Unresolved Safety Net Hospital Issues

Mr. Keefe,

First, thank you for taking the time to read my post and comment. There is no question that you have played a significant leadership role in health care reform both as a CEO of a major integrated healthcare delivery system, and now as the chair of the board for the Massachusetts Hospital Association. It is clear that your intent is to advocate for the best interest of your organization. However, I did want to offer a few comments in response:

Recent Actions: Credit is due for moving forward more aggressively to reduce costs than other organizations in similar situations. I understand CHA attempted to strike a balance and find cuts in different ways, which have not always resolved in a manner to CHA’s liking . Yet I would be remiss if I did not make note of the language chosen that should be worrisome to policy makers.  As you wrote :

“effort to improve efficiencies, lower costs, eliminate redundancies” have come “over the last 18 months” and were “contingent on retaining state and federal dollars.”

Wasn’t part of reform that these efforts start 54 months ago when the law was signed? Do strings have to be attached?

Payments: My bigger concern is that CHA and BMC continue on an unsustainable path. The fact remains that numerous special funding arrangements were put in place in 2006, and today CHA and BMC still argue that supplemental payments are necessary. Further, other valuable urban systems such as Baystate Health and Mercy Medical Center in Springfield, South Shore Medical (St. Luke’s) in New Bedford, and Lawrence and Lowell General Hospitals have struggled through reform without favorable treatment. While I don’t believe that I suggested public hospitals become superfluous, I do want to ask if you meant to argue that supplemental payments are justified because CHA and BMC have a more welcoming environment and translation services? Do these other hospitals not offer unique services as well?

If I were a state policy maker, the positions articulated in your comment would make me very nervous for the future. As you probably know, Pioneer exists to raise tough questions for policy makers, and we have been consistent on this issue since early on in the debate. The bottom line remains, the current financial path remains untenable. Do you disagree? If so, then why is CHA looking to merge or seeking a partnership?

The goal of my post was to highlight the past funding arrangement for BMC and CHA, and cite concerns under the federal expansion that directly impacts safety net hospitals. While CHA may provide “30x the health care to the uninsured” and “10x the health care to Medicaid/Commonwealth Care patients,” to the broader policy community it should raise some challenging questions. How is it that with almost 98% coverage, CHA is providing this much care? Are the Governor and Connector Board’s numbers wrong?

Alternative Focus: Unsustainable reimbursements are driving more patients into safety net systems as doctors refuse to take new Medicaid/Medicare patients, and it is likely to worsen as the Federal government expanded Medicaid to 16 million new people, and cut half a trillion dollars from Medicare. Doesn’t this seem like an issue of greater significance?

Payment Reform: It is great to hear that CHA is planning to participate in payment reform pilots, especially given your experience with the special three year MCO pilot I mentioned. Yet, do you believe that payment reform will eliminate the need for extra payments? Will we be having this same discussion in 3-5 years?

Election year: Beyond the funding issue, I must disagree that this issue is purely tied to the election cycle. It is slightly misleading to suggest this as the fiscal year ends now and budget gaps become public as a result. It should also be noted that Pioneer has argued in support of payments for BMC and CHA when the Governor proposed making cuts retroactively .

Finally, I must push back on your restaurant and soup kitchen analogy for two reasons. In this scenario, you suggest that patients only have access to the soup kitchen. However under health reform, the customers were given a ticket to access either location. Isn’t it possible that on occasion they might break their habit and end up going to the restaurant? It doesn’t necessitate closing the soup kitchen, but it might mean some change.

Secondly, I am sure you would agree that it is a disservice to compare CHA to a soup kitchen given CHA’s reputation for good services. I hope that we both can agree that providing better care for patients for less cost, whether private or public monies is a move in the right direction. It is my hope we can continue this discussion as health reform proceeds forward, and some of my questions can be answered.

Kindly,

Josh