Big Box Medicine? Yes!

I’m stuck at the intersection of harried and impatient, CVS pharmacy pick-up.

When a staffer yells, “Consult!”, customers grumble like a time-eating latte request had infiltrated the black coffee line. I smile, bearing witness to what is fast-becoming nostalgia -- actual in-person interplay with a licensed medical professional.

I’m imagining how the pharmacy and its retail personality will morph as big-box and digital behemoths enlarge and repackage their patient pathways and services.

CVS, Walgreens, Walmart and Amazon are pumping billions into new insurance partnerships and subscription services, home care, clinics, dentists, audiology, X-ray techs and behavioral counselors.

They want to be our medical homes for everyday maladies that needlessly jam emergency departments and for annual shots, labs and cleanings. Their sales pitches lean on convenience, simplicity and, relentlessly, connectivity.

The retailers are targeting the low-hanging, fixable dysfunctions in our sort-of health system, profitable process improvements, coupling one-stop shopping for health and household needs.

Sick, no doctor? How about a Costco clinic visit concluded by stuffing your cart with cheesecake, detergent and potting soil before retrieving your RX? Our mishmash of urgent-care centers can’t top that.

CVS, which owns the insurer Aetna and MinuteClinic, is spending nearly $11 billion to expand its pharmacies and health insurance plans into primary care medical practices, especially Medicare. Amazon has invested nearly $4 billion in a similar venture with annual memberships.

Big hurdles include shortages of providers, state curbs on reciprocal licensing and limits on the scope of some medical practices. Then there’s possible bad photo ops of full service becoming too full.

Retailers extol a new “digital ecosystem.” Algorithms, artificial intelligence, your medical history and your pulsating BP and real-time blood glucose infused to your smart phone.

No surprise, more patient involvement is required. Think about your last lab trip. Aside from a phlebotomist’s draw, didn’t you do most of the computer-entry work?

I’m excited by multimedia public education involved in building Walgreens or Walmart patient health homes, links to neighborhood centers and easing disparities, possibly using promotores, community health workers, for Hispanic outreach.

This is a small part of restructuring the legacy healthcare marketplace which still regards tertiary-care hospitals as everything’s medical hub.

Hospitals would remain a linchpin for in-patient critical care but would be more sharply branded and educationally defined by what they are not.

The United States acted nobly when it broadened care for its citizens, introducing Social Security in 1935, Medicare and Medicaid in 1965 and the Affordable Care Act in 2010.

The system has fallen flat in patient education and preventing remediable problems from resurfacing as critical-care needs. Hospital invoices remain more indecipherable than the Dead Sea Scrolls. If there’s no clarity, there should be no government reimbursement or licensure.

Even in framing their survival strategies, hospital execs aren’t patient friendly: “harnessing inefficiencies … embracing alternate payment models … creating a symbiotic relationship between hospitals and vendors.”

While I futilely pursuing an ear specialist, his phone tree repeatedly reassured that my time and patience were valuable and that I should treat whoever answers the phone with kindness. The scars of Covid remain fresh.

Medical mail retailers are spared the 24/7 overheads of hospital trauma centers, the plethora of state-specific earthquake mandates and billions in uncompensated care costs.

Vacant strip malls and regional shopping complexes are being revived as condos, homes for the unhoused and new retail-medical partnerships. The Urban Institute reports the nation has 1 billion square feet of surplus or obsolete retail space.

We shouldn’t continue to merely reset acceptable levels of deterioration in healthcare access. Opponents of the Affordable Care Act warned that if we educated consumers a little, they’d consume more medical services and worsen the costly logjams.

I’ll wager that there are successful retail business models in right sizing care for non-urgent needs, alleviating a chunk of “sit, wait and ache” emergency department visits.

I’m imagining healthcare shifting from complaint driven to compliment inspired. I’ll grab chocolate bark at checkout to feed that buzz.

John G. Taylor is a former journalist and retired California hospital system executive. He lives in El Dorado Hills, CA.

My Daughter: A Teacher With Covid

(My daughter, Erin Taylor Koht, is a public school teacher who lives in Rescue, CA. She posted the following on Facebook on Nov. 24, 2020. I’m sharing it, proudly, with her permission. Please celebrate the holidays — all days — safely using your free will to share good will.)

“I don’t understand why no one can talk about their Covid diagnosis.

“I am Covid positive. I am a mom, wife, and a teacher. I told my class when I tested positive. Everyone has been awesome. I’ve had a few friends be harsh, but I believe it’s because they are scared. I have had families tell me I’m brave for telling them. Brave .... I’m not brave. The front-line workers are brave.

“ I just wanted to give my parents a peace of mind as they received an anonymous email that someone was positive. Why is this a secret? Why are people ashamed?

“I didn’t do anything to catch this or give this to my family. It’s a pandemic. Why can’t we take care of each other ... lift each other up.

“I know on (Thanksgiving) Thursday I’m giving thanks ... thanks for my family having the holiday together, thanks we are surviving this, and prayers to the families that have lost ... I feel thankful my family has survived this pandemic.

“Love and hug your family.”

Empowering Yourself for a Hospital Visit

I kick into self-defense when I walk into a hospital. It starts with homework done long before my head is gridlocked by worry, basic research everyone should do.

The pandemic is a pointed reminder that we invest more thought in buying hair color than knowing where’s the nearest trauma center. Or why that should even matter.

We lump hospitals together with cemeteries and prisons. We shoot them a glance, a glare or a glad I’m not there.

I’ve been an insider, working for a hospital system, trying to translate its idiosyncrasies to community leaders and electeds and to modify some of its idiocies.

I’ve been a patient, flatlined and been revived. I’ve welcomed kids, cringed over grandkids’ broken bones. I’ve bid prayerful farewells. Hospital staffers are a praiseworthy tribe.

Still, try as some do, hospitals rarely engage the public in holistic ways. Thus, our first encounter may be stepping through a million-dollar weapons detector, followed by the castor oil of “insurance card and ID, please,” and questions that beg Methuselah-like memory.

No surprise then that hospitals haven’t persuaded us that emergency departments are not the Yellow Brick Road for all needs, dental through mental.

One hospital size – the one nearest you -- may accommodate but not fit all needs. If you’re knocked catawampus in the mountains, the hospital that first greets your bones may be the one that keeps you alive until you’re shipped to a more complex medical center that saves your life.

If hospitals listed ingredients like Frosted Flakes, choices might come clear: a rehab center for hip fractures (protein) vs. a cosmetic lip enhancement specialist (additional sugar).

Self-empowerment improves the likelihood of your getting appropriate and successful treatment.

You can start by compiling a personal health history, a bullet list of surgeries, injuries treated, allergies and current medications and homeopathic products. Include dates, dosages and providers names.

Providers are required to create (and share, within legal limits) your electronic medical records, so this is your starter kit.

Mine is two typewritten pages.

Because I can review its contents, I can engage my stressed caregiver who’s likely skimming the document and may overlook a crucial sensitivity (allergy to mint, perhaps, which is infused in most toothpaste and floss).

Our family lists are kept in a red emergency folder, along with a durable power of attorney and key family phone numbers.

