Nibbling Around the Edges

My wife and I had an incredible experience in the Luke’s downtown ER last night. Lynn has a 40-year history of kidney stones, and she was in incredible pain when she presented herself to the ER. Everyone from the admission desk to patient transport to the CAT scan techs and most certainly the doctors and nurses who treated her last night were competent, professional, and exemplary in the way they discharged their patient care duties and responsibilities. We are lucky to have such human capital in our medical communities in Idaho. Thanks to everyone.

The problem is that over the past 10 years, St. Luke’s has been guided by an administration and a Board of Directors that has lost their sense of “mission”. They have only to look to and follow the lead of the clinicians working in their hospital to become again committed to their stated mission of patient care.

Instead, they have taken their cues from government agencies and large corporations and lobbyists representing large medical groups and hospitals—not patients. There is always a change in the commitment to serve the patient when secular values replace Christian predicates of charity and compassion. A former CEO of a major hospital system in Boise once told me “John…..no margin, no mission”. The mission for health care clinicians—doctors and nurses, in Idaho has always come first. Those making very important decisions in the administration of our hospitals—not so much. Those people working in direct patient care and the patients of Treasure Valley deserve better leadership. I am reminded of

St. Luke’s—should we stop using the (St.) in front of Luke’s—?, has become an institution primarily concerned with profit. They are a real estate company, a bank, an insurance company, and quasi-institution “in politic” and most recently “in law”, and a finance company that is the epicenter of the securitization and redistribution of government transfer payments. They have a former CEO who made over $18milion his last two years on the job, at least a portion of which was derived from fungible government transfers. They have well over a billion dollars in revenue—closer to two billion and over a billion dollars in reserves, and much more of that in commercial real estate assets. They pay no property taxes and very little sales tax. They publicly disclose their financial positions on IRS Form 990, but never submit themselves to a complete and in-depth financial audit to be made available to the people of Idaho via their legislators—the people who fund their revenues with taxes and those who decide budgets for agencies that regulate and then redirect transfer payments.

The promise supported by both the Idaho Hospital Association and The Idaho Medical Association during the Affordable Care Act debate and then the debate surrounding Medicaid Expansion was to increase access— increase quality—and decreased costs. None of those promises have been realized while at the same time the absolute value of the State’s contribution to the $4.5 billion Medicaid budget has increased dramatically due to the underestimation of Medicaid enrollees, increasing costs, and estimated 33% rate of fraudulent enrollment and an estimated 30% increase in “up billing” and “upcoding” by providers.

When the Federal Medical Assistance Percentage changes, the burden on State budgets will be severe, but not as severe as the burden on patients and their families. And everyday citizens and employers will pay the price by increasing insurance premiums and taxes. For a review of this almost certain eventuality read a recent Wall Street Journal article https://www.wsj.com/articles/fitch-downgrade-could-mean-medicaid-cuts-expansion-utah-financial-ready-plan-a48c7278

The system is a mess, and our legislators tell us that we can only “nibble away at the edges”. This is an irresponsible response to a system that is already making access more difficult to those who the system was supposed to help in the first place and who should be helped—those living on the margins who through no fault of their own cannot take care of themselves. Here are some ideas if our legislators want to be serious and responsible moving forward:

1. Nibbling around the edges won’t help.
2. There should be independent signed partners forensic audits of all institutions that receive over $100million of transfer payments per year. These should be made available to the legislature and the people on an annual basis and be a condition for future transfer reimbursement.
3. The sales tax and property tax exemption for “non-profit” institutions needs to be reviewed and when appropriate withdrawn. These two institutions paying taxes could lessen the tax burden on citizens.
4. The Department of Health and Welfare needs to be audited by an independent auditor—ASAP. The Idaho Health Information Exchange bankruptcy needs to be reaudited and explained.
5. Assessment fees for providers is an idea that was just presented to me today and that I will have to explore. It was suggested once before twenty years ago and didn’t receive much traction due to the pressure put on the legislature and Governor by the hospital and physician lobby.

To those people who work in the clinics and the ERs and operating rooms, and those who take care of mothers in labor and their babies and anyone who has made it their vocation to take care of sick patients are the true “lions in the fight” I again say thank you.

I am reminded of comments made about the British infantry in WWI regarding the leadership and the troops:

“They were lions led by donkeys”. Donkeys “nibble”. Lions take big bites.