| Report
of the Lynn Health Task Force on Implementation of the DON Conditions
Relating to the Union Hospital-North Shore Medical Center Merger
March 1, 2002
INTRODUCTION
This year marks the fourth in our annual reports to
the Public Health Council concerning North Shore Medical Center's
compliance with health care access commitments negotiated by the health
care consumer community of Lynn through the Lynn Health Task Force in
connection with the sale of Lynn's only community hospital. For the first
two years of this journey, the Task Force joined the Medical Center in
jointly reporting, in generally favorable terms, a series of new
initiatives undertaken by the Medical Center to meet the commitments made.
These were invariably initiatives undertaken after consultation with the
Task Force and other interested groups and individuals. We also reported
on those matters not satisfactorily addressed and proposed joint efforts
to correct these deficiencies. The Task Force's written remarks and
presentation to the Public Health Council were generally consistent with
the reports of the North Shore Medical Center or issued jointly with the
Medical Center, tracking progress on specific conditions and generally
offering a favorable impression of the actual programs and efforts
undertaken and the working relationship between the two entities. Last
year's report offered some reservations concerning this relationship and
detailed some serious deficiencies in progress under several of the most
important conditions - now many years behind schedule in implementation.
We offered at that time our hope that these efforts would move forward and
that the working relationship between the hospital and Task Force would
continue to develop constructively but expressed some reservations about
the tenor of recent conversations and efforts. We hoped to be able to
report to you this year major progress on these neglected fronts through
mutually agreed approaches to meeting the remaining pressing health care
access needs of Lynn residents. We hoped to but we cannot.
This year has been a tale of two contrasting
experiences. Earlier in the year, the Task Force was productively involved
in the development of plans for the creation of a new community health
care facility in an underserved section of Lynn. This effort was designed
to address several of the remaining unfulfilled conditions commitments and
through a facilitated process involving the Medical Center, the Lynn
Community Health Center and the Task Force an effort was undertaken to
provide a real opportunity for collaborative involvement in the planning
for this center.
While that effort seemed promising, it now seems to
have been a negative bellweather in relations between the hospital and the
Task Force. In hindsight the process seems to have been manipulated by the
Medical Center's participants who failed to divulge centrally important
information about the process and their intentions as it was going
forward. Despite a lengthy and superficially open process, ultimately many
if not most of the critical decisions made concerning the means for
delivery of services from that facility were made by fiat by hospital
officials after the formal collaborative process ended. The decisions
routinely ignored the wishes of the Task Force and its consumers and in
some instances the hospital's other collaborative partners. The hospital
seems to have reached a decision to abandon community collaboration all
together and, since the process ended, has issued a series of ultimatums
and edicts about a range of services and conditions, essentially
abandoning any real commitment to meet the letter and spirit of its early
commitments and abandoned any but the most superficial and hollow elements
of true collaboration.
We must report that while some significant new
initiatives have begun to be developed, the nature of the working
relationship between the hospital and Task Force and the overall progress
in moving forward on meeting the remaining conditions has reached a new
low. From where we stand, it seems that the process of community
collaboration has, for the hospital, become simply a nuisance, and that
the hospital's response in recent months has been to simply issue a series
of ultimatums, most completely unsatisfactory from the standpoint of
health access in our community. What were in past years joint planning
meetings and discussions, have devolved over the last several months into
simply forums for the announcement of flawed decisions made in complete
isolation by hospital staff. These decisions represent surrenders by the
hospital - decisions to simply refuse to provide the level or type of
service earlier promised. The Task Force wishes to take this opportunity
to be clear about these failures and about the fact that the decisions
made concerning several of the most critical conditions are actively
opposed by the Task Force and were undertaken without Task Force input in
some cases and without our agreement or acquiescence in many others. We
have reached a point in relation to several of the conditions that we
cannot continue to be a party to a sham process that disrespects and
disregards our input and simply uses our presence as a false indicator of
community participation.
Our only regret is that we did not see this coming
earlier and, having watched the situation deteriorate over the last
several months, did not speak up sooner and more forcefully. We admit to
having been seduced for a time by the trapping of collaboration even as
the reality was rapidly disappearing.
We must report that in some instances the decisions
reached in isolation by hospital officials will actively harm local
residents. In some cases they will result in minor improvements from a
presently completely unsatisfactory status quo, but at the same time
represent major retreats from explicit commitments already made to the
Task Force and to this Council. In each instance, we want to be completely
clear that the decisions reached were reached over our strong and
principled objections and that, when all is said and done, the hospital
officials have simply not cared. If the last year is a harbinger of things
to come, it will be necessary for the Task Force to be in more regular
contact with the Council, seeking forums wherever and whenever possible to
actively protest the hospital's retreat from a genuine concern for
community based collaboration concerning the health care needs of our
community's most vulnerable residents. Let us take each of the most
fundamental areas of concern separately.