When my wife recently broke her collarbone, my usually reliable brain panicked as the emergency medical team arrived. I grabbed the folder and regained focus as questions surfaced at the hospital.

Such a health resume is your personal protective equipment. If a relative were quarantined behind a nursing home window, I’d want that tip sheet in my hands.

It needs a critical companion – a grasp of what services your local hospital offers and what it does especially well.

“The Golden Hour” refers to the narrow time window to preserve life, brain and body following accident, heart attack or stroke.

For heart attack symptoms, beeline to the nearest hospital. For stroke and serious trauma, the keys are access to clot-busting medications and microsurgery specialties. There’re typically in major urban medical centers.

You can browse hospital services online, like buying sheets from Target. Better options include chatting with the nurse or volunteer next door and, when the pandemic is history, testing your hospital’s vibe by lunching in its cafeteria.

The pandemic reminds how thin our government and medical resources can become. The budget-cutting ahead may worsen that.

I can’t fathom a healthier step now than becoming an effective self-advocate.

John G. Taylor, a former journalist and retired California hospital system executive, lives in St. George, Utah.

(This first appeared as an op-ed in the May 4, 2020 edition of the Salt Lake Tribune.)

Holiday Mayhem: Media as Victims

Forty years ago, before random shootings became commonplace, a hilarious holiday gathering of Milwaukee journalists concluded with an after-party at a bar called the Knew Boot.

I wrote the attached story on the 10th anniversary of the tragedy that occurred at that bar. It was published in 1989 by the American Society of Newspaper Editors. I’ve lost track of Paul and John, but I’ve never forgotten what happens when journalists become the story.

The Original Story

Living Without California

The sweaty gym sock of San Joaquin Valley air is in the rear-view.

When I mushed to California nearly 40 years ago, a mechanic said my Wisconsin car “had the disease” – from Rust Belt road salt. I leave now mottled from the disease of breathing -- allergies, asthma and bone-stripping prescription rescuers. My wife, a Valley native who twice sang in Europe with California choirs, has surrendered her choruses to coughing fits.

We can no longer live the aspiration that pollution is being slowly throttled. To us chokers, it’s a pipe dream.

Long-timers aren’t surprised by our leaving.  Many friends are weighing their own pull out.

Allergies, asthma and bronchitis steal into your life – no red flags, just dingy skies caked in microscopic particulates and baked in invisible ozone.  The scat we breathe is born of wildfires, agriculture, fireplaces for ambiance and for heat, cow methane, pesticides, diesel-spewing 18-wheelers and the geographic bad luck that wedges fetid Valley and Bay area air into a 50-mile-wide fissure of ag land, cities and national parks and forests.

We snore, thrashing riotously in phases of apnea. We breathe as though gargling through our noses. Our lungs rattle like a bag of marbles.

Oblivious, the Fresno area pulsates with new people and businesses. It’s affordable in a state riven and weakened by economic extremes. Affordability has primacy in California’s Maslow’s scale of livability.

My first 20 years in Fresno earned me the scar of asthma. Who knows how much ozone and PM 2.5 I’d blithely breathed. Some 20 years later I’ve joined the cast of “sensitive group,” a gelatinous term to diminish that all of us are living in a toxic risk environment.

Maybe if the daily air smelled and tasted like burned popcorn we’d pay attention. Maybe if we all wore beeping air monitors as though reconnoitering Chernobyl. Maybe if our electeds viewed us as more than a churning of mine canaries. That maybe is more real than the likelihood our health will stabilize or (ha!) get better by staying and praying.

Trust the regulators? The kind of pollution detector you employ, where it’s placed, how it’s read and how and when you share its data – that’s tinkering with my expiration date.

Medical remedies? We survive on crutches of antihistamines, decongestants, injections and, especially, daily maintenance and emergency inhalers. They can morph you into a chattering squirrel, saturate you in sweat and exhaust you like a spent marathoner.

For sensitive groups, “getting out” in Central California means getting the mail and taking out the trash. Hiking in Yosemite? Hollering for the Grizzlies Triple A team and the post-game fireworks? Too risky for pollution hermits.

Leaving packs a gut punch of guilt. We’re walking away from one of life’s treasures. The kids we raised here have stayed. We can – we could -- watch their kids converge on a soccer ball or wiggle holding an academic award. When hard luck hit, we offered welcoming shoulders.

Instead, we’ll schedule time-zone-friendly Skype calls. And being alive, however remote, will be our presence. There are no friends or family – yet – in our new Utah locale.

Guilt led me to another question: Have I been complicit in allowing our air to be salted with manure? Consider how we’ve passively, progressively allowed our airways to be crammed with every manner of fragrance or chemical taint.

An air-freshener electric pump has replaced the Glade manual sprayer. New cars and offices are dabbed with wallet-opening aromatic enticement. Sen-Sen has reappeared to spur a gag reflex. Try to find a toothpaste without mint. Is your mouthwash aroma different than your toilet-cleaner scent?

Real, faux and toxic scents – who wants a vanilla world? Soon, the hot item might be a scratch-and-sniff card for clean air. And suddenly the most important players on the football field are the bench-side oxygen tanks.

We’ve invested most of our lives in establishing family roots and growing with Central California, my wife as a teacher and I as a journalist. We will grieve it hard but lingering here might be the last bad move of our lives. We can’t chance it.

John G. Taylor, a former Fresno Bee reporter and editor, is owner of JT Communications Company. Write to him at jtcommunicates@comcast.net.

Below is a link to a podcast and story by Valley Public Radio reporter Kerry Klein detailing the personal impacts of Valley air pollution:

http://kvpr.org/post/some-move-work-or-family-these-fresno-residents-want-escape-air

The Inhaler as God

John G. Taylor

Running out of time. The grandkids are finishing Tee-ball, soon the inhaler will go from Mom’s purse to their gear bag.

Central California -- the state’s backwater, the nation’s breadbasket, a glance while ogling Yosemite at 30,000 feet -- is roiling in money and newcomers with nowhere else to go. It’s kicking up the Fresno-area economy as grape vines and fruit trees are disked and mulched to make way for 300k-starter homes, more warehouses for the Gap and Amazon, waystations for international truckers and sheds for deep-drillers of fast-vanishing wells.

In our bedroom where the air purifier echoes Darth Vader, we awaken with plenty of sinus congestion and coughs. Any hope that the San Joaquin Valley will see resolution of its acidic pallor is receding faster than our reservoirs.

More than 100 languages are spoken here. For nearly 40 years I’ve added Brooklynese to this once-swell place where your kids walked with nary a fear to the school playground. I’m a “blow in” compared to my wife whose Mennonite kin have worked as farmers, judges and business owners for generations in Fresno’s neighbor, the once-tiny ag city of Reedley which posted her family name on a nice tree-lined street.

We chat in arcane code about the day’s threats … ozone, PM2.5, red flags and co-morbidities. Steroids help us edge through. Pills, inhalers, shots, sometimes multiples in a day, each leaching calcium from our bones, weakening our immune systems and slapping a depreciation sticker in our life-insurance actuarial tables.

Our aspirations accelerate our respirations spurring our expiration.

