Archive for July, 2011

How My Career Taught Me To Be a Better Father

This article first appeared on the PBS affiliated Website This Emotional Life.

“There is no instinct like that of the heart.” Lord George Gordon Byron, British poet

The old adage is true: Timing is everything.  No matter how straight and narrow the road ahead may seem, one must always take into consideration the unexpected, that one, untamable variable that may at any time upset the apple cart and leave us scrambling to regain both composure and apples. For just over 108 months, I was the CEO of a hospital.  For three overlapping months, I was also a father.  The end to one significant stage of my life coincided with the joyous beginning of another.  Timing always rules the day, and, as I have found, it also enjoys irony.

Recently, I made the commitment to pursue certain credentialing and board certifications in health care management, even as my position in this field was in transition.  With a new child at home, a new career to forge, and a new professional distinction in my sights, I dived head first into an unrecognizable abyss, hoping that some yet-to-be-defined synergy (in the form of a very large net) would break my fall. As luck would have it, one of my first assignments was a book by Tom Atchison, Ed.D., which introduced me to “The Synergy Factor.”  As I understand it, this concept is a coalescing of sorts between certain intangible inter-relational ideas and tangible processes within health care administration.  There, in the middle of my matutinal study of the Synergy Factor and health care leadership, my mind started to wander toward my son, and I began to delve into the ways in which I could enhance our relationship in these early stages.

Young children (and many adults as well) exist in the crossroads of the tangible and intangible.  Matters of genetic makeup, demographics, and fiscal stability are common, tangible discussions for many new parents who aspire to provide for their latest family member. More often than not, however, that which is tangible is also hardest to control. The intangible part of parenting, namely the notion of instilling a mutual trust, respect, pride, and joy into the parent-child relationship, also happen to be what Atchison describes as “the source of a sense of purpose and meaningful work as a result of living the mission, values, and vision.” (Atchison, Leadership’s Deeper Dimensions: Building Blocks to Superior Performance, 2005).

Although not necessarily represented in equal proportion, certain factors such as the color of his eyes, the sound of his voice, the bed in which he sleeps and the neighborhood where we reside all share attributes that extend to varying degrees beyond my parental jurisdiction.  But the intangible ways in which I deliver certain messages that speak of and lead to trust, respect, pride, and joy are almost entirely within my control, regardless of those aforementioned tangible realities, as well as any challenges I may face now or in the future as a parent.

Now, as my studies force me to probe deeper into the core of health care management, I constantly find myself reflecting upon my real life lessons learned over the past nine years. No matter what educational background or prior experience a hospital CEO brings to the table, certain on-the-job assignments will necessitate fast, critical thinking.  With such knowledge comes the hope that I myself faced each hospital challenge with a combination of what I learned in school, what I learned from past work-related experiences, and what just felt like the right response. And as I continue to read about tangible and intangible notions in health care management as well as other industry terms and phrases, I begin to realize that I had in fact embraced most of these concepts during my tenure, in deed if not in word as well.

As I reflect upon the past decade with these thinly disguised affirmations from my present studies, I wonder also how I will come to assess my first nine years as a father. At the outset, I am very mindful that this new role differs from the last with respect to the events over which I was ultimately responsible. Now I share the top position with my wife, although to be sure my involvement is shaped by the needs of a newborn and the physical limitations of a father.

Without anything resembling an owner’s manual to follow as I try to build connections with my son while navigating the uncharted waters of new fatherhood, I realize that my instincts will be my second greatest ally, preceded only by those of my wife.  Thanks to the recent validation of these very instincts in hospital management, I am mindful that timing is still everything, and not all variables can be controlled.  Some must be dealt with as they emerge. Certain concepts that previously had no words in health care management may also be unknown terms to me in parenting.  For now, however, I can reassure myself by embracing both the tangible and intangible, and perhaps borrow some of these newly acquired definitions from health care to light my way.  After all, my goal is to build a solid foundation with which to give me footing among these intangibles in preparation for a lifelong journey with my son. In many ways, this is not so different from the way in which I approached the running of a hospital.  This time, however, the stakes are more profound, not to mention precious.


Health Care Reform in California: What Does It Mean for Attorneys and Clients?

The following article appeared in the July 11, 2011 Daily Journal.

At the end of June, the 6th U.S. Circuit Court of Appeals weighed in on the health care reform debate, focusing in particular on the constitutionality of the health insurance mandate embedded within the Patient Protection and Affordable Care Act (PPACA). This was the first mid-level Federal Court to opine on the subject, casting the decision as an important benchmark as PPACA inches closer toward intervention by the U.S. Supreme Court.