SPECIALTY PHYSICIAN CARE
When the Lynn Health Task Force first became
involved in issues of the sale of Union Hospital in Lynn, access to
specialty physician services for the uninsured was viewed by the Task
Force's community board as one of the most fundamental and central
concerns. Time and time again, low income Lynn residents without regular
health insurance coverage are admitted to Union Hospital either through
the hospital's emergency room or their own provider, when they are lucky
enough to have one, and emerge with bills for tens of thousands of dollars
in specialty physician care. These residents regularly approach the Task
Force facing these crushing demands for payment for services they
literally could not live without but also have absolutely no means to pay
for. The most dramatic examples invariably involve hospital based services
and procedures which are regularly the most expensive and most difficult
for an uninsured patient to secure.
Despite the enormity of the problem for the consumer
community, solving it is relatively easy. Mechanisms exist in
Massachusetts that, with even slight cooperation and constructive
involvement by a local hospital, can ensure that specialty physicians
providing these services are paid for the care they provide and are not
forced to look to low income residents with no ability to pay for the
costs of this care, effectively bankrupting poor residents for receiving
life saving medical services. When the time came to negotiate and
prioritize public health concerns in Lynn in connection with the sale of
Union Hospital, fixing this problem was near the top of the list. It
remains so today.
The solution is simple. Under the Massachusetts free
care pool, a physician providing services from a hospital licensed
facility and under contract with a hospital can have their services
reimbursed by the pool when provided to a free care eligible individual.
Thus, Union hospital simply has to be willing to enter into contracts with
providers to provide care in order to solve this problem.(1)
Last year the Public Health Council staff report questioned whether it was
feasible for Union hospital to condition staff privileges for all
physicians on willingness to enter into contracts to provide care, refrain
from billing free care eligible patients and, at their option, receive
reimbursement under the free care pool, even though the hospital
acknowledged that this was the operating philosophy at most other Partners
facilities.(2) The Council's staff
expressed their confidence that a "joint planning process will be
undertaken during the next six months" to address full compliance
with the specialty care condition.
Based on the Public Health Council staff's report,
the Task Force immediately abandoned its request that the hospital use its
staff privileges to coerce compliance and simply asked and expected the
hospital to develop a voluntary system, operated under its license, to
recruit and contract with providers on a voluntary basis to provide this
care and to then coordinate, using hospital systems, the use of these
volunteer resources. That was little to ask. In its last report to the
Council the hospital, in the process of acknowledging its utter failure to
make progress on this condition, pledged to the Task Force and to the
Council that it would "have arrangements in place for (several)
specialties by October 31, 2000." That date came and went and
absolutely nothing was accomplished. Another year passed and the hospital
made absolutely no progress under the condition.
Recently, Union Hospital issued the Task Force one
of a series of ultimatums simply refusing to participate in any such
system or play the role that the hospital needs to play for this kind of
system to be established and to succeed. The hospital offered no
explanation. They simply refused. Instead, they proposed to make this
commitment, a commitment they made in these proceedings four years ago,
someone else's problem.
They suggested that responsibility for this process
be passed off on the Lynn Community Health Center. They proposed that the
hospital absolve itself of any responsibility to operate this system and
that, instead, that out-patient specialty services be provided in space in
a newly proposed West Lynn health center licensed by the Lynn Community
Health Center for the Health Center to operate its own specialty physician
free care system without the hospital's involvement. Both the Task Force
and the Lynn Community Health Center have looked at this proposal,
recognized that it simply does not work and rejected it. Both the Health
Center and the Task Force have argued to the hospital that this approach
is fatally flawed. As with so much else recently, it appears that the
hospital could not care less. They have not listened and they do not seem
to care. Their only interest is in passing responsibility for resolving
this problem onto someone else. Their solution's only virtue is that it
lets the hospital off the hook . From the standpoint of the consumers
these conditions are designed to benefit, their approach will be a
complete failure.