Our lungs are tenements of soot, soil and fuel toxins. The remedial promises of regulators, lawmakers and moneymakers are as squishy as cow manure pits. The pits’ residues soon marinate into breathable fragments along with acid rain and fog, and forest fires fueled by trees suffocated by pollution and vermin.

Wherever you live in the US, the cheap coin of blame and accommodation arrives by front-end loaders.

• Clogged sewers converted the relief of a New York City summer rain into pungent Okefenokee in Brooklyn streets.

• When summer smog engulfed Hartford, Conn., long-timers assured me it was a summer thing, just go fishing early.

• In Groton, Conn., the sea-breeze window opened only when Pfizer wasn’t brewing a noxious pharmaceutical.

• Milwaukeeans blamed the industrial fountains of Gary, Indiana, for the taupe swirl of skanky metals in the air near Lake Michigan, though I found it scant danger compared with the turgid nightly spew from south Milwaukee tanning plants and downtown beer brewers.

Maybe we can taper off, detox ourselves, with emission curbs, carbon tradeoffs, green-friendly transit and agriculture, quickening the speed of pimple-sized Fiats that tremble from the buffeting of 18-wheelers. But maybe is a weak drip feed. Maybe is our palliative care.

When we talk it’s like gargling, words spew with coughs. We cringe as our children now adults grapple with the drought of breathable, non-medically enabled air that imperils their kids, our grandkids.

We are all “on the clock,” morphing into statistics for the likes of the American Lung Association and the Alliance of Automobile Manufacturers. Clean air as optional extra. Chevy Nova to Prius to hearse.

I wrote this after being interviewed by Detroit Free Press (and former Fresno Bee) reporter Phoebe Wall Howard for a story detailing air pollution impacts vs. the fight over vehicle emission standards. Our comments comprise the story’s last five paragraphs.  Here’s a link: https://on.freep.com/2GSoeKO

John G. Taylor, a former Fresno Bee reporter and editor, is owner of JT Communications Company. Write to him at jtcommunicates@comcast.net

The many lives of newspaper dating ads

Before eHarmony and Ashley Madison, there were words-only newspaper dating ads, resembling agate listings of losing baseball teams.

The Fresno Bee rolled out its version in the early 1990s. Time heals, so I stand now to offer the Bee public forgiveness for a misdeed.

I had been cajoled then into placing an ad by two married friends, insisting I’d become too painful to watch in becoming suddenly single after twenty years. I guess Sugar Pops and Pepsi for breakfast further eroded my moribund mojo.

So, I nudged my DWM out there along with slivers of G-rated hankerings that, if so charmed, could progress to a pay-per-listen phone message.

I felt like both chum and chump. With several popes’ worth of monogamy under my belt, I weakly whispered a call for wise, witty and professional women with affinities for the Yankees and “off-beat” lectures. I intoned about the whereabouts of the Dead Sea Scrolls.

Though sounding as amorous as a shedding sloth, I experienced occasions for a catholicity of sin. There was the test of coffee, tea and woe-is-me; a taste of Friday Hot ‘n Now; golf as religious and spiritual obstacle course; and other Freudian tête-à-tête that fed my mind with endless replays of a favorite Allman Brothers’ tune, “Whipping Post.”

During this rapture, I also worked as the Bee’s religion reporter. This was the heyday of the Promise Keepers movement, Louis Farrakhan and scandalous televangelists. While I was meekly trying to set up something, I wondered about being set up.

Cancel the ad, I ordered. Immediately relieved, there followed a weekend of penitential repair for force-feeding spaghetti into a garbage disposal.

Then rang the phone. The Bee had screwed up. The dating ad was published again, past its cancellation.  

She’d seen me dripping wet, reporting from a soggy Martin Luther King Day parade. She was a marcher, who liked galleries, museums and the Yankees.

I activated my deflector shield of civility. Well, says I, to the sunny-voiced woman from Reedley, if you ever visit Fresno (lo, a biblically long 25 miles), do let me know and…

She called my bluff, concluding my dangling sentence by calendaring a Sunday lunch in a public place (my request).

She wore a green sweatshirt and a pulsing, peach-colored smile.  I could sense her warmth, as I deliberately walked past her sitting at the restaurant, pretending she wasn’t just about the mall’s only other sorry soul seeking a solution to solitary Sundays.

As I neared the down escalator -- I swear I was about to turn around – she left nothing to chance. No way, she said later, no way you were getting away that easy. I went through a lot expensive phone calls to catch up with you.

Thus, did the Bee’s mistake jump out from the page.

After she finished her pastrami, I suggested a short drive for a quick tour of the Bee news and press rooms. We could watch robots move tons of newsprint!

I told her to follow my white Toyota. I was driving a white Honda. Had her guessing.

I swear the redhead’s Ford pickup had a gun rack, along with a pox of dings, dents and a relentless fluid leak. 

She insisted she was a Mennonite pacifist and hinted I was dumber than an empty Pez dispenser when it came to knowing about sliding windows and pickups.

I recall little else beyond her inviting me to a second, equally unique date the next week at City Hall. There, as she snuggled a grandbaby, I watched the family celebrate her son-in-law’s police swearing in.

Some call the printed news a snapshot of history. Twenty years, roughly how long I was in the Bee’s trenches, and there were mistakes on both sides, So, boss types, no need to promise a “free” paid obituary to set things straight, although it would be a kick to have.

We’ll chalk it up to it just desserts as we celebrate our 20th wedding anniversary. When you’re married to the news profession sometimes it will marry you, even by mistake.

John G. Taylor, a former Fresno Bee reporter and editor, is owner of JT Communications Company. Write to him at jtcommunicates@comcast.net.

The charade of patient education

The healthcare system has saved my life but my only trust is in its dedication to delivering incomprehensible bills.

Promises of patient-friendly invoices quickened with the Affordable Care Act in 2010. But closed-door jawboning has resulted in what many view as the usual self-perpetuating flimflam.

To wit: “The government created the mess that we’re forced to use (hint: blame them). … If we become too public, our competitors will put us out of business. … The formula for what we charge is proprietary information (suspicion: there is no reward for clarity).”

Invoices are a Pandora’s Box of hieroglyphics and hierarchies culminating in “patient share … pay this amount.” There’s neither  education nor empowerment in the drumbeat toward collection agencies. Ghosts still run the machine, which seemingly flaunts examples of excess.

Take the NYC Health + Hospitals corporation. The public health system cut nearly 500 management positions this year, saying it would save $60 million in fiscal year 2018.

"Today we've implemented a difficult but necessary action to help build a stronger, more agile and more stable public healthcare delivery system," said Stanley Brezenoff, interim president and CEO, in Becker’s Hospital Review. "By restructuring and reducing unnecessary layers of management, we can better direct resources where we need them most — at the front line of patient care."

So, until now, the resources were being squandered by layers of bureaucracy putting care was risk? We all pay for this doublespeak.

Executives know the price of everything but the value of nothing – save grandstanding. Why else would Daniel Snyder, CEO of Shreveport, La.-based University Health System, try to one-up a Louisiana state senate hearing inquiring why his company hadn’t paid a $12 million debt for Louisiana State University physician services.

There’s not be enough documentation to support the request, said he before whipping out a $6.2 million check from his coat for said services. So there, enjoy the half a loaf I’ve been carrying for lunch.

