Are US hospitals in trouble?

Many hospitals, especially more rural ones, have been in trouble for some time. More on the rural hospitals later.

“More than 33% of all hospitals are operating on negative margins, according to the American Hospital Association,” per Michael Popke of Benefits Pro in a piece called “America’s hospitals facing ‘massive growth in expenses’.” Here are two select paragraphs from the piece that tell the gist of the story.

“Hospital employment is down approximately 100,000 from pre-pandemic levels, while hospital labor expenses per patient through 2021 were more than 19% higher than pre-pandemic levels. A new report from the American Hospital Association highlights the financial and operational toll the pandemic and inflation has taken on hospitals — concluding that more than one-third are operating on negative margins.

‘Hospitals and health systems have been nimble in responding to surges in COVID-19 cases throughout the pandemic by expanding treatment capacity, hiring staff to meet demand, acquiring and maintaining adequate supplies and personal protective equipment to protect patients and staff, and ensuring that critical services and programs remain available to the patients and communities they serve,’ notes the nine-page report released this month. ‘However, these and other factors have led to billions of dollars in losses over the last two years for hospitals.’”

Per an article called “The South’s health care system is crumbling under Covid-19. Enter Tennessee” by Daniel Payne of Politico, the demise of heath care in more rural areas has been exacerbated by COVID-19.

“Rural hospital closures have been accelerating, with 181 since 2005 — and over half of those happening since 2015, according to data from the University of North Carolina. But that may be just the beginning. Over 450 rural hospitals are at risk of closure, according to an analysis by the Chartis Group, one of the nation’s largest independent health care advisory firms.”

The rural hospital concerns predate the advent of the Affordable Care Act. Too many hospitals had high percentages of indigent health care costs, meaning people without insurance. If they were not funded by a county, the hospital was at severe risk of closing. Since fourteen states have still not expanded Medicaid under the ACA, the opportunity for getting paid did not increase and many have closed. And, the patients, employees and communities suffer.

Yet, a major part of this cost dilemma existed before COVID-19. The US has the most expensive health care system in the world, but we rank around 38th in health care quality. That is a pretty poor rate of return on one’s spend. Hospitals spent too much on technologies that need to be used. There exists a correlation between the ownership of a technology and its higher frequency of use. Yet, with COVID-19 and its aftermath, fewer elective procedures and tests were done in hospitals.

These issues need to be evaluated outside of the political lens and with data. Yet, that is not bound to happen. It would at least be helpful to see more people covered with full Medicaid expansion, but that has been politicized for zero-sum game reasons, not to actually help people. It would be helpful to see Medicare expanded, at least down to age 62 from 65. As Medicare works reasonably well, I would like to see it go lower, but whatever we do, it should be evaluated on its results, not a politician’s beliefs.

If people think I am unfairly picking on politicians, it would not be a stretch to say most politicians do not know a whole lot about health care. We saw this with the atrocious “throw stuff against the wall” repeal and replace discussion in 2017 by the thirteen Republicans, which came within one vote from passing the Senate. That would have screwed about 20 million Americans. Senator John McCain gave it a thumbs down vote for its lack of veracity and its poor protocols on evaluation.

And, we saw it with the discussions and passing of the ACA, which Republicans refused to vote for which is strange since it has several Republican ideas in it from Romneycare in Massachusetts, when Mitt Romney was governor there. The ACA is not perfect, but at least we should fully implement it and shore up its deficiencies. It is only people’s lives.

Medical debt impacts 23 million Americans per Kaiser study

In an article called “The burden of medical debt in the United States” by Matthew Rae, Gary Claxton, Emma Wager, Cynthia Clark, Jared Ortaliza, and Krutika Amin, the results of a Kaiser Family Foundation (KFF) are noted. Per the article, a link to which is below, the following conclusion can be drawn:

“We find that 23 million people (nearly 1 in 10 adults) owe significant medical debt. The SIPP survey suggests people in the United States owe at least $195 billion in medical debt. Approximately 16 million people (6% of adults) in the U.S. owe over $1,000 in medical debt and 3 million people (1% of adults) owe medical debt of more than $10,000. Medical debt occurs across demographic groups. But, people with disabilities, those in worse health, and poor or near-poor adults are more likely to owe significant medical debt. We also find that Black Americans, and people living in the South or in Medicaid non-expansion states were more likely to have significant medical debt.”