Why? The answer is very simple. The most expensive
services received by patients from specialty physicians are services
delivered exclusively from hospital licensed space. In order for
physicians to be reimbursed via the Free Care Pool for care they provide
to uninsured patients, they must be delivering that care from space
licensed by the entity that pays them for the services and the that entity
then seeks reimbursement from the free care pool. In the case of all of
the most expensive specialty care services, that entity must, therefore,
be the hospital. Whether surgery, CAT scans, or other diagnostic
procedures, these services must be part of any even vaguely credible
response to the issue of specialty care access. Under the hospital's plan,
while uninsured patients may, hopefully, have access to out-patient
consultations with specialists (at least to the extent that specialists
volunteer to participate), uninsured patients will continue to receive
enormous bills for services rendered by specialists on-site at the
hospital. The hospital has refused to make arrangements with its
specialists under which it would salary the specialists and then be able
to bill the free care pool for services delivered to uninsured patients.
So, at best, under the hospital's plan, a patient could receive an
out-patient consultation with a specialists, but if s/he needs surgery or
a procedure at the hospital, s/he will be billed for that care! This is
the exact result that causes uninsured patients to refrain from using
medical services - either they fear the large bills, and unceasing debt
collection that follows, or once having been treated in this way, are
unwilling to subject themselves to further abuse as the cost of receiving
medical care. Any system that pretends to address the issue of specialty
care access while effectively ignoring this huge range of services and
leaving patients vulnerable to massive bills for hospital delivered
services is a complete sham.
The hospital's poorly conceived approach also fails
to recognize the hospital's unique relationship to these physicians, a
relationship that the Community Health Center in no way shares. When the
hospital came before the Council last year arguing against a compulsory
system they did so claiming that through their relationship with these
providers they could create a system that would work effectively on a
volunteer basis based on their relationship with these providers and their
commitment to the effort. Now they come before you seeking to avoid any
responsibility for the system at all. Their retreat from their commitments
in this context is complete and is in clear violation of a commitment
they, not the Lynn Community Health Center, made to the Task Force and to
Council. That commitment must be enforced.
The Lynn Community Health Center understands this
and has supported the Task Force's approach. The hospital, we suspect,
understands the flaws in its model full well and the advantages of the one
we have proposed and the Health Center has supported, but it simply isn't
willing to accept responsibility to operate this system and make it work -
responsibility that it promised to accept under the negotiated specialty
care condition five years ago. It would rather pass this responsibility on
to a third party under a system that cannot work. We believe that its
efforts to do so violate the letter and spirit of the condition and will
ensure that the specialty physician access commitment made by the hospital
will not be met. We ask you to enforce the condition now and require the
hospital to operate a free care specialty referral system under its
license from hospital licensed space which can cover the cost of services
delivered from hospital licensed facilities. Anything else is a disastrous
abandonment of the commitment now five years overdue.
FREE CARE
The hospital remains dramatically out of compliance
with the regulatorily-mandated free care maintenance of effort condition,
and its performance is getting worse, not better. The condition requires
Union Hospital to maintain Free Care billings which represent 4.24% of
gross patient service revenues. In fiscal year 2001, the most recent for
which data are available, the actual percentage was 2.90%. As a percentage
of gross patient revenues, the hospital's performance is less than 75% of
what it should be under the condition. The hospital has not taken
meaningful steps toward meeting the requirements of the condition. A
rational specialty care system, utilizing voluntary hospital based
contracting with specialty physician volunteers, as described above, could
and would have a major impact on this violation of the conditions. Were
the hospital expending any efforts, let alone best efforts, engaging in
the specialty care contracting that the Task Force has recommended, a
significant improvement in free care pool utilization would necessarily be
the result. Thus, the hospital's underutilization of the pool and its
unquestionable violation of the condition is not inevitable, it is a
matter of choice. The hospital has chosen not to take readily available
steps that would both improve its performance under the free care
condition and begin to meet its obligations under the specialty care
condition. If these conditions mean anything, the Council should not
acquiesce in a hospital decision to refuse to take steps that would
improve its performance under a condition it is dramatically violating.
PRIMARY CARE/ WEST LYNN HEALTH CENTER
In its October, 2000 report to the Public Health
Council the hospital addressed the primary care condition by explicitly
agreeing to develop a plan that would include "phasing in five new
physicians over the next two years." The following year began with
great promise. The hospital announced its interest in securing a new
health care site in West Lynn, an area the Task Force has repeatedly
indicated it believed was underserved and in need of additional primary
care resources. The hospital entered discussions with the Lynn Community
Health Center and supported a facilitated three way discussion with the
Health Center and the Task Force to reach consensus on the location and
use of such a center and the types of services that should be delivered
from it. The Task Force joined in these discussions eagerly.
Superficially, one would think this process
represented a great advance for the community based on the hospital's own
report. The outputs seem very significant - planning for a new community
health center in West Lynn, with space for and resources to support new
primary care physicians and an investment by the Hospital of more than a
million dollars. That is how it seemed to the Task Force as well, while it
participated very actively in these discussions to develop plans for this
new Center.