"If this is how you conduct business, the future doesn't seem to be too bright," replied a stunned Finance Chairman Sen. Eric LaFleur in Becker’s Hospital CEO newsletter.

Patients are jittery as they enter the sprawling boxes of concrete with jail-like windows. How do I get to the head of the line and out of here quickest -- in good health?

We are compelled to present government identification, proof of insurance (sound like a traffic stop?), to sign and pre-pay (credit card would be ideal, I’m told, but is that a good idea?) and authorize things that supposedly shouldn’t occur but which I’ll never recall approving anyway.

I’m compelled to trust whatever caregiver is assigned to me -- who changes every eight to 12 hours -- that they will adhere to the same care plan and advocate for me as my condition changes. That’s a fragile, frightfully important task remanded to strangers when my physical and psychological faculties are unsteady.

Troubling, too, is how little caregivers know about the cost of services.  More than 60% of emergency medicine clinicians can’t accurately estimate the costs of care, according to a study in the Journal of the American Osteopathic Association.

That’s odd given that administrators expect doctors to stick to a formulary of medications and a defined storehouse of gear and tests that have been proven to cost-effectively get the job done.

Fiscally empowered doctors can involve patients in cost containment.  When told that as part of cataract surgery I could have lenses installed that would end reliance on eyeglasses – if I forked over an additional thousand dollars – I opted to keep my eyeglasses.

Given the punitive nature of billing, it’s no surprise that:

• A survey from Bankrate, a financial planning site, found that a quarter of 1,000 adults went without treatment because of cost.

• Nearly 70% of patients with hospital bills of $500 or less didn’t pay off their balance in 2016, up from 49% in 2014 (Healthcare Financial Management Association).

• Those who can fork out thousands a year can bypass insurance by buying concierge care – “me first” access to doctors and medical facilities.

Explaining a hospital bill ranks right up there with educating patients about lifestyle choices. They’ve been triaged out of the picture by politicians and providers as too costly, time consuming and raising more questions they don’t really want to answer.

(Also published as an op-ed in the July 8, 2017 edition of The Fresno Bee.)

John G. Taylor, a former Fresno Bee reporter and editor, is owner/operator of The JT Communications Company LLC. Write to him at jtcommunicates@comcast.net.

Telling a doctor 'no' -- A healthy option

By John G. Taylor

No, you can’t autopsy my father. When I was 19, saying no to a physician was like cursing at a priest.

I mustered the answer because it carried certainty – funeral then burial then true mourning. Years later, I grasped deeper consequences – Dad becoming body, then cancer specimen, then data blocks and, overriding all, an autopsy delaying everyone getting on with their lives.

In medicine, saying no has muscle. Patient told there are no beds, no chances of survival and no water after midnight. Physicians told no end to paperwork (verifying, testifying, glazing over), no end to pushy hospital administration (earn your privileges) and no relief from second-guessing.

It takes courage for a patient to say “no” or “not yet” to a physician’s recommendations. It arises from conflict –  frustration, mistrust, fear.

For some, it launches dialogue –  persuade me how your therapy will benefit me now and 10 years from now. For the newly insured, it’s a blunt challenge to the white-smocked expert that he explains my care in simple doughnut-shop speak.

Why is such transliteration not built in? The jagged-glass payment system doesn’t reward education and lifestyle management.

No requires homework. The doc says you need a total knee replacement. After a lengthy wait for a second opinion, you opt for a simpler, outpatient meniscus repair. In between, you’d scoured the Web, talked to physical therapists and patients. Maybe you’ll need a new knee, but you weren’t sold now.

No – to hand reconstruction. That was a hand surgeon’s high-cost, long-recovery remedy for a recurring cyst.  You chose less radical but highly cringe-worthy draining by a primary care doc. Author-surgeon Dr. Atul Gawande said incremental care, providing a grocery store of services, never gets the credit it deserves. Skilled specialty surgeons draw research grants and myriad resources, while primary care docs are lucky to afford a nurse.

Biopsies, mammograms, colonoscopies – gray areas to patients. Physician-as-mentor won’t pillory you for wariness. There is time in a bottle – watchful waiting -- for lots of ailments and diagnostic tools. Even so, the patient should feel compelled to remind a physician about worsening aches or discolorations.

Physicians are rarely praised for their relentlessness, selflessness and frenzy. Neither are abusive physicians pursued for their self-lubricating criminalities with the zeal we accord terrorists.

Some patients need to be told no. Some milk the system to feed addictions (so much so that California enacted CURES, an electronic data base that tracks prescriptions for painkillers and other controlled substances). Some saturate emergency departments as though they were taking free carnival rides (Fresno County has taken steps to deter such “frequent fliers”). And some patients – and doctors – need to experience a hard stop when it comes to pumping kids with cough medicine and useless antibiotics for the convenience of pawning them off as healthy enough for day care.

Patients should weigh their words carefully. Unlike politics, good manners and civility count for something. A January 2016 study in Pediatrics found that nurses and doctors didn’t provide the same quality of care when they encountered rude behavior.

Navigating no is getting more complex. For one thing, the hands-on part of caregiving is diminishing. Your doctor visit doesn’t routinely include checking ears, throat and eyes unless they’re attached to your complaint.  Medical intermediaries abound – tasked with gauging your blood pressure and pulse, taking an X-ray. You’re supposed to know – instinctively? -- what not to ask them.

So, digging in your heels may get you the higher-up attention you want. Any doctor who doesn’t appreciate a patient’s commitment to his own well-being deserves a turnstile not a waiting room.

(Also published as an op-ed in the Jan. 28, 2017 edition of The Fresno Bee.)

John G. Taylor, a former Fresno Bee reporter and editor, is owner/operator of The JT Communications Company LLC. Write to him at jtcommunicates@comcast.net

Hunting for a new MD: Recurring nightmare

On a scale of dreadful things, searching for a new family physician ranks up there with hunting for a divorce attorney.  Unlike divorce, pursuit of a new doctor has become nearly an annual punishment.

What’s worse, the triggers for this torture are increasing.

• Elections: It was called the Patient Protection and Affordable Care Act when it became law in 2010. But political demonization quickly lopped off “patient protection.” It’s not hard to imagine that repealing/replacing Obamacare will hugely upset the patient-physician relationship.

• Networks: Insurers annually rejigger their accounting Rubik’s Cubes, and our favorite docs quietly disappear from “the network,” leaving us “physician du jour.” Patients lose in the caregiver numbers game. The California Health Care Foundation found 40% of California physicians provide 80% of Medi-Cal visits.

• Life cycle: Physicians die or open wineries in Paso Robles. The Physicians Foundation found that 46% of 17,000 doctors surveyed are accelerating their retirement, cutting back on patients or getting out of direct, hands-on care. For those who remain, morale is tanking.

• Bad habits: Injecting 20 million newly insured into a chaotic industry has encouraged the Dickensian viper pit behavior of the worst medical practices while leaving unmet the need to educate new patients.

Doctor shopping is the opposite of speed dating. Docs aren’t standing by the window with shades open. This is more a mandatory trial marriage or the luck of a mail-order spouse. It comes with a whole built-in family of doctor/insurer-preferred relationships – the preferred hospital, X-ray services and pharmaceuticals.

