Community Health Improvement Planning
I have a bunch of pieces related to this, many within the rubric of a recommendation that DC could create a world class public health infused hospital and health and wellness program "East of the River", which I wrote about in a bunch of pieces in 2017.
-- "Ordinary versus Extraordinary Planning around the rebuilding of the United Medical Center in Southeast Washington DC | Part One: Rearticulating the system of health and wellness care East of the River"
-- "Part Two: Creating a graduate health and biotechnology research initiative on the St. Elizabeths campus"
-- "Part three: the potential for donations around an expanded program"
-- "Revisiting East of the River medical care: United Medical Center"
-- "Update on DC's plans to build a new United Medical Center," 2018
A couple months ago, DC's Mayor announced a "health task force." ("Mayor Bowser Establishes Commission to Help Transform Health Care Delivery," press release). Frankly they should start with my writings...
This piece, a kind of follow up, discusses how the Affordable Care Act requires that hospitals create community health impact assessments. The ones I've read are so general as to be worthless, and that is the case for the documents I've read that have been produced within DC.
-- "Another example of a failure to do public capital planning in DC: Council votes to stop funding United Medical Center," 2019
While following up today on something else, I came across the Monroe County Nutrition Workgroup in Wisconsin, which is part of the county's public health system and also is connected to Cooperative Extension.
And that led to the county's Community Health Assessment and Improvement Plan, which is referred to as a CHIP or Community Health Improvement Plan. According to the forward of the plan:
The Wisconsin Association of Local Health Departments and Boards, along with the University of Wisconsin Population Health Institute’s County Health Rankings & Roadmaps, partnered to develop the Wisconsin CHIPP Infrastructure Improvement Project.There are plenty of writings about community health assessments of various sorts. DC has a formal process too:
-- Community Health Needs Assessment, DC Department of Health
But given the example of the cessation of the DC Cancer (Support Services) Consortium discussed in a recent Washington City Paper cover story, "The Collapse of the DC Cancer Consortium Left Gaps in D.C.'s Cancer Care Network," as well as the problems in implementing opioid abuse interdiction programs ("DC opioid crisis: Overdose initiatives still in planning stages," Washington Post), and the decision by the Department of Disability Services to shift a key support program from Georgetown University to a firm with a lot of DC contracts, but many of them around maintenance and construction ("Backlash intensifies over DC plan to end disabilities services contract," Post), I suppose like a lot of the city's planning documents, there is a major disconnect between planning and implementation let alone a sense of urgency to act.
Labels: equity planning, government oversight, health and wellness planning, provision of public services, public health, urban planning
posted by Richard Layman @ 4:29 PM&Permanent Link
7 Comments:
https://www.theatlantic.com/ideas/archive/2019/08/what-america-got-wrong-about-opioid-crisis/595090/
also interesting Washington local John Delaney ( I knew him when he lived in Georgetown 25 years ago) makes on medicare for all -- that is what Howard bas been going through (almost no private insurance) and why it was financially failing for a number of years. I don't think your proposed EOTR plan can deal with that reality (that medicare/medicaid can't pay for the cost of a hospital program).
I'd also say DC has a chance with the insurance market to drive some innovation (state-like) for urban needs. Better HSA options, better options for concierge medical care, more competition. Not an insurance person but I don't see why (other than Grasso doesn't want it as former Blue Cross lobbyist) that any company that want to sell a corporate plan (federal workers) has to offer a private option as well.
Granted the number of non-insured people is very low in DC as a result of medicaid expansion -- although the medicaid program is terrible.
Good points, especially about Howard. I didn't realize you've been here that long... and I didn't know Delaney was once here, but it makes sense.
WRT your point about my SE hospital proposal, I am sometimes too pie in the sky theoretical. There's a reason the city doesn't want financial involvement with UMC, it's a sinkhole, and will only grow over time.
OTOH, not having decent health care EOTR results in different kinds of costs.
I figure that combining the two cost-revenue streams could make it work, but I am no financial analyst.
But it does get at the point that we are debating the wrong stuff. Ultimately, it's all about "insurance" when it should be about health and wellness care.
E.g., the article about the Type 1 diabetes 26 year old who went off family insurance, didn't have the $ for insurance, and died.
We need various methods of providing care, and paying for it.
I am not wedded to "Medicare for All." I do believe we need health care for all, special programs for dealing with chronic conditions, etc.