The 6th Circuit concluded that the insurance mandate, sometimes referred to as the minimum coverage provision, is constitutional and within congressional authority under the Commerce Clause. However, this most recent ruling is not alone in its attempt to define the future of American health care.  Other noteworthy if disparate decisions also on point include: an opinion last December from a District Court in Virginia striking the same (insurance mandate) provision, but confirming at least indirectly the overall constitutionality of PPACA; and a ruling in January from a District Court in Florida, declaring PPACA unconstitutional in its entirety.

These are exciting times for medical professionals, including health care practitioners and other attorneys who confront issues of contract, real estate, tax, employment, tort, bankruptcy or antitrust law in their practice.  But what effect does the fluidity of the modern American health care structure have on our clients as PPACA continues to work through its growing pains? It is often easy to overlook important, client-centric issues when daily media headlines spew prognostications of unprecedented historical importance.  Esoteric as they may appear on the surface, however, these high profile discussions offer a wealth of relevant information for attorneys and their clients, even if such wisdom is hidden beneath a cloak of ambiguity as thick as the pages of reform legislation itself.

By setting their sights on two of the basic concepts contained within PPACA, health care practitioners are better suited to cut through the controversy and rhetoric, and focus instead on the needs of their clients.

The first issue impacts nearly everyone in the field, including attorneys who may represent individuals or businesses:

To meet PPACA’s requirements in 2014, individuals have the option to: enroll in a government program such as Medicare, Medicaid (California’s version of Medicaid is “Medi-Cal”), or TRICARE; participate in qualified insurance programs offered through employment; or purchase a qualified insurance policy, either through a series of state exchanges that are scheduled to begin in or around 2014 or directly from an insurer. To be “qualified” a plan must cover certain “essential health benefits,” at least up to a defined percentage of actuarial value.

Starting in 2014, failure to obtain or maintain preexisting qualifying health care coverage will result in a penalty of $95 or 1 percent of the individual’s income, whichever is greater. In 2016, this penalty increases to $695 or 2 percent of the individual’s income. There are companion penalties for families (capped at three times the per-person flat amount) and dependent children (half of the per-person flat amount).

In the end, the debate over whether or not the Commerce Clause was designed to extend this far will be of little value to individual clients who seek professional advice in understanding how much they may be required to pay or have deducted from income tax filings. This may impact the tax returns of approximately 140 million clients, as well as 15-20 million others who previously did not file, a sizeable client base for any law firm.

While PPACA will require individuals to obtain health care insurance, businesses are under no obligation to offer coverage to employees. Instead, larger employers constituting 50 or more full-time employees will face a $2,000 per employee penalty (which does not apply for the first 30 full-time employees) in the event these employees receive federal subsidies for health insurance. Furthermore, if businesses offer health care plans that are too expensive – known as “Cadillac Plans” – they will face a 40 percent tax imposed in 2018.  On the other hand, small businesses stand to gain generous new tax credits designed to encourage the implementation of qualified health insurance plans for their employees.

As the ongoing debates continue to unfold, both large and small businesses would do well to seek legal consultation in balancing the competing variables before making decisions pertaining to coverage. In deciding whether to offer a health care plan or pay the $2,000 per full-time employee fine, proper advice may necessitate expertise in tax, employment, and/or contract law, in addition to a certain amount of health care acumen. And while not an issue today, practitioners should be aware that they may face scrutiny under the California Rules of Professional Conduct, and Rule 3-310 in particular, for representing both individuals and businesses (small and large) in deciding whether or not to obtain or offer health care insurance.  These are just a few of the complexities upon which attorneys will be called for assistance as health care reform flexes its newfound muscles.

The second issue involves the possible future of health care reimbursements, and Medicare in particular. In April 2011, the Centers for Medicare & Medicaid Services (CMS) published regulations designed to change the structure of hospital reimbursements. Authorized within PPACA, CMS will start paying hospitals Medicare “bonuses” based upon overall performance, adherence to quality measures, and patient satisfaction.  This hospital value-based purchasing program is another step toward shifting the focus of reimbursement infrastructure from the cost of services during a hospital stay to improvements in patient health and performance during a hospital stay.

With the laudable intertwined goals of improving patient care nationwide while saving money for the Medicare system, beginning in October 2012 hospitals will be entitled to share bonus money from an $850 million fund based upon their scores in these newly defined measures. The following year, hospitals will face a 1 percent [reduction] overall on Medicare payments under the inpatient prospective payment system, as these funds will be redirected toward the aforementioned performance bonuses. By 2015, hospitals with a track record of poor performance will not only face exclusion from the bonus pool, they will also face additional cuts in reimbursement.