I’ve rarely seen it happen, but it would help if doctors and patients openly aligned their expectations from the start.

• Timeliness, courtesy, clarity and follow-up. Mistakes ought to be rare and acknowledged. Dishonesty and evasiveness, unacceptable.

• Bring a script or crib sheet reminding you why you’re seeking medical help. Also, bring a list of medications, surgeries. And take notes while the physician is assessing you. “Patients need to be more sophisticated and do more homework,” said Dr. Alan Kelton, a Fresno primary care physician and faculty member who specializes in internal medicine at the University of California, San Francisco Fresno medical education program.

• “There’s less touching than in the past, and fewer head-to-toe exams,” said Kelton. Patients need education on routinely self-monitoring chronic conditions such as high blood pressure and diabetes. More physicians are engaging in email follow-up with patients, although payment and liability concerns remain. A patient’s after-hours call needs a better mechanical engagement than “call 911.”

• The need and value of medical tests needs to be weighed, especially given disputes about mammograms, PSAs and others. What will insurance cover – and what may happen with the results? Still more tests, involving a specialist?

If there is truth to “patient-centered” care, then we must vaporize the dehumanizing institutional maze.

Patients are not “the 2:30 appointment.” Often under-dressed and sometimes dehydrated, they are cold-shouldered into an overly bright room encountering a man whom they see rarely and briefly but always in the most vulnerable times in their lives. The feel is like slipping into a crevasse.

Doctors are not typically coddled craftsmen who flash through patients like FBI mugshots while whining about burdensome paperwork that rewards them comparatively lavishly. In slivers of time, they must repeatedly sleuth a remedy based on what patients say, how they look and act and what new evidence can be uncovered. Success and satisfaction aren’t assured and rarely arrive in tandem.

For both parties, access remains the No. 1 issue. A backed-up waiting room may well signal a compassionate and involved physician – someone who has trouble turning away need. Physician and patient are wholly interdependent. Both need to get their acts together because every failed audition ultimately can turn tragic.

(Also published as an op-ed in the Dec. 10, 2016 edition of The Fresno Bee.)

John G. Taylor, a former Fresno Bee reporter and editor, is owner/operator of The JT Communications Company LLC. Write to him at jtcommunicates@comcast.net

Hospital quality: Spinning the 'Wheel of Fortune"

What’s a good hospital? The one good enough in a life-or-death event – the nearest emergency department for a heart attack – may not best when you have time to plan for a heart bypass, knee replacement or hysterectomy.

Truth is, the wellspring of informed intelligence for patients on medical decision-making is murky and likely will take years to clarify.

Irrespective of the Affordable Care Act, reform was urgently needed for our episodically wonderful and nearly indecipherable health system.

But the critical conversion from volume-driven payment to pay-for-performance – quality outcomes borne of cost-effective, best practice medicine – hasn’t yet resulted in a universal, reliable value-driven scale. Sure, the jargon bandied about is sensible enough for Google News readers – centers of excellence, star ratings, the patients’ choice.

Consumers are being told what they want to hear and where they ought to seek care. But there’s no definition – among insurers, providers and regulators – on a single set of benchmarks to separate fair, good, excellent and execrable. No one has created a medical Federal Reserve Board to oversee and certify best practices and practitioners.

Yes, the Joint Commission, the premier hospital evaluating body, has certification programs. So do insurers and organizations like the National Cancer Institute. But it’s not clear if they share their criteria or evaluation methods.

Consumers are still tasked with substantial, Byzantine self-education. So, in a Yelp world, how about a star ratings system for hospitals? That major controversial step occurred last July.

The Centers for Medicare & Medicaid Services released its first star ratings for hospitals based on 64 quality measures ranging from patient satisfaction, to mortality, readmissions and safety and effectiveness of care.

Few hospitals earned five stars; some prestigious names earned one. The Central Valley had one five-star facility (Fresno Surgical Hospital) and one of the state’s and nation’s lowest (Tulare Regional Medical Center with one star). Even those who did well criticized the methodology.

Consider a few of the wild cards involved.

Take readmissions. Not every hospital operates an emergency department, and even fewer are teaching hospitals which educate future physicians.

Hospitals which have both, like Fresno’s Community Regional Medical Center, are likely to see more patients with multiple chronic illnesses that have sporadically, if ever, received medical attention. They arrive in bad shape, take longer to leave the hospital as an inpatient and are more difficult to place with follow-up continuing care. For socioeconomic reasons, their progress may be hard to track. As a result, many are readmitted within 30 days of discharge for their same problems.

The result: Such hospitals may be hit with federal financial penalties. And their star ratings suffer.

How about patient experience? One survey aspect involves querying how pain is being addressed. Pain management is a complex science that factors in a patient’s ailments, age, other medications – and whether substance abuse is an issue. Here again, safety-net hospitals get hit harder on ratings that those that don’t have emergency departments or take Medicaid patients.

“They liken or cheapen medicine to a 4-star hotel rating,” one longtime Valley physician told me.

Fact is, being held to a very public standard of accountability – however shaky it now is -- insults some, infuriates a few and encourages those who believe in a more holistic, transparent approach to well-being.

“Administrators know the lay person cannot ascertain truth concerning quality care nor can they define it,” my physician friend said.  “It is an experience!  And the image is part of the experience.”

Many folks don’t know anything about their caregivers – their training, what they do well and, more importantly, what they do rarely or poorly. Patients may not know an endoscope from an angiogram. They trust and do what they’re told.

They don’t research (asking Siri doesn’t count).

The myriad of ratings and possible excellence centers is, at best, a convoluted start for the clear, sustaining education that consumers – and caregivers – urgently need.

(Also published as an op-ed in the Sept. 24, 2016 edition of The Fresno Bee.)

The martial arts of common courtesy

We continue to screw up two of our most powerful words: thank you.  Give a simple “thank you” to a cashier. If you get a response, it’s: “No problem … Sure ... Who’s next?”

The airing of “You’re welcome” makes you gasp. And “It’s been my pleasure” transports you to Downton Abbey.

We’re nearly as lousy with “I’m sorry.”

Apart from politics, we’ve fallen so far in the art of civility that it’s costing money and prompting action. Nearly every industry is attempting to hardwire customer service – aka, common courtesy -- into its employees.

Hospital attorneys are even coaxing some administrators and doctors into injecting “I’m sorry for our errors” into oral and written explanations to patients and their families irrespective of lawsuits that often attend medical mistakes.

Most of us are forgiving folks. Just don’t spit in our faces if you’ve accidentally jammed a door into us. “What can I do to make it right” goes a long way in affirming good will, especially if it can be made real – a complimentary meal, a write off of charges.

Doing the honorable thing has become such a surprise that I can easily recall three personal examples.

A jammed bathroom pocket door had trapped a granddaughter during a visit. She was in tears by the time we extricated her. We hired a carpenter and were satisfied with the outcome of his hours of work.  He shook his head. Don’t give me your money, he said. It doesn’t pass my muster.

Wow.