Several years ago, I cited a study that noted medical debt was the number one reason for bankruptcy by individuals, so the above result is not a surprise. The groups that are most exposed are non-Hispanic Blacks at 16% and people in the age 50 to 64 demographic at 12%. Some of the reasons for this age group being higher is Medicare does not kick in until age 65, people are getting downsized in that group and employer retiree medical benefits have largely gone away.

I posted a piece from Politico the other day about rural health care suffering. An important reason is the fourteen states who have not expanded Medicaid to those below a certain poverty level. This has led to more rural hospitals closing and exposed people who do not have coverage to higher medical debt or forsaking care all together. The debt comes with people waiting until they are a train wreck before going to the ER, a more expensive place to get care.

One of the things I have found in my consulting experience as well as patient and care taking experience, access to health care is critical to a person’s health. The ability to get preventive care before the train wrecks also lowers the cost while improving one’s health. In the US, one of our warts is we are the most obese country in the world per the World Health Organization. We have supersized ourselves to earn that mantel. We must get ourselves on a better path before it becomes too late.

Access to care is key to getting on that better path, but making it a more affordable journey. When people say we have the best health care system in the world, that simply is not borne out by the data – we have the most expensive health care in the world; we rank in the low thirties in health care outcomes. We must use the system more wisely. All of us.

Rural Health Care is suffering (and COVID-19 has made it worse)

In an article called “The South’s health care system is crumbling under Covid-19. Enter Tennessee” by Daniel Payne of Politico, the demise of heath care in more rural areas has been exacerbated by COVID-19.

A key reason is the closing of rural and small town hospitals that has severely impacted immediate health care. A key paragraph from this article is telling:

“Of the 50 counties with the highest Covid deaths per capita, 24 are within 40 miles of a hospital that has closed, according to a POLITICO analysis in late January. Nearly all 50 counties were in rural areas. Rural hospital closures have been accelerating, with 181 since 2005 — and over half of those happening since 2015, according to data from the University of North Carolina. But that may be just the beginning. Over 450 rural hospitals are at risk of closure, according to an analysis by the Chartis Group, one of the nation’s largest independent health care advisory firms.”

These hospital closings are not new nor did they just happen. The financial difficulties predate the passage of the Affordable Care Act. In essence, a significant portion of the cost of running these hospitals went toward indigent care, meaning people without insurance. In some cases, it was over 50% and even as high as two-thirds of the hospital budget. This meant some of the revenue may be reimbursed by the local county, but if the county was in financial trouble or this was a private hospital, the hospital was out of luck.

The ACA brought with it the expansion of Medicaid, should a state opt in to cover people. The federal government would reimburse the state those costs for three years and then drop to 90% thereafter. All but fourteen states have so expanded. Per the non-partisan Commonweath Fund, Medicaid expansion helps the state economy, rural health care and the people in those locations. Former Republican presidential candidate John Kasich called Medicaid expansion a “no brainer” when he was governor of Ohio.

And, these hospitals are usually a major employer in these towns. So, when one closes, a lot of revenue leaves the town budget and economy. Belhaven, NC Mayor Adam O’Neil, a Republican, pleaded with the state leaders to expand Medicaid, but to no avail. So, he walked to Washington, DC to plead his case there. It should be noted that North Carolina remains as one of the fourteen states who have not expanded Medicaid.

As a retired benefits consultant, manager and actuary, I know the ACA is not perfect and could use some shoring up. But, a key reason for the ACA is patients need access to care and hospitals need to get paid for services rendered. If a patient has health care insurance, he or she will seek more preventative measures to stave off problems. Plus, he or she will seek care if needed, rather than avoiding it.

All of the above greased the skids for a problematic response to COVID-19. Without hospitals close by, people would forego care until it was too late. Plus, coordination of care with doctors to do triage and offer vaccines is hindered.

The ACA is not perfect, but it has improved access care for many people. I have written before about some suggestions to improve it. Yet, in fourteen states, the ACA still has not been fully implemented and in many of those states, they lag other states on health care results per the Commonwealth Fund. Expansion of Medicaid could be a major step.

https://news.yahoo.com/public-health-disaster-shuttered-hospitals-110000044.html

Every community needs a Mama

Since we are at the Ides of March in a month to celebrate women’s history, let me offer a brief glimpse of a woman who almost everyone in a small community in southwest Georgia called “Mama.” Not that they were related, but Mama was a health care giver for the community, a self-appointed nurse who helped many while the regional doctor was away.