In reality there are benefits to the initiative and
they should not be minimized. The plan calls for devoting some of the
space in the new facility to a primary care practice dedicated
specifically to the needs of Southeast Asian residents. This
specialization and focus on cultural competency for this hard to reach
population is a welcome addition to the local health care system.
Likewise, the development of pharmacy services at this site will go a long
way toward providing a permanent solution to the prescription drug needs
of local low income residents.
But in other respects the plan is not what it seems
and the benefits marginal at best, largely because of hidden agendas not
revealed as these discussions began. Little did we know as we began our
participation in this effort that it came with a significant price - one
not revealed to us at the outset. Only after two of the three facilitated
meetings had already occurred did the hospital begin to put its cards on
the table. At that late stage of the process they issued yet another
ultimatum. The quid pro quo for the development of this new resource would
be the destruction of an already existing one - a presently operating
hospital licensed health center in the same neighborhood. When one looks
at the two developments side by side, something we were not privileged to
be able to do until well into the process when the hospital revealed its
real intentions, the net benefit is not what the hospital would have you
believe.
West Lynn is currently home to a facility called the
Market Square Family Health Center, a hospital licensed and supported
clinic staffed by two full time primary care physicians, a physician's
assistant, midwives and other support personnel. The Market Square
facility has been in existence for almost a decade with a solid patient
base, access to care for the uninsured and two primary care physicians who
have been with the practice for several years and are known and respected
in the neighborhood and in the community as a whole. We now understand
that the hospital's decision to withdraw its support for this practice
will result in one of the two primary care providers leaving the community
entirely. We understand that the second provider is considering the same
option, withdrawing from the community entirely. Even when, in the context
of the facilitated discussions, the hospital did finally reveal its
designs to destroy the Market Square practice, the hospital gave the Task
Force every indication that it had an agreement with at least one of the
providers to remain. It now seems that was not the case. As a result, it
now seems that this effort, theoretically designed to increase the number
of primary care physicians in Lynn, will begin by eliminating two that are
currently practicing in Lynn under the auspices and with the financial
support of the hospital. As with its approach to specialty care, the
hospital's approach here seems primarily designed to divorce the hospital
from any direct responsibility for any of the services required to be
delivered under the conditions, gradually removing itself as a partner and
player in the public health system in Lynn.
When these conditions were negotiated and these
discussions begun, the Task Force, based on substantial input from its
consumer leaders and the community at large, sought two important
components in the development of improved primary care access in Lynn. It
sought to establish a base of medical resources that was consistent with
objectively determined patient need in the community and it sought to
encourage patient choice through the delivery of services from a diverse
group of providers under different management and geographically
distributed through the community to improve access for the poor. It is
important to consider what the current West Lynn plan will accomplish in
each of these respects.
First, the plan will likely result, on a short term
basis, in a reduction in primary care capacity. Ultimately it will result
in a very small increase in primary care capacity, an increase that will
very dramatically violate the hospital's specific and explicit agreement
before this Council to add five new primary care physicians within two
years. Finally, the new center, when coupled with the destruction of the
existing Market Square practice will result in less provider choice for
consumers in the community.
A short term reduction in primary care capacity will
result because the initial plan calls for the Lynn Community Health Center
to assume control of the Market Square practice on a temporary basis while
the new facility is under construction. The information avialable to us
indicates that at least one of the primary care practitioners will not be
willing to accept this arrangement and will leave the area. The other, as
we understand it, has yet to make up his mind about whether he will stay
or go.(3) There are no plans to add any new
capacity at this stage of the process so the net effect through the
development of the new center more than a year from now, will be the
reduction of primary care capacity in Lynn by one and possibly two
providers. In addition, the providers leaving the community will are known
practicing physicians with full patient loads and considerable consumer
support while any replacements will have none of these attributes. Thus,
the true net effect will be even worse than simply the reduction in FTE's
involved. By the time the Hospital's two year commitment to this Council
and to the Task Force to guarantee five new physicians in Lynn comes to
term, the real number may well be zero..... or less.
Another immediate impact will be the savaging of
patient choice in this community for its low income residents. Currently,
there are only two good and one poor choice for the uninsured in Lynn in
need of primary care. They can enroll as patients of the Lynn Community
Health Center, they can become regular patients of the hospital-licensed
Market Square practice or they can seek their care from the emergency
department at the hospital. Leaving aside the unsatisfactory choice of ED
care, the two remaining alternatives are quite different in character and
each appeals to a different segment of the local health care consumer
community. The Health Center is a large scale multi-disciplinary and
institutional practice with significant attention to integration of
primary care with other support and ancillary services. The Market Square
practice, in contrast, operates much more like a small private medical
practice.