News reporters and editors often don’t see eye to eye. During my decades in the newspaper business, the office atmosphere was “condemn in public and praise in private.”

I once cautioned a Fresno Bee editor about a story I was covering on a Saturday night. Nation of Islam leader Louis Farrakhan was scheduled to speak.  He was regularly in the national spotlight, frequently criticized for anti-Semitic comments. He would talk for hours – loading his most contentious remarks in his final 90 minutes. I’d listened to numerous speeches and knew the arc of his oratory. This won’t work within regular deadlines, I said.

Deadlines are deadlines, the editor told me. We’ll publish what we can in the Sunday paper and trust that will be enough.

As usual, reality snickered at benchmarks.

Local television and radio had captured the midnight hour rhetoric, commanding the Sunday airwaves. Community leaders were outraged that their newspaper of record contained nary a word. And my byline was attached to a story that chronicled only the eloquent calm before the vitriolic storm.

The next day my editor sought me out. I blew it, he said. You were right and I should have figured something out. I’m sorry. Will you please write a follow-up story and make it right with the readers?

Wow. Never heard such self-effacing comments from an editor before or since.

Lastly, some expressions of honesty crack the mold. I was 30, living in Wisconsin when my mother died suddenly in the New York City area. During her wake, her physician – who’d taken care of me as a child back in the days when doctors made house calls – pulled me aside.

I’m shocked and sorry, he said. I should have better monitored the potassium levels for her heart. As I struggled to react, he shook his head and then my hand, and walked away. It was the last time I would ever see him.

As I near the age at which my mother died, I’m still astonished and refreshed by his “out of nowhere” candor and caring.

I’m a tad late. Thank you, doctor.

(Also published as an op-ed in the Aug. 27, 2016 edition of The Fresno Bee)

Killing off, adding hospital beds --- Why?

Hospitals nationwide appear to be seesawing over the fate of hundreds of inpatient beds and, with them, the future of thousands of jobs, entire communities and how patients will get care. The add-them, subtract-them decision isn’t so much a show of uneasiness as it is the result of hard realities, often unique to a hospital’s geography, as well as redesign born of healthcare reform.

In California, billions are being spent on retrofitting or new construction to ensure that hospitals meet earthquake standards that take effect in 2030. The deadly 1994 Northridge quake resulted in a legislative mandate that has caused some hospitals to close, downsize or sell to others who envision something other than intensive care beds on hospitals’ pricey, seismically rocky coastal real estate.

Whether the end result will provide sufficient beds to handle California’s growth and aging Baby Boomers depends on where in the state you live. In a 2015 report, the California Health Care Foundation said the San Joaquin Valley and the Inland Empire may be hard pressed to meet demand by 2040.

Different factors play out in rural areas, especially in southern states. Changing reimbursements have inhibited the ability of smaller hospitals to weather financial challenges, to satisfy requirements for installing electronic records and to lure and retain physicians, especially specialists. Some may call them “mom and pop” hospitals, but many smaller hospitals are critical “way stations” for healthcare emergencies, tending to patients until they’re transported to higher-acuity locales.

With fewer than 100 beds – many of them unoccupied – these hospitals are closing or becoming freestanding emergency departments where state laws permit.

Sometimes a single decision can push a once-successful small hospital to the edge. That’s occurring in Coalinga, Calif., where the district hospital took a huge fiscal hit when California shifted care of nearby state inmates to distant, newly created prison hospitals.

In New York City, the problem has been a chronic oversupply of beds coupled with costly, politically charged labor agreements.  Sometimes that has meant paying sizable staff and operational costs when there were few or no patients to oversee.

Nearly 20 city hospitals have closed since 2000, and Mount Sinai Beth Israel has been facing a fiscal crisis threatening its existence. It’s opted to try something radically different. Over the next four years, it will replace its existing 856-bed hospital with a 70-bed hospital with an ED as part of a massive expansion of outpatient care services.

The scale of transformation at Mount Sinai is astounding. Some of the 4,000 unionized workers will need to be retrained or laid off.  Perhaps $700 million in hospital real estate will be sold. The institution’s goal is focused on outreach and public education, to avoid or remediate medical issues before they necessitate costly inpatient care.

The seesaw effect of the Affordable Care Act of 2010 is nowhere close to flattening. The U.S. Centers for Disease Control said the nation’s uninsured rate in 2015 fell to 9.1%, the lowest on record. It was 16% when the law was signed, 14.4% in 2013 before its major provisions kicked in, and 11.5% in 2014.

The newly insured continue to seek treatment for ailments they habitually ignored, some of which have become chronic and irreversible. Many will need highly specialized care, complex surgeries and other sustained interventions and costly hospitalizations. Hospitals in regions of historically high unemployment and shortages of medical access can expect high rates of inpatient utilization to endure for years.

The reward for doing what matters – cradle-to-grave education and prevention, and doing it very well – will be empty hospital beds. That still sounds like a “pay me later” experiment, where later means future generations while today we’re addicted to “Hot ‘n Now” results. Ultimately, for hospitals, it forms the only solid ground when choosing to add or subtract inpatient beds, or just flat out go out of business.

(Also published as an op-ed in the July 30, 2016 edition of The Fresno Bee)

Pharmacists: the National Guard in lean times

The front line of healthcare is crammed between the linguica and callus removers. Yet we breeze past pharmacists as though they were dried prunes.

It’s time to break that habit. Pharmacists and a handful of others – including nurse practitioners and midwives -- are part of a growing, important corps of service providers called “physician extenders.” Although that makes them sound like a variety of Hamburger Helper, they are bridging the very real gap between the doctor supply and the unmet demands of newly insured patients.

They’re becoming advocates, educators, psychologists, lifestyle translators, life-saving human data bases, and red, green or yellow flags to our habits. They’ve come a long way from the tart British description of pharmacist as “chemist.” Fact is, you can almost always find a pharmacist. How quickly can you see your doctor? And, behind-the-scenes, pharmacists are playing increasingly important roles at patient bedsides.

Legislation has placed both retail and clinical pharmacists at the nexus of ethically complex encounters that can include providing medications for patient-assisted suicide (or not), over-the-counter contraceptives (once the prescription-only province of physicians) and involvement with medical marijuana.

While still answering “do I feed a cold and starve a fever” queries, they also now translate the arcane world of formularies. That includes sometimes determining whether a pricey brand name drug prescribed by a physician –unaffordable for some patients and therefore unused – can through science and diplomacy be changed to a cheaper generic acceptable to everyone including insurers.

“The needs of people go beyond their medication needs,” said Will Ofstad, Pharm.D., BCPS, CDE, assistant dean for education at California Health Sciences University (CHSU), which opened in Clovis in 2012. “A big part is education. Another big part is motivation.”

Ten years ago, pharmacists handled medication dosing and didn’t spend time outside the four walls of their offices, said Bruce A. Lepley, RPh, director of pharmacy at Fresno’s Community Regional Medical Center.

They’re now part of a daily caravan of stethoscopes and smocks, visiting hospitalized patients, working with other professionals on treatment plans and medication selections.

“We try to get to know you better than your family physician does,” said Lepley, who has been part of the profession’s metamorphosis for nearly 40 years. In the next 10 years, pharmacists will likely become more involved – and get more cooperation from physicians some of whom initially rebuffed interactions with harsh words and an occasional tossed scalpel.