The maturation process of American health care reform has a long way to go, with each new stage bringing with it a complex set of issues. At each turn, attorneys will be called upon to assist clients in understanding and incorporating structural, legal, and ethical changes. If this alone was not enough of a challenge to our profession, we must also address the inherent conflicts between the desire to make health care better and less expensive and the knowledge that to do so may compromise the livelihood of a hospital, doctor, or medical facility.

As sweeping as the far-reaching implications of PPACA may sound, attorneys must be ever mindful of their clients’ needs as they navigate what is sure to be a future filled with shifting terrain. Regardless of health care reform’s political ramifications, the fundamental concepts behind the upcoming reorganization of the reimbursement paradigm are epic. In many ways, replacing cost-based reimbursement with performance variables appears just as drastic as eliminating income as a factor for calculating individual taxes in favor of implementing a series of assessments designed to quantify the benefit an individual may or may not confer upon society. To truly provide for our clients in upcoming uncertain times, we must be able to relate to the ramifications not only of today’s health care structure, but those that tomorrow has in store for us as a nation.


Breaking Language Barriers in Health Care

This article first appeared in California Healthcare News.

“Most of the fundamental ideas of science are essentially simple, and may, as a rule, be expressed in a language comprehensible to everyone.” – Albert Einstein

Imagine finding yourself in a hospital, only to discover that you no longer have a mouth or ears.  You cannot explain your symptoms, identify next of kin, or describe your medical history, nor can you understand the doctor’s diagnosis, instructions, or prognosis.  For the growing number of patients in Emergency Rooms across the United States who arrive unable to communicate effectively in English, this is no dream, but a frightening reality.

In an emergency time is short, and swift, accurate communication is essential for establishing a foundation from which the doctor can attempt a diagnosis. According to a survey by the Health Care Interpreter Network, more than 70 percent of American health care providers admit that language barriers regularly compromise patients’ understanding of their disease, increase the risk of complications, and make it difficult for patients to communicate effectively with their doctors, often leading to costly delays in treatment.  Furthermore, in some cases the stigma and frustration attached to having limited English proficiency (LEP) is enough to discourage people from seeking treatment altogether, while those who are able to overcome their fear or embarrassment run the risk of misunderstanding the physician’s instructions, especially when it comes to home follow-up care and the taking of medication.

Many of the facts surrounding issues of language in a hospital setting are surprising.  Statistics from the United States Census show that nearly one in five legal American residents speaks a language other than English at home, adding up to nearly 60 million people nationwide, and that number continues to rise with each passing year.  However, this growth is no longer limited to large urban environments, as many of today’s immigrants are finding pockets among smaller towns in states not often associated with immigrants, such as Arkansas, Kansas, Colorado, Kentucky and Tennessee, leaving local hospitals scrambling to find the appropriate means to deal with newly presented language barriers.

Furthermore, Spanish is by no means the only issue.  Though by far the most common language encountered, it is joined by such disparate tongues as Chinese, Russian, Arabic, Vietnamese, Portuguese, Hindi, Japanese, Korean, and American Sign Language, to name a few, making it nearly impossible for most hospitals to cover the needs of their entire patient-base.  Even in situations where a low-level translator is available, errors in diagnosis may occur as a result of “false friends.” For example, in Spanish the word “constipado” refers to a respiratory rather than a digestive condition, meaning “unable to breathe.”  Similarly, “intoxicado” means simply “dizzy,” without regard for reason why.

While such communicative chaos is certainly bad for patients, it also places burdens on hospitals, as the cost of the resultant unnecessary tests, longer treatment times, decreased provider efficiency, and repeat visits are often thrust onto the shoulders of the facility.  Under Title VI of the Civil Rights Act of 1964, hospitals receiving Medicare or Medicaid are obligated to provide free translation services to patients, though the government provides little or no reimbursement. Neither Medicare nor the vast majority of private health insurers covers issues of interpretation, though both deal in high volumes of LEP beneficiaries.  Depending on the language involved, medical translation services can run as high as $400 per hour.