In the Task Force's public speak outs, focus groups
and community forums on primary care, its consumers have repeatedly
expressed their desire to have both types of practice available. Each has
strong supporters and each, more importantly, is simply unacceptable to a
significant segment of the local consumer market. If either of the two
practice models disappear, consumers who currently have satisfactory
arrangements for care no longer will. The elimination of choice and
patient options cannot help but have a significant negative effect on the
health care environment in Lynn. In addition to providing absolutely no
increase in primary care capacity for the forseeable future, the current
West Lynn plan will result in the complete elimination of one of these two
alternatives. It will, like the other initiatives the Task Force
strenuously opposes, have the principal effect of removing any real role
for the hospital in the delivery of primary care in the community by
eliminating the only practice that the hospital operates and has real
responsibility for. This is another example of the hospital simply seeking
to wash its hands of any real responsibility for the delivery of care in
this community, strategically divorcing itself from any long term
commitments to this community's public health needs.
Even when it is completed several years from now,
the hospital's current West Lynn plan will lead to a marginal increase in
the primary care resources available in Lynn. The current business plan
provides that in year 1, the total staffing will be 2 family practice
physicians and one obstetrician. The Task Force has made clear that its
call for primary care physicians does not extend to obstetrics, a
specialty that in relation to the true primary care needs in Lynn serves
more of a marketing and patient harvesting commercial opportunity for the
hospital interested in developing its lucrative delivery business than it
does a response to a public health need. Thus, given that two existing
doctors at Market Square will be lost, the net increase in primary care
through the Spring of 2003 will be zero.(4)
The business plan calls for a further increase of
one primary care physician during year two. Thus, by Summer of 2003, the
net increase will likely be 1. This is an explicit violation of the terms
of the conditions and of the explicit assurance given by the hospital to
the Council the last time it appeared here to make five new primary care
physicians available in this community by October of this year. That
commitment should be enforced.
Equally disturbing, this new center is also being
offered as the site for the delivery of specialty care services. Its
ownership and management by the Lynn Community Health Center is being
offered as a principal rationale for the hospital's surrendering any
responsibility to participate in the delivery of these specialty services.
In that sense the consequences of the new center are negative relative to
the specialty care condition, as the center is being offered as the
justification for the hospital's abandonment of its own role in specialty
care. It should be understood that the Task Force would prefer a hospital
based specialty care system operating from hospital space than the
arrangement the hospital now seeks to inflict on the community as a part
of the West Lynn health center process. If the result of the arrangement
that the hospital now seeks to unilaterally impose is to insulate it from
its obligation to comply with the DON requirement to create a genuine
solution to the problem of specialty access for uninsured patients, then
the community would be better off with no specialty physician space in the
new West Lynn site.
In sum, relative to primary care, the current
situation is abysmal. In furtherance of its hidden agenda to put out of
business the only free care accessible primary care practice operated
under the hospital's own license, the hospital will in the next year
effectively and purposefully drive out of the community two of the
community's most effective and productive primary care physicians -
physicians who provide the only real option for uninsured and marginally
insured patients outside of the community health center system. What they
will be replaced with is far from clear. At best, it appears from the
vague and sometime contradictory information furnished by the hospital, by
late 2004 there will be one new primary care physician and two
replacements for the two existing doctors driven out of Lynn by this plan.
When those doctors will be available is anyone's guess. This is a complete
breech of the condition and of the very specific agreement reached last
year to provide five new doctors in the community, a number that is still
far below the projected need based on available studies of primary care
access in the community. The agreement made last year with the Council
should be enforced.