“Including a pharmacist in a care team leads to significant savings -- $10 for each dollar invested – and reduces medical errors,” said Ofstad. “It improves access to high-quality, patient-centered care, particularly in underserved communities.”

Ofstad, a certified diabetes educator, said benefits can be keenly felt in that disease which hits hard in the Central Valley and costs California $24 billion annually. Diabetes hospitalization accounts for half that spending.

As the region’s safety net, Community Regional and its pharmacists try to alter that trajectory. “Can we convince patients to get well in the time we have them? Then we can make a difference,” said Lepley.

Discharge planning – where to guide patients for continuing care when they’re healthy enough to leave the hospital -- can reduce costly hospital readmissions. “The more we can do before discharge the more effective we are,” he said. Once out the door, do they keep taking their medications? That follow-up’s tricky when patients have no permanent address or phone number.

Building a new sustainable dietary way of life for a diabetic is far preferable to helping them adjust to a prosthetic leg from an avoidable amputation. Yet some insurers won’t pay for diabetes education.

Pharmacy education goals are changing. At CHSU in Clovis, the published targets include civic engagement and “a high degree of innovation, divergent thinking and risk taking.” The future mandates such adjustments, says the American Association of Colleges of Pharmacy:

* We’re living longer and, consequently, getting more chronic diseases;

* We’re presented with medications and devices in increasing numbers and complexity;

* More physicians are retiring and fewer are specializing in primary care (let alone gerontology);

* We’re trying to control costs and ensure quality, and

* We’re relying more on preventive, home and long-term care.

The number of pharmacy schools and colleges in the United States has exploded – from about 80 in 2000 to about 135 now.

There were more than 297,000 pharmacists in 2014, earning about $121,500 annually, according to the U.S. Bureau of Labor Statistics. Most than 50% work in pharmacy, grocery or department stores, and about 20% in hospitals.

However, there are kinks in the hose.

Researchers warn of a pharmacist glut. The labor bureau estimates job growth at 3%, slower than the average of other occupations. And the market is shifting.

Hiring is slowing in retail – where pharmacists were once lured from hospitals by better pay, bonuses and shorter hours. Corporate mergers and online and mail-order pharmacies are eroding that face-to-face market.

Demand is tilting toward direct patient care. But there are problems.

Hospitals need a reimbursement formula that pays fairly for pharmacists as the delivery system shifts from volume to value based. Medications can be ordered from many specialists, but pharmacists are expected to assess them and prevent screw-ups. Who has a rewards category for errors avoided? Another hang-up: Less than half of pharmacy colleges and schools offer patient physical assessment courses. Those courses are required by California’s SB 493 which created the hands-on category of Advanced Practice Pharmacists in 2014.

So, sit and wait as your prescription is filled at a Walgreens or CVS. You may overhear personal talk of great complexity with little filtering.

Will this drug make my wife’s constipation worse? I know it makes you sick so I’m trying to get your doctor’s permission to switch to another medication, and his staff is slow about returning calls. I know it’s a hassle, but the law requires written prescriptions each time you get pain medication to limit abuse. Yes, we can provide bottle labels in Spanish.

Throw in a flu shot. Guidance on using the free blood-pressure tester. And help in purchasing a cane. These investments of time and skill aren’t usually built into a physician’s workday.

Give the future a whirl. Spend less time selecting salsa and a few minutes asking for a pharmacist consultation.

(Also published as an op-ed in the June 23, 2016 edition of The Fresno Bee)

Hospital billing, exec comp: These fixes are bogus

When last I gleefully waved my paycheck in anyone’s face I was earning my first dollar an hour. But as wages and responsibilities grew, they became my private business.

So, I understand why titans of industry get ticked when their salaries are paraded for public pillorying. But my nerves get rattled when my telephone bill arrives with minutiae that totals up to more than my first teen-age work week. And when nobody at the utility can simply explain how my phone bill was concocted, I become more inclined to question why the digital big cheese merits his millions.

The same holds true in spades when it comes to healthcare. Nothing about medical costs, and very little about the care processes, can be translated into seventh-grade text, which was long the benchmark educational standard for writing and editing daily newspapers (where I worked for 30 years). And when I worked as a government advocate for a nonprofit hospital system, I saw the same bewilderment among the very industry fiscal experts and government regulators who built and papered over for decades the acronym soup that drains checkbooks and fattens frustrations.

Those twin thorns of healthcare costs and executive compensation are again being furiously wiggled in Sacramento by lawmakers, community activists and labor organizers using legislation and ballot initiatives.
It’s the usual carrot and stick.  Labor leaders usually want access to additional hospital members and their dues. Pouncing on hospital complexity is a reliable weapon.

When it comes to finances, critics reach deep into the murk of charity care, community benefits, bad debt, profit margin and costs vs. charges to dig a labyrinthine trench that only CPAs and $500-an-hour lawyers can assess. The critics don’t help the Twitter universe define what constitutes charity care even as they parse it in more puzzling ways to dramatize their case.

They don’t clarify evolutions underway in the post-Affordable Care Act world in which more people are granted coverage but not pathways to access it – in part because the payment methodologies don’t encourage broad physician participation.

When it comes to compensation, critics are now stretching their reach beyond the top tier of nonprofit leadership – who are already required to publicly report their compensation on the federal 990 forms – and invading layers of health professionals whose salaries, bonuses, overtime, pension and other compensation may total $250,000 annually. That’s potentially a heckuva lot of people – if the clear purpose is outrage, what is the good end?

Fact is, the sizable salaries of numerous elected and professional California employees – from mayors to police and sanitation workers – are accessible on many public websites including the libraries of large daily newspapers.  Yet the same labor leaders who levy multipliers of how hospital executives are paid hourly compared to rank and file staff have themselves mustered legislative and legal challenges – up to the Supreme Court – to quash or limit how easily fellow union members can determine how their dues are spent and where they’re given a voice.

Hospital CEO salaries are not a significant factor in health costs – the big money goes to total employee wages and benefits, and pharmaceuticals and new technologies.  The California Hospital Association estimates that average total compensation for a hospital CEO is less than one-tenth of one percent of a hospital’s budget.

Both the finance and compensation chokepoints are usually carefully targeted so as to affect nonprofit hospitals that are not already solidly in the hold of organized labor.

The ballot tactics require tens of millions of dollars to execute – and millions more by their targets to defend. So many ballot initiatives were floated this year that it’s been reported that California petition workers were paid $5 for each valid signature gathered.

These so-called fair billing and equitable compensation campaigns inject neither illumination nor innovation where the public needs it. They are retributive -- not remedial -- efforts.

In reality, various hospital systems are implementing bare-bones billing policies. Their true value ultimately will be reliably equating them with quality outcomes. Some chargemaster policies no longer bill patients for items – such as ibuprofen or antacid – if they’re available over the retail counter at places like a hospital’s outpatient pharmacy. That’s a good first step to eliminate the $15 aspirin headline.

And hospitals – the ones that will survive, anyway – are fast moving away from keeping every bed filled and every practice specialty flooded with patients and switching to benchmarking success by years of quality, productive living returned to patients in cost-effective manners. That’s a longer haul.