When the doctor was in the area for his monthly visits, Mama would accompany him on his visits to hear and see what he had to say, but also to share her thoughts. She had such a good rapport with the doctor, she named one of her twelve children after him. In the interim, Mama would make sure the patients took their medicines, rested and did what the doctor asked. Since this was in the 19th century, many of the cures were home or natural remedies.

I have shared the story before about how her youngest boy loved gymnastic type exercise and would tumble or use any prop for his swings and dismounts. One day, he fell and knocked his two front teeth out of his mouth. He gathered them up and ran in with his bloody mouth. Mama sat him down and boiled some water while she cleaned his mouth. She then dipped the end of a dish towel in the hot water and rinsed it quickly. She told the boy to put the towel in his mouth “as hot as he could stand it.” She cleaned the teeth off and then shoved them back into his now-swelling gums and they held.

I love this example and have heard and told this story many times. Her name was Carrie Jane and she was my great grandmother. Since everyone called her Mama, my grandmother’s children included, they would call their own mom “Mother” in deference to Carrie Jane. I never got the chance to meet Mama, but I do know her children grew up as both characters and with character, my grandmother included.

As an example, she called one of her daughters Carrie Bell, but my grandmother would not call her sister that. Instead, she would call her “Cow Bell” as a means of teasing. And, when Carrie Bell would come to visit, she would ask us kids if we wanted to play “marbles” which was her name for the board game Aggravation.

Growing up in a rural area (using town would be inappropriate), people formed a kinship and helped each other out. These folks could not pay Mama for her services, but would bring the family fresh produce as a means of recompense. If a baby was coming, everyone would go find Mama. I think there are mamas like this in every small community.

These are the kind of women I wish to honor today. People may not have been related to them, but they touched many lives. Thanks Mama and all of the mamas in our history. Tell me about the mamas in your history.

True story of a community health care provider 100 years ago

I have shared before stories about my maternal grandmother’s family. She grew up in southwest Georgia in a small community along with her thirteen siblings, with one passing at birth and another dying as a young adult. My grandmother shared that her Mama was the chief health provider in the community and would accompany the visiting doctor when he would make his rounds once a month.

The following two paragraphs were written by my third cousin based on interviews with his grandmother (a sister of my grandmother) and her brother who was the youngest of the surviving children. It is further evidence of their Mama’s health care role, using a very appropriate historical marker in one episode.

“There was a bad flu epidemic in 1918 and five of the children were in the bed with the flu at one time. People all around were dying, and my great uncle tells me he vividly remembers the hearse passing their home several times during this flu epidemic. The hearse was a glass enclosed carriage drawn by big white horses. My great grandmother was able to get her children well by using a home remedy of kerosene, turpentine and tallow. She made bibs, soaked them in the above mixture and placed them on the sick children. Also, they had cedar water buckets that were smaller at the top than bottom. They would fill the eight-to-ten- quart bucket with water and put a little fresh turpentine in it and drink it for colds.

Other home remedies included using the gland from a hog and placing it on the clothes line to dry out. When it dried, my great grandmother would boil the gland and remove the jell which was used for arthritis. She called this jell ‘pizzle grease.’ She did not understand or have the education to know why it worked, she only knew it did. Today this ‘pizzle grease’ is know as ACTH which is a polypeptide hormone of the anterior part of the pituitary gland that stimulates hormone production of the adrenal cortex and is used to treat arthritis.”

Let me add one more story that I have shared earlier. The youngest sibling noted above liked being a gymnast. When he was an adolescent, he was swinging his whole body over a single bar like the male gymnasts do. He fell and knocked out his front teeth. Mama asked him to sit down as she cleaned the teeth and boiled some water. Once boiled, she put a clean towel in the water and rinsed it with cold water. She said put this in your mouth as hot as you can stand it. This was to swell his gums. Once swollen, she jammed the cleaned teeth back into the gums and the teeth held.

These stories amaze me at her ingenuity and practicality. A couple of sidebars to this story, my great grandmother married when she was only fourteen, begetting fourteen children. My third cousin also writes the family survived the depression, as did many farmers, by growing their own crops, raising their own meat sources and making their own soaps. He noted they only bought sugar and coffee. They had no electricity using kerosene lamps and wood stoves (in a separate from the house kitchen). And, water was stored in two 66 2/3 gallon barrels they called Hogsheads, which sat in the covered walkway to the kitchen.

We should remember these stories when we complain the wi-fi is down or the power goes out. Please feel free to share your reactions and own stories in the comments.