OUTREACH SERVICES
Developments relative to hospital based outreach
services this year are another example of the hospital's complete
abandonment of collaboration with the Task Force. We have spent literally
years discussing with the hospital what we have understood to be a jointly
held belief that the hospital's outreach efforts lacked focus. During the
course of this discussion the Task Force's position has been consistent
that a fundamental element of a successful effort should be the
involvement of a supervisor/leader with expertise in this field who can
bring professional experience and training to the project. In the past,
while the outreach effort floundered, it has never had any leadership with
any outreach experience whatsoever. Instead, the outreach team has been
led by a succession of hospital administrators from different disciplines
none of whom had any public health or outreach training or experience. The
hospital has always indicated it agreed with this basic premise. To that
end the hospital, after years of delay, finally hired a consultant to
review and make recommendations concerning the outreach effort. Our busy
and committed volunteer leaders have spent countless hours working with
hospital staff and the consultant on what they understood to be a
collaborative effort to make decisions to restructure and improve the
service. Then, at a recent meeting, the hospital simply announced its
unilateral decision to install its interpreter coordinator as the
supervisor of the outreach effort. This decision had never even been
hinted at in the past. While this individual, Carol Peña, is a lovely
individual, she has absolutely none of the professional experience or
training that would suggest she is appropriate to bring focus and
leadership to this outreach effort. Had this decision ever been hinted at,
let alone discussed with the Task Force, we would have made clear how
strongly we oppose it and why. But the hospital apparently saw no reason
to think it should or would discuss this decision, instead simply
announcing it, and when Task Force representatives made clear their
serious reservations, the hospital told us that the decision was made, it
was an internal matter and, in essence, none of our business.
Similarly, in spite of our ongoing dialogue with the
hospital about the need for vision, focus and planning for the outreach
initiative, we were not involved in any discussion to "align the
outreach more closely with the hospital's current services" and do
not agree that this avenue is the best use of the limited outreach staff.
By definition, it is very limited in scope because, as noted in the
report, Union Hospital's services are quite limited. As a facility with no
obstetrics or pediatrics and very limited out-patient services, to focus
the effort on "aligning with the hospital services" by its very
nature fails to serve large segments of the population. Furthermore, the
hospital has long recognized that it does not serve many segments of the
community who seek their care elsewhere. Limiting the focus of the
outreach effort to people who have already been connected with the
hospital perpetuates that reality instead of tackling it. The decision to
narrowly focus outreach efforts, like the other decisions described above,
was made without discussion with the Task Force and was simply announced
as a fête accompli.
That, in sum, is our experience of late with the
hospital and we have had enough of it. Our leaders' time is too valuable
to be spent discussing issues in an environment in which the hospital
feels completely comfortable ignoring every word said in these
discussions. We will no longer be held out as evidence of the hospital's
community centeredness and openness to community feedback and suggestions
when that impression is increasingly a sham. While that openness and
cooperative ethic was certainly genuine at one time, and Lynn's health
care system was greatly improved as a result, it is simply no longer the
case. Both the North Shore Medical Center and Partners HealthCare
representatives to these discussions have lost any ethic of genuine
respect for community based processes. Their working model is now decide
and announce. Our leaders are too busy to attend meetings simply to serve
as an audience for their announcements. Thus, this year we bring very deep
seated and fundamental concerns to your attention and ask for genuine
assistance from the Council.
What we ask is simple. We have followed your
precepts in our dealings with the hospital. Where the Council has
indicated that a request by the Task Force was unreasonable we have
moderated it. We have joined in efforts to allow the hospital to escape
immediate responsibility for long standing explicit violations of the
conditions by accepting their representations about equally explicit
remedial steps that they would take at dates certain in the future. These
future commitments have been made directly to you. The future is now. We
ask you to enforce these conditions by holding Partners Healthcare and the
North Shore Medical Center to the explicit agreements and commitments they
have made. Commitments to operate a specialty physician system under their
own auspices that fully addresses the need developed through a genuinely
collaborative planning process. A commitment to add five new primary care
physicians in Lynn by October of this year. We have been patient and we
have been fair. It is time for the Hospital to meet its commitments.
OTHER MATTERS
In addition to these fundamental issues, the Task
Force remains concerned about several smaller issues referred to in the
hospital's report. They are discussed individually below.
1. Statutory Free Care
As we have indicated consistently over the years
since the merger, and as noted above in the Free Care section (page 5),
Union Hospital has failed to meet its commitment to maintain Free Care
billings which represent 4.24% of gross patient service revenue. The
hospital's effort to minimize this failure by stating that in actual
dollars, the pool reimbursement has been relatively even is disingenuous
at best - since the percentages have dropped precipitously, it is obvious
that the reason that actual dollars are relatively even is that the total
patient revenues have increased, while free care has not kept pace as a
percentage of the revenues. The regulatory requirement is established as a
percentage, not as actual dollars, to prevent a claim such as the one made
by NSMC that suggests that it is acceptable to have a decreasing
percentage of Free Care utilization if the actual dollars remain even. In
addition, it is notable that while the percentage of free is declining,
the hospital has been successful in increasing overall revenues. This
success demonstrates that the hospital is able to achieve increases when
it has a genuine commitment to doing so - a genuine commitment that we
fear is lacking in the area of increasing free care utilization.