On compensation, California healthcare is a unique beast in job complexity, especially in the nonprofit world. The California state Legislative Analyst’s Office says that 70% of the state’s hospitals are nonprofit, most of them providing the state’s largest share of care to the neediest of patients. Volunteer boards of trustees usually oversee how nonprofit execs are paid and vet their strategies. Board members usually live where the hospitals conduct business, and often go there for medical care. They don’t live over my back fence but they’re way more reachable than Wall Street.

The recurring political targeting of hospital pricing and executive comp doesn’t address what’s ailing us.  It’s diversionary.  Its only transparency is its own self-serving nature.

(Also published as an op-ed in the May 21, 2016 edition of The Fresno Bee)

Hospitals: Taking it to the streets

Catering to and fostering people who want to be healthy. That’s the healthcare environment we’re evolving toward. That’s not yet the propelling force behind many hospitals.

Once you’re in the hospital door, you’re often regarded – from security screening, to triage station to patient financial services -- as another clot in an already sclerotic system.

You encounter warnings and scrutiny -- not hospitality, education and encouragement. Leave your valuables at home. Prepare to provide a co-pay on admission. Bring a designated care advocate – with legally binding permissions – to stand up for your rights.

There may be valet parking and a colorful folder explaining confidentiality, billing and patient care services, but there’s signage suggesting perdition -- “perfusion lab … densitometry scans… interventional radiology.”

When fiscal or physical dilemmas arise, you are pointed where the nomenclature turns dark. Charge nurse. Case manager. Ombudsman. Administrator on duty.

You hear that sizable staff are assigned to quality/infection control, risk management -- suggesting variability abounds and unpleasant experiences lurk. If you’re looking for the forward-thinking positivism of a chief imagination officer, try the Sundance Film Festival.

Patients receive arcane brands. “Non-compliant” means not following instructions (though if a caregiver can’t speak the patient’s language, that tag can be mistakenly applied). “Frequent flier” – that will get you bonus airline points but in hospitals it’s attached to those who frequently and often needlessly use emergency services (often for lack of public social services like behavioral counseling). “LWBS” – left without being seen, as hours turn to days of waiting for non-emergent care.

Fortunately, the inherent cultural infirmities of hospitals are changing. More patients with insurance mean heightened demands as well as expectations. Government reimbursement hinged on paying for quality and penalizing for lapses – faulty as it is, particularly for safety-net hospitals serving disproportionate numbers of chronically ill patients – is hastening improvements as well as sometimes-warranted closures. Retirements and shortages of physicians and nurses will translate into extending scopes of practices for other providers, and a rocky hand-off that will be.

Most hospitals were not founded with the mandate of putting more feet on the street – sending out multilingual social workers and educators, creating transitional housing for the homeless, lobbying governments to increase green grocers and green space, safely accessible to the public. That was the presumed province of government agencies and community organizations.

But better care at lower costs means systemic re-invention.

Ultimately, more empty hospital beds are part of the success story. That was no more the benchmark college curriculum for most of today’s healthcare execs than experiencing rigorous interrogation by patients of treatment options was for physicians educated a decade ago.

The innovations and experiments needed for that re-invention are evident.

• The Mayo Clinic has created a staff burnout task force, recognizing that rested and rejuvenated caregivers provide better patient service.

• The University of Illinois is funding apartments for as many as 20 chronically homeless Chicagoans for a year, easing emergency department usage.

• Kaiser Permanente is testing patient “health hubs” in Southern California, described as a kind of “public square” where care mingles with yoga classes, cooking demonstrations and educational classes.

• And in Fresno, Community Conversations -- a collaborative of health providers, community, government and other activists -- has not only revived a county mental health system eviscerated by funding cuts but also established a one-stop entry point to a usually Byzantine network of behavioral, substance abuse and homeless resources in the region.

Ultimately, the hospitals that flourish will increasingly empower those they serve. And they certainly will be more hospitable.

(Also published as an op-ed in the April 23, 2016 edition of The Fresno Bee)

Death, deliverance, dollars

"Please submit death certificate."  That was my “good morning” email from a legit insurance company. When I called, they couldn’t find me in their database. Clearly, as I get ready to retire from a 15-year career in healthcare, I’ve not done enough to register as energetically living.

Fact is, I think the “state of healthcare” is more robust when I first signed on to communicate and advocate on medical issues. That’s largely thanks to the 2010 Affordable Care Act. Still, the nation’s so-called system is also a heavy breather on life supports. To me, healthcare expectations generally fall under “delivery, deliverance and dollars.”

Delivery: Since 2010, we’ve added 17 million Americans to the rolls of newly uninsured. Every business says customer satisfaction is Job One. So, those 17 million are a lot of new Job One’s. We didn’t conjure up additional doctors or, in most states including California, allow other medical professionals to perform services historically done by physicians. How long you wait for treatment often depends on where you live and if you need specialized care. The California HealthCare Foundation found that only 52% of Valley primary care physicians were accepting new Medi- Cal patients. In part, that’s because reimbursement doesn’t cover their costs. So, after 15 years, the outlook for delivery/access to care is -- short of hospital emergency departments -- chancy.

Deliverance: Call this surviving vs. thriving. The roadmap would drive Siri nuts. First, the array of healthcare scorecards and “best practices” is confusing, contradictory and stitched with self-interest. Atop scorecards, the US just rolled out this ICD-10 creature -- the 10th revision of the International Statistical Classification of Diseases and Related Health Problems. It adds 125,000 diagnostic and procedural codes to your hospital visit (insect bite, left nostril, second time; arm injury, flying saucer). It may explain why more people work in billing than in hands-on patient care. Lastly, the growth of electronic medical records will be more of a lifesaver once differing computer systems can chat, staffers don’t leave unencrypted flash drives at Starbucks and physicians remember than looking at, listening to and touching patients are at least as critical as the mandated punching and poking at computer workstations.

Dollars: Along with flying a kite with Mary Poppins, our hearts expect when a medical bill arrives, it will be “one and done.” We daydream that the invoice won’t have children and will be only slightly more difficult to swallow than peanut brittle. We should be stunned then, when in a rare moment of bipartisanship, both hospitals and Congress concur that prices and billing practices virtually violate the “first, do no harm” oath. To be fair, providers adapted to poorly crafted rules written 40 years ago that are now being rewritten daily. Payment for each service rendered is being replaced by pay for positive outcomes (and penalties for most anything else). Pharmaceutical profiteers are scalping where they can. And, retirements, mergers and closures have skewed the marketplace to where patients feel like they’ve parachuted at night into a minefield.

Somewhere along this path, we will recognize that getting and staying healthy takes work. And as the patient increasingly becomes the CEO, the levels of expectation and the need for education for said CEO will rise. Be interesting to check back in 15 years to see just how many hospital beds are empty, how many schools have full-time nurses and whether urgent care clinics replace Big Gulp fountains at 7-Eleven’s. Maybe if I dodge another email request for a death notice...

(This blog originally appeared at www.communitymedical.org)

(Also published as an op-ed in the Jan. 17, 2016 edition of The Fresno Bee)