Mercy (St. Louis). Mercy is committed to delivering a transformative healthcare experience, launching several health initiatives to improve patient care. Every few years, the system conducts a community needs assessment to understand how to increase access to care. They use the assessment to understand how to increase access to services. Through the assessment, the system provides $550 million in community benefits annually. Since its founding 200 years ago, Mercy has put a strong emphasis on health equity. As part of the emphasis, the system uses de-identified data from decades of advanced EHRs to achieve a more complete view of patient needs. The approach helps to reduce any patient inequities. The system is also committed to diversity, equity and inclusion initiatives, attracting workers and senior leaders of different backgrounds. The system also has mentorship and development opportunities for women and employees of color.
Becker's Hospital Review
12/6/2023
Interesting points about the difficulties of approving projects in the face of multiple hospital systems and their plans, and the overall effect on health care costs.
How many cancer beds does Boston need? Planned Dana-Farber hospital sparks questions.
https://www.bostonglobe.com/2023/12/14/business/boston-cancer-beds-dana-farber-beth-israel/
The institute plans to build a 300-bed hospital just for cancer care, working in partnership
with Beth Israel Deaconess Medical Center. Burstein sees this coming development as
momentous as the one in 1997, one that will again influence the nature of treating cancer in
Massachusetts for decades to come.
... But the ramifications of the new hospital could reverberate far beyond Dana-Farber and its
patients, for its expansion isn’t happening in a vacuum. There are other hospitals with big plans on cancer care and the combined effect of those will present state regulators with the difficult duty of figuring out just how many new beds the state needs and can afford to have. A miscalculation could result in higher health care costs — ultimately saddling patients with the bill.
... Building more beds is not only the most expensive solution to the current capacity problem, it also is one of the riskiest. Hospitals tend to use the beds they create,whether there may be
less expensive ways to care for patients, exacerbating the very spending problems the state
has long sought to remedy.
... It is this delicate calculus that Massachusetts regulators now must weigh. But often there are shortcomings in how the state reviews projects — critical to controlling unnecessary medical spending — and it has repeatedly failed to do the health care planning it is obligated to do.
“We’re shooting in the dark,” said Don Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement and former administrator of the US Centers for Medicare and Medicaid Services. Without more data, Berwick said, large health systems will set their own agendas for expansion. “That may or may not be good for taxpayers, patients, the Commonwealth, and other badly needed social investments.”
Despite the unanswered questions about the future, one thing is at least clear about the
present: there isn’t enough capacity at hospitals across the state, with patients sitting in
emergency rooms waiting for beds.
... Yet, the demand for in-patient beds is nonetheless expected to increase because patients needing hospital care will likely be sicker and require more intensive treatments and hospital
service, Jones said.
... Calls for better planning that would identify such problems and help regulators determine what the state needs have gone unheeded for over a decade.
https://www.bloomberg.com/news/articles/2024-01-23/nathaniel-witherell-nursing-home-is-a-strain-for-wealthy-greenwich-connecticut
Even This Wealthy Town Struggles to Run Its Nursing Home
Greenwich, Connecticut, owns a 121-year-old nursing home. That makes it unusual, since only 5% of nursing homes are government-owned.
... Its Nathaniel Witherell nursing home, however, like many such facilities across the country, is losing money.
Founded as a contagious-disease hospital in 1903, the 202-bed nonprofit facility offers short-term rehabilitation as well as long-term and memory care. Situated on what the town describes as 24 rolling acres — two miles from downtown — it touts staff turnover that’s a fraction of the national rate. Its kitchen gets its produce from the facility’s culinary wellness garden that was built in 2017 with donor and volunteer contributions.
But Greenwich had to write off $4.1 million in bad debt from the nursing home last year, according to documents for an upcoming $115 million bond and note offering. It still expects to continue funding the nursing home’s operating losses in subsequent general fund operating budgets.
... There’s also a lot more pressure on small, single sites, which can’t achieve economies of scale, she said.
Seeking to stem the nursing home’s losses, Greenwich put out a call in 2020 for an outside operator and is negotiating a long-term lease agreement with a chosen operator, according to its recent bond documents.
“I think a lot of people would agree the town is not looking to sell the facility or the land; we’re looking to see if there’s a better way to deliver services,” said Camillo, whose position is equivalent to mayor.