Further, as noted above, the Task Force's proposed
mechanism for the delivery of specialty services for free care patients
(making arrangements for specialist to be salaried to deliver specialty
services to uninsured patients both at the hospital and at
hospital-licensed space in the community) would have a significantly
positive impact on the hospital's performance under this condition, yet
the hospital continues to refuse this option and has not offered any
rationale to support is position.
Finally, as noted in the past, the amount of patient
charges billed to the free care pool ($4,271,803) does not reflect a
hospital financial contribution as the hospital receives reimbursement
from the pool. Any claim of financial contribution should be net of
reimbursement from the pool.
2. Interpreter Services
Paragraph 2.f. - The hospital reports that it has
maintained the staffing required by the merger conditions at five
full-time interpreters (two positions existed at the time of the transfer
and three positions were added). The hospital has recently made the
coordinator of interpreter services the supervisor for the outreach
initiative (the coordinator is one of the five full-time interpreters). As
a result, it seems inescapable that the actual capacity of the interpreter
services is being significantly reduced. Thus the requirement of five
full-time interpreters does not appear to be met under the current plan
for including supervision of the outreach program by one of the full-time
interpreters.
Paragraph 2.g. - The merger condition requires that
the hospital publicize the availability of interpreter services both
within the medical center and in the community. Task Force members are
unaware of any efforts undertaken in recent years to publicize the
availability of interpreters at Union Hospital. We have not seen publicity
at community agencies, nor on local cable nor in any periodicals
circulated in languages spoken by Lynn's linguistic minority groups.
Furthermore, regarding efforts within the hospital, your commentary
mentions signage in four languages. In our experience, the hospital has
resisted our suggestions about a significant effort at improving signage
for linguistic minorities. The only signs in languages other than English
that we have observed are the free care/EMTALA signs required by
regulation and the two sets of interpreter flyers that are in the
registration department and the Emergency Department. For those flyers,
the visible sign is in English, with the flyers on interpreter
availability in four languages not visible unless a patient actually goes
up and takes a flyer. The location in the emergency department is not
visible at the door or registration area, so a patient would have to have
already successfully registered and been triaged before possibly seeing
those flyers. The hospital has apparently rejected our suggestions of
having some visible signage outside the hospital making a welcoming
statement for non-English speakers, has also not followed through on other
suggestions such as a more general review of signage for non-English
speakers (can you imagine finding your way to the registration office as a
patient who can not read English?) and repainting the hospital's medical
van with messages in languages other than English.
4. Financial Investment
As you are aware, the NSMC and the Task Force agreed
last year on a process in which the Task Force would retain an independent
consultant to evaluate compliance with this condition. The Task Force did
hire a consultant, Professor Nancy Turnbull, in June, 2001. She made
requests for information from NSMC in order to perform this assessment. In
spite of her efforts to get the necessary information, she did not receive
all the information she needs until this month. Since NSMC did not provide
the consultant with the materials she requested, the Task Force has not
yet received the report from the consultant, and we therefore are not able
to comment on this condition at this time. We propose making this a focal
point of our reporting at the next reporting cycle, which will be in the
fall of 2002.
5. Primary Care
Paragraph 5.b. - The hospital's report notes that
its original commitment was to support two school-based health centers in
Lynn. The Task Force has no dispute with the hospital's support for the
school-based health center at Breed Middle School. However, there has not
been a second school-based health center supported by the hospital. We
recognize that other sources of funding have supported expansion of
school-based health centers in Lynn, but in any even the net effect has
been to reduce the contribution of NSMC from the commitment to supporting
two school-based health centers to actually supporting only one.
Paragraph 5.c. The Task Force's concerns about the
West Lynn site plans are described above on pages 6-10.
7. Transportation
The Task Force remains frustrated that there has
continued to be no systemic effort to address the undisputed issues
involving transportation to medical care in our community. We acknowledge
that NSMC has provided financial support for various discrete intiatives,
such as early and late van service for seniors (it is our understanding
that this service is for seniors only, not seniors and people with
disabilities as reported in the draft report) and taxi vouchers. However,
the Task Force has, since the initial merger discussions, proposed a more
comprehensive solution which would involve a central access point which
would permit patients to make one call and then be provided with a
solution to whatever the person's transportation issue might be, ranging
from the Ride, to senior transportation, to van and taxi usage. These
discussions have gone no where to date, leaving the Task Force
disappointed with implementation of this Condition.