Recognizing the effect on both patient and facility, many hospitals have begun to address this burgeoning issue with the attention it deserves.  With the added incentive put forth by the Joint Commission accreditation standards begun in 2008 and set to take effect in January 2011, today’s medical facilities have started to focus more keenly on their commitment to supporting numerous languages and providing new solutions to the problems caused by the inability to communicate in a health care-related setting.  For example, many larger hospitals now boast a combination of in-house and freelance interpreters to cover the needs of their community, as well as hiring more bilingual employees in both medical and non-medical capacities.  Recent years have also shown greater emphasis on training in-house staff to work in conjunction with interpreters and an increase in overall cultural awareness. Though expensive, phone interpretation is another way in which hospitals can effectively procure important information in an emergency.

Since the aftermath of Hurricane Andrew in 1992, picture boards have increased dramatically in popularity among hospitals with high numbers of LEP patients.  These laminated panels provide simple icons depicting health issues such as cuts, burns, trouble breathing and chest pain, as well as images of body parts to show where the patient is affected.  Though limited in scope and detail, the boards are an effective way to give the physician a quick overview of the situation while an interpreter is being located, and they work equally well for those patients who are deaf, mute, or unable to speak due to a medical condition or as a result of a breathing tube or apparatus.

Though only an initial step, the edict put forth by the Joint Commission serves to publicize the need for more effective translation services in America’s hospitals while adding incentive for health care facilities who do not wish to lose Medicare and Medicaid funding due to non-compliance.  Bettering doctor-patient communication in the future is essential to the vitality of our health care system, as it is a proven and effective way to cut costs, improve care, and save lives.

Our Fear-Driven Regulatory Realm

The following article first appeared January 27, 2011 in the publication Payers and Providers.

Our Fear-Driven Regulatory Realm: One Event, Not Day-to-Day Reality, Pushed SB 1953

As the CEO of a small Los Angeles County hospital who has dealt in the past with the Office of Statewide Health Planning and Development, I read Jim Lott’s recent opinion “Is OSHPD an Obstacle to Growth?” with great interest.  Mr. Lott’s astute recap of both the potential behind SB 1953’s initial design and the corresponding shortcomings in its deployment was in my opinion insightful.

However, to cast the blame entirely on OSHPD is not necessarily fair, especially when it comes to state-mandated seismic safety standards.  In marshalling all California hospitals in the direction of SB 1953, OSHPD has been charged with a Herculean task, which has been compounded by our current economic climate. With such responsibility thrust upon the shoulders of an underfunded, understaffed department, efficiency was certainly never a priority in the minds of its makers. Furthermore, as important as this role may be, upon reflection it stems in large part from the fear generated by a high profile tragedy and the arguable overreaction of state policymakers and popular media.  Too often after these events the course of health care shifts its aim away from the big picture to dwell on anomaly, often to the detriment of both patients and providers.

To be certain, the isolated events that capture our attention are often devastating, tearing apart families, communities, even cities.  In early January an angry, disturbed young man killed six with his gun. Some of the victims were high profile and others were tragically young.  As the fallout from this shooting captured the nation’s spotlight, significant focus centered on episodes of unidentified bipolar disorder and schizophrenia.  Mental health experts trumpet the warning signs of illness leading to such a violent event much like Californians speak of “The Big One,” even though less than 0.004% of the U.S. population is likely to die from firearms each year.  When this occurs, the spotlight is shifted away from more prevalent threats such as diabetes, obesity, and heart disease, though the after-effects on the families of those who die from these understated killers are no less devastating.

Similarly, when fear of catastrophe sets the tone for policy, funding is often funneled away from its most deserving targets. The idea for SB 1953 came about after a 6.7 magnitude earthquake in Los Angeles County, California killed 72 people in January, 1994.  Seventeen years later, hospitals across California are spending their part of the estimated 90 to 120 billion dollars to ensure they meet the seismic safety requirements mandated by the state legislature, regardless of their day-to-day fiscal health.  While the Northridge Earthquake unquestionably caused tremendous damage to Southern California, the proposed price tag when broken down runs about $1.7 billion per fatality.

As an administrator, it is confusing to me that America’s health care is so often dictated by the after-effects of an aberrant, high profile tragedy, while more subtle yet more prolific killers go largely unpublicized as their cures remain underfunded and their victims die without fanfare, or essential, ear-marked funds are rerouted to assuage tomorrow’s fears. Seismic compatibility is a goal worth attaining, but in these troubled economic times as hospitals both large and small struggle to keep their doors open to a dependent public, it certainly does not hurt to understand the origins of this expensive overhaul, and question whether these funds would be better spent on preserving the quotidian rather than planning for a possible catastrophe.  By 2015 all functioning California hospitals should be prepared for the Great Shock, but how many will remain to be left standing, regardless of the whims of Mother Nature?



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