John Livingston News Opinions / Op-eds

Where Does The Money Go?

In 1974, I was assigned as a Navy medical student for 3 months active duty at Portsmouth Naval Hospital in Portsmouth VA. This was at the end of the Viet Nam War and I had the privilege of being involved in the care of many wounded and injured sailors, soldiers and Marines including 36 returning POW’s several who became family friends later on in my career. At the time Portsmouth was able to accommodate 2000 patients—including the convalescent “C” units. The hospital had 2000 doctors, nurses, technicians and civil servants to take care of those patients—a ratio of one provider to one patient.

I was asked to visit Portsmouth several years ago and I had the opportunity to talk to staff and resident doctors. They have built a new hospital on base that can now accommodate 200 patients. There are now almost 4000 staff on base for a ratio of 20:1!

I asked what they used the old 17 story hospital for—the new one is 4 stories, and they said for administrative personnel.

I have been concerned long before the ACA, Medicaid Expansion, and the formation of Accountable Care Organizations (ACO’s) that the number of administrators was increasing and the number of providers was decreasing at a time when the number of patients was increasing. Economists know that when supply decreases and demand increases prices will always go up. We need more doctors, nurses, and technicians not more administrators and government bureaucrats. But the opposite is happening primarily because of the increasing numbers of regulations and the increasing scope of what health care really is supposed to do. Should our scarce resources with alternative uses go toward taking care of sick patients, or toward public health programs and preventive care? Should scarce mental health resources be used to identify and treat schizophrenia in adolescents, or should progressively decreasing resources be used to subsidize rehab services for the 4th time 45-year-old drug addict who has relapsed knowing that her recidivism rate will now be over 90%? Where do we draw the line when allocating resources between health and welfare, education, public safety, and transportation? Or do we just keep spending on everything not holding accountable the organizations and government agencies who traditionally have been tasked with defining and taking care of the public good and commonly allocated resources?

So in 2014 when I was given the opportunity to be briefed by Director Richard Armstrong and his staff and Dr. Ted Epperly who helped developed the Idaho Healthcare Innovation Plan (SHIP) I was hopeful until I saw the details of the plan. In my opinion, I could not see how any of the $40 million Federal Grant money was going to help those most in need living at the margins who through no fault of their own cannot afford to pay for their health care. As I again review founding documents via the DOH&W Web site that anyone can Google—Idaho SHIP Department of Health and Welfare, I am even more concerned.

It seems to me that the stated goals in the introductory statement of improving outcomes, improving access and the patient experience, and decreasing costs have little to do with paying for computers and internet platforms that will help implement new payment plans, introduce new data systems to evaluate morbidities and mortalities, and even help private practices buy Electronic Medical Record (EMR) updates. Are we building new infrastructure to accommodate new government regulations, or are we helping the 15% who don’t have insurance via the individual market place or their employer?

Two days ago in the Wall Street Journal was an article about the fact that many states are looking to cut Health Care benefits for State retirees. “States are testing how far they can cut benefits for current and future retirees as a way of coping with existing liabilities and future budget shortfalls.” From 1980 forward the accompanying graph to the article shows that the Consumer Price Index has increased 250% while the health care CPI has increased 550%. Interestingly this rise persisted even during 4 recessions when tax revenue to states decreased. Today the Federal contribution to Medicaid is over $650billion almost the same as the States’ unfunded retirement health care obligations.

Our legislators have put us in a real “pickle”. Is it not time to ask for full accountability from all stakeholders in the health care business including large non-profit providers, insurance carriers, and the State Department of Health & Welfare?

Maybe we should pass a law that all non-profits with over $100 million of transfer payments be required to undergoes an annual independent signed partners audit to be presented to the people’s representatives—the legislator who confer upon them their non-profit privilege.

Maybe we should insist that State agencies be required to present an annual audit of how monies are spent. Do we even know how the $40million for the SHIP program has been spent and have their stated goals of improving outcomes, improving access and the patient experience, and decreasing costs been realized? Has there ever been an audit of SHIP?

Maybe the State of Idaho should just build a 17-story building to house the ever-increasing health care bureaucracy—or is that what the Hewitt Packard transaction is all about?

Citizens have the responsibility of asking that our public and private and non-profit organizations be accountable to us. The reason this has taken so long to happen is that lobbyists—special interests like the IMA/IHA/IACI/COC have had more influence over our legislators than patients citizens and constituents, not to mention the influence of out of state organizations who have far more resources to support legislators or ballot initiatives

As we said 8 years ago

Cost before coverage

Coverage is not access

Access is not quality

Time for a change and some accountability on all fronts

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