We also note that while the draft report touts
efforts at internal education which have resulted in an increase in taxi
voucher utilization in the ED to 20/month, this rate seems surprisingly
low. Given the need for taxi vouchers reflected by other community
agencies, and the descriptions we have heard of the patient population
using the ED (up to 10 patients/day who are uninsured and/or unconnected
with primary care), 20 vouchers per month seems to reflect a continued
philosophy in the ED of lack of concern with serving patients who do not
fit the desirable profile.
9. Free Care Services
Paragraph 9. (b) - Pharmacy -- Once again, we note
that the draft report cavalierly refers to the pharmacy at 189-191 N.
Common Street as providing prescription drug access to all patients of the
site, which glosses over the Task Force's strenuous objection to the
hospital's plan to avoid licensing the specialty clinic itself.
The data for the Union Hospital Free Care Pharmacy,
while reflecting a positive trend, seem somewhat like the taxi voucher
usage in the ED. While the patient traffic through the ED has been
described as "as many as ten patients/day who are uninsured or
unconnected to primary care," the total of 15 free care discharge
prescriptions per month seems to be far short of the potential need. This
suggests that all staff are either not familiar with the possibility or
are not making real efforts to provide access to this service.
Paragraph 9. (c). - Free Physician Services - The
concerns of the Task Force in the area of specialty physician services is
discussed above in detail (pages 3-5). As is also noted above, if the
hospital accepted the Task Force's proposal for delivery of specialty
services, it would have a positive effect on the statutory free care
commitment, while its current plan does not.
10. Substance Abuse
Paragraph 4 - We note that while the draft report
indicates that the hospital is supporting an evening treatment program
provided three nights per week, it is our understanding that the service
is only operating two nights per week, from 7:00 pm to 8:30 pm (a total of
3 hours per week). See flyer attached.
Paragraph 6 - The meeting of the SHOLC Steering
Committee with DPH staff did not take place in late February - it may be
rescheduled for late March.
11. Mental Health Clinicians
Boston Street - The Task Force remains
disappointed in the performance of the Boston Street mental health
program. While the service may remain busy, it does not seem to be
succeeding in meeting the needs of patients with the biggest barriers to
receiving care. In particular, the Task Force is focused on the needs of
non-English speakers and uninsured patients. The Boston Street has had
very limited success in hiring bilingual staff. This seems particularly
hard to explain because the Task Force provided NSMC with a resume of a
Cambodian-born Khmer-speaking clinician. To our knowledge, she has not
been contacted. Furthermore, while the Boston Street site has the capacity
to serve uninsured patients and bill the free care pool, the data we have
seen shows an extremely low rate of free care patients (1%) which we know
is not reflective of the community's mental health service needs. We urge
the hospital to focus on advertising the service and the availability of
free care for uninsured patients to make this program genuinely available
to the many patients who are in need.
CONCLUSION
The Task Force is genuinely regretful that NSMC
seems to be retreating from its commitments. In our view, we have no
choice but to report to the Public Health Council on the major steps
backward we have seen in implementation of the DON conditions since our
last report in October, 2000. At that time, the hospital acknowledged
substantial failures in meeting its obligations and made assurances it
would do so in the next reporting cycle. As this report demonstrates, they
have not met their obligations in the areas of primary care, specialty
services for the uninsured, and free care. The Task Force has been patient
and reasonable in its efforts to seek implementation of the public health
commitments embodied in the DON license transfer conditions. We ask that
the Public Health Council hold NSMC accountable and enforce the DON
conditions that NSMC agreed to over four years ago.
1. Union Hospital has made
arrangements to prevent billing by its own staff physicians including
radiologists, anesthesiologists and emergency medicine staff physicians
but has done absolutely nothing to prevent billing from non-staff surgeons
and other specialists performing procedures at the hospital.
2. We note, in this connection,
that in a recent Boston Globe article about the upcoming retirement of
Partners CEO Samuel Thier, Partners states that it "has begun an
initiative to bring the best medical practices from its major teaching
hospitals to its three community hospitals..." (Boston Globe, Feb.
20, 2002). We are simply asking that Partners extend its policies on
requiring physicians to serve the uninsured to our community hospital.
3. In its report, the hospital
describes the arrangement as the "current NSMC Market Square Family
Practice will move to the new site and become part of the expanded
practice." As noted above, the doctor who started the Market Square
Practice has refused to join the new facility and will therefore be
leaving the Lynn area, and the second doctor at Market Square is also
likely to not join the new program. The Task Force find it disingenuous to
say that the current Market Square Practice will become part of the new
program when at least one, and probably both, of the providers associated
with that practice will be leaving the area.
4. Even if the obstetrics slot is
considered a primary care position, it is likely that this position will
be filled by relocating an existing area provider rather than by
increasing actual capacity.
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