Series on hospitals in North Carolina

The Raleigh (N.C.) News  and Observer had a nice series last week (Prognosis Profits) on the hospital industry in the state, focusing on the profitability of non profit providers, and the difficulty of the uninsured navigating the system. Many assume that if you are uninsured you just show up and get whatever care you want, never pay, and suffer no harm. This is false.

The link to the entire series is here (~100 links, with some top notch reporting).

A few highlights of the series:

The bottom line for me from the story is that there is a great deal of public money flowing to support non profit hospitals in North Carolina, but that money could be spent in a more efficient manner that could provide a clearer answer to what patients can expect (to receive and to pay) if they are uninsured and need hospital care.

Hospital Market Concentration Discussion-ctd

Austin (@afrakt) posted a FAQ on the effect of hospital market concentration on hospital prices last week. Avik Roy (@aviksaroy) also posted about this recently and Dan Diamond (@ddiamond) and Charles Ornstein (@charlesornstein) are tweeting with them about the influence of hospital/health care system aggregation on the health care system generally. They have generally been noting that health care systems/large hospital providers have far more market power than do health insurers.

In my neck of the woods, UNC Health Care System yesterday rejected a $750 Million hostile takeover bid from WakeMed, to purchase Rex Health care, a hospital and health care system based in Raleigh, N.C. The players are as follows:

  • UNC Health Care is the University of North Carolina at Chapel Hill’s health care system, whose flagship is UNC Hospitals. It is a state-owned system. There are massive budget cuts for the University this year, so the potential of a $750 Million cash infusion could be attractive.
  • WakeMed is a large hospital in Raleigh (N.C.), around 30 miles from UNC hospitals. Wake Medical Center is a large county hospital that is now the center of this large Not for Profit health care system known as WakeMed.
  • Rex Health Care is a Non Profit hospital and health system also in Raleigh, (N.C.) that UNC Health Care owns, and which WakeMed says UNC hospitals uses to unfairly compete with them. WakeMed wants to buy it from UNC.
  • Unmentioned in this story is the other massive player in this area, Duke University Health Care, that owns Duke Raleigh Hospital, another Non Profit hospital and health care system in Raleigh (N.C.). Duke also controls Durham Regional hospital and the hospital in the county immediately north of Durham county.

At some level, everything around here is UNC v. Duke, be it basketball or health care. There has been tremendous aggregation of medical practices in Orange county (where UNC is located), Durham county (where Duke is located) and Wake county (where WakeMed, Rex, and Duke Raleigh) are located. Duke and UNC mostly have Durham and Orange counties locked up, and both have been competing for practices in Wake County as has WakeMed; the quickest way to gain power is to purchase a hospital and its affiliated physician practices.

One event that may have touched off or accelerated this attempt by WakeMed to challenge UNC’s power, was the announcement last winter of a pending joint venture between UNC Health Care and Blue Cross Blue Shield of NC, the largest private insurer in North Carolina (with around 70% of the market share) to directly provide health care in the Research Triangle area.

From where I sit, the only real long run provider system question in this area is whether the Research Triangle becomes UNC v. Duke only, or whether WakeMed is able to survive, thrive and grow to make it a three-way competition? How these sorts of questions play out in many local markets nationally will have a great impact on the health care system in the future.

*Full Disclosure: I am an employee of Duke University. I have no role in the functioning of the health care system in either a policy or administrative manner. My wife is a nurse at UNC Children’s Hospital in Chapel Hill, an affiliate hospital of UNC Health Care.



Two Thoughts About Hospice and Reform

Eleanor Clift has a nice article recounting a personal story about her husband’s experience with hospice, and how this fits into health reform.

Second, Brad Flansbaum’s suggestion to yesterday’s post–An Example for the Super Committee–of looking at this piece on readmissions was a good one. The summary of their arguments (in the table) are that the move to address

readmissions, while understandable, may penalize hospitals for factors beyond their control. Most importantly, they worry that low income and marginalized communities may be far more likely to experience what I would call ‘social readmissions’ that could result from inadquate family/careigver/social support. They end up in the hospital for reasons that the hospital cannot be expected to address, and this could lessen the willingness of hospitals to care for such communities.

I agree that as we currently think of hospital care such issues are outside the purview of hospitals. However, if this is the reality of some of the patients covered by Medicare, we need to figure out how to address these problems, both on a quality and cost basis.

In the original post, I was noting the need to tear down silos. Hospice and palliative medicine are disciplines who claim to address the full patient and to begin from their goals to devise a plan of care that makes sense for them and their family. This expertise, which is now “siloed” is needed more broadly in the health care system. The focus on patient goals and accounting for the needs and abilities of caregivers is needed throughout the system. Just blaming the hospitals (and paying them less) for readmissions won’t cut it. We need to figure out a way to deliver the needed care to the patients covered by Medicare. This is the type of breakthrough that the many demonstration projects created by the ACA are designed to lead to.  I hope someone manages to show the way ahead in dealing with these issues. It is much easier to point out the problems than it is to devise practical solutions.

Not to belabor it, but this will be hard to do under any circumstances. If any pilot project that brings hospice or palliative medicine techniques and perspective to bear on other aspects of the health care system becomes “death panels” or some other absurd misstatement, we have no chance. We desperately need a political health reform deal so that moving forward to address quality and cost throughout the system is the responsibility and expected tasks of both political parties. And so that we learn to seek evidence, evaluate what it means, and move ahead to improve policy without everything having to first and foremost be another “bullet” in political war.