Rural Nursing Homes Are Closing, Hollowing Out Small US Towns
https://www.bloomberg.com/news/articles/2023-10-11/us-rural-nursing-homes-are-closing-hollowing-out-small-towns
At its peak, about two decades ago, the Good Samaritan nursing home in Mott had 60 residents and employed 80 staff, pumping $1.5 million into the local economy, says Troy Mosbrucker, the town’s mayor and school-bus driver, as well as the owner of a car wash and a storage depot. Business at the town’s drugstore dropped 40% after the home closed in July 2022, according to owner Chuck Oien. His wife’s grocery store also saw a decline, as did restaurants and hotels that catered to out-of-town family members when they visited.
... The sequence of events that led to the home’s closure started in 2019, when Good Samaritan, then the largest nonprofit operator of nursing homes in the country, with 200 facilities, merged with Sanford Health, another nonprofit and the dominant health-care provider in the Dakotas. Sanford announced it would be shutting the Mott facility down in a May 2022 letter to residents and their families that cited difficulties in recruiting staff and attracting residents.
... Rachel Werner, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania’s Wharton School, says state and local governments have to “step up” to save homes. But she acknowledges that’s not likely, given there’s “very little appetite to invest in long-term care in this country.”
Mott is trying to be the exception. When the nursing home closed, residents sprang into action. They hired consultants, went on local TV to draw attention to the town’s plight, and compiled a YouTube video highlighting the home’s history and their quest to reopen it. The publicity helped the town secure a $1.2 million grant from the state’s commerce department. A committee put the money to work on a renovation that will shrink the number of beds to 22, freeing up space for the town’s existing clinic to move into the building. The home, which is slated to reopen next month, will operate as a basic-care facility, with less than two dozen staff members, meaning it won’t be able to accommodate patients such as Gratz’s wife, who needed round-the-clock attention.
Raising the money was the “easy part,” Mosbrucker says. “Staffing is going to be the hard part.” Covid-19 exacerbated an existing labor shortage in rural North Dakota, which had been losing population for decades as small farms merged and mechanization displaced workers, scattering young people to Bismarck, Fargo, Minneapolis and other cities.
https://www.bloomberg.com/news/features/2021-10-01/mercy-hospital-gets-second-chance-to-provide-health-care-to-chicago-s-poor
For most of the 20th century, local governments ran the hospitals that cared for their poor. But starting around 1970, health-care costs began steeply and steadily rising; per capita spending on health care is now 31 times more than it was then, according to federal figures. The public hospital model became a burden for local taxing districts, and more jurisdictions turned their health-care systems over to the private sector.
Today, fewer than 10% of general hospitals in America are owned by governments or a public hospital district. Those that remain—a list that includes Provident, which is run by Cook County—often complain they’re forced to compete on an uneven playing field. Privately operated hospitals aren’t held to the same standards of social responsibility, they argue, and as a result can cherry-pick patients likely to bring them a profit.
... They placed much of the blame for the hospital’s struggles on the way medical insurance works for the poor. Only 22% of Mercy’s patients were covered by private insurance plans, they explained. A majority were on Medicaid or were uninsured. The patient mix is important because different insurance plans pay hospitals different amounts for the same services. Private insurers reimburse hospitals roughly twice as much for all services as does Medicare, according to a 2020 survey by the Kaiser Family Foundation. Medicaid, the government plan for the poor, pays the least: Another Kaiser study reported that Illinois’s Medicaid program reimburses hospitals just 61% of what Medicare does. Taken together, these surveys suggest that when a private insurer pays $1,000 for a procedure, Medicaid in Illinois pays about $307. Federal and state aid programs compensate hospitals that provide charity and reduced-cost care for poor patients, but Trinity officials said it’s not nearly enough to bridge the difference.
“The Medicaid funding model does not cover the cost of care,” Edward Green, a lawyer representing the company, told the regulators, “let alone leave any room for equipment or capital repairs or improvements.”
... The big hospitals were “siphoning off commercial and Medicare patients,” in his words. The only new patients Mercy could attract seemed to be the poor who were abandoned after the closures and downgrades of other South Side safety nets. “The burden of treating those patients has largely landed on the doorstep of Mercy,” said John Capasso, Trinity’s executive vice president.
... Inside the Dearborn Homes public housing project, Etta Davis opened Facebook and stumbled across a post about the hospital’s pending closure. This was news to her. She started asking around, wondering if she was the only one in the neighborhood who hadn’t heard.
“Nobody in my community knew about it,” she said. “Nobody knew. I was like, ‘You mean to tell me Mercy didn’t even give their patients the right to know they’d be closing?’ ”
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