenorphine and methadone to every New York State resident struggling with a heroin or opioid addiction; 2) mandate that every Office of Alcohol and Substance Abuse Services (OASAS) funded program at least offer buprenorphine and/or methadone to people using opioids; 3) support the creation of safer consumption spaces, also known as supervised injection facilities.
…
New York State does need to ensure immediate access to drug treatment on demand for all its residents, but to tackle the overdose crisis it must also ensure that the treatment offered adopts evidenced-based approaches that work. Additionally, many New Yorkers, especially those in rural counties, have limited or no access to proven public health interventions like sterile syringe access, naloxone, buprenorphine or methadone, leading them to continued heroin and opioid use.” (D)

“Physicians are increasingly being asked for pain medication and some struggle to determine how to prescribe appropriately. It may be obvious that a patient needs some pain management after a procedure or while managing a painful condition. And it might be clear that an endless supply of opioids puts a person at high risk for addiction. But how much is enough? How much is too much? Three tablets? Six? 12?…
Practicing Wisely™, a new initiative aimed at developing measures of clinical appropriateness, does just this. States can use the program’s opioid measures to track variation in physician prescribing behavior for specific cases of opioid use, such as prescription rates following a C-Section. Comparing physicians’ prescribing patterns to the prescribing patterns of like-specialty physicians, performing the same procedure on a similar patient population can help to identify physician outliers. That is, physicians whose prescription rate deviates constantly from the rates of their peers for a given type of opioid use. Importantly, physicians can gain insight into how their peers are responding to demand for opioids and can consider any adjustments to their own behavior that might be more in line with what is typical among a similar population.
To manage and (eventually) reverse the opioid epidemic, state Medicaid programs should now take a deeper look at the role prescribing plays, and they can tackle the “gray” area of appropriate prescribing through the deployment of appropriateness measures.”(E)

“In the wake of President Trump declaring the opioid epidemic “a national emergency,” Express Scripts, the nation’s largest pharmacy benefit manager (PBM), has rolled out a new opioid management program that will limit the number and strength of opioid drugs to first-time patients…
Express Scripts’ Advanced Opioid Management solution is expected minimize early exposure to opioids while helping prevent progression to overuse and abuse, while ensuring access to medication patients need.
In a pilot study, the PBM observed a 38% reduction in hospitalizations and a 40% reduction in emergency room visits after educating patients about the risk of opioid use. An educational letter was also sent out to providers who showed high prescribing patterns and held counseling calls. Among this subset, a 19% decrease in the day’s supply of opioid dispensing during six-months of follow up, was observed.
Meanwhile, the American Medical Association (AMA) has found fault with the program, saying that treatment decisions should be left to physicians and their patients.
Here are 7 things to know about Express Scripts’ program to limit opioids:..” (F)

“Three local library systems are training staff in the use of the opioid overdose antidote naloxone and others are considering the move as more government agencies are joining the fight against Maryland’s opioid epidemic.
Library staff in Harford, Carroll and Anne Arundel counties have begun to offer training in administering naloxone, also known by its brand name, Narcan.
Meanwhile, library systems across the region are giving patrons access to a database of ebooks, audiobooks and other resources on addiction, recovery and the opioid epidemic, part of an effort to make libraries a greater resource for people confronting drug abuse.” (G)

“Mr. President, if you are serious about stopping America’s opioid crisis, instruct Attorney General Jeff Sessions to have the Department of Justice join in these legal actions, bringing the investigatory and legal weight of the FBI to battle the multibillion-dollar pharmaceutical opioid industry and the largest distributors and retailers of the drugs. Don’t waste federal resources on isolated overprescribing doctors and puny drugstores — the states can handle those cases. Tell Sessions to nip this tsunami in the bud by going after entities that garner more than a billion dollars a year off opioids. Tell Sessions to nip this tsunami in the bud by going after entities that garner more than a billion dollars a year off opioids.
Stop the export of America’s opioid crisis.
Stop the import of fake and copycat foreign-made opioids. “ (H)

“Dr. Leslie Blackhall handled that case and two others at the University of Virginia’s palliative care clinic, and uncovered a wider problem: As more people die at home on hospice, some of the powerful, addictive drugs they are prescribed are ending up in the wrong hands.
Hospices have largely been exempt from the national crackdown on opioid prescriptions because dying people may need high doses of opioids. But as the nation’s opioid epidemic continues, some experts say hospices aren’t doing enough to identify families and staff who might be stealing pills. And now, amid urgent cries for action over rising overdose deaths, several states have passed laws giving hospice staff the power to destroy leftover pills after patients die.” (I)

(A) America’s self-inflicted opioid crisis, by Ken Fisher, http://medicaleconomics.modernmedicine.com/medical-economics/news/america-s-self-inflicted-opioid-crisis?page=0%2C1
(B) Government’s role in opioid crisis deserves review, http://newsok.com/article/5560720
(C) Abuse Deterrent Formulations are a Critical Step in Solving the Opioid Crisis, by Doug Schoen , https://www.forbes.com/sites/dougschoen/2017/08/18/abuse-deterrent-formulations-are-a-critical-step-in-solving-the-opioid-crisis/#708e9a174b87
(D) CityViews: Calling Out Cuomo for the Opioid Crisis, By Jeremy Saunders, http://citylimits.org/2017/08/18/cityviews-calling-out-cuomo-for-the-opioid-crisis/
(E) How Medicaid Programs Are Managing the Opioid Crisis, by Parie Garg, http://health.oliverwyman.com/transform-care/2017/08/how_medicaid_program.html
(F) Seven things to know about Express Scripts’ plan to limit opioids, by Tracey Walker, http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/seven-things-know-about-express-scripts-plan-limit-opioids
(G) Libraries join opioid addiction fight through Narcan training, by Mina Haq and Jon Kelvey, http://www.baltimoresun.com/health/bs-md-library-opioid-resources-0809-story.html
(H) How Not to Handle the Opioid Crisis, by LAURIE GARRETT, http://foreignpolicy.com/2017/08/22/how-not-to-handle-the-opioid-crisis/
(I) Dying At Home In An Opioid Crisis: Hospices Grapple With Stolen Meds, by Melissa Bailey, http://khn.org/news/dying-at-home-in-an-opioid-crisis-hospices-grapple-with-stolen-meds/