X-Message-Number: 18949 From: Date: Mon, 22 Apr 2002 02:56:48 EDT Subject: Of Medicine, Money and Cryonics Often people are appalled at how badly cryonics organizations get along with each other. They are shocked at how mistrustful and paranoid they are. They are amazed at allegations of dirty tricks and less than truthful allegations. There's some truth to these perceptions, but the reality is that things don't usually start to get really ugly in the world until money or religious fervor are involved, or, God forbid, both (and both are really about survival and dominance). As medicine melts down in the US under the weight of nearly 30 years of fairly heavy socialization the nastiness is getting worse. Here in Riverside two major hospitals, Parkview Community and Riverside Community, are in the death throes of a down and dirty battle that would humble any John Grisham plot line. So, presented for your information and amusement is the following tale courtesy of Dr. David W. Crippen of St. Francis Medical Center (SFMC) at the University of Pittsburgh Medical Center. Dr. Crippen is Chief of Critical Care Medicine at SFMC and is one of the leading Intensivists in the US (doctors who practice intensive care medicine: as in ICU doctors) and an expert on end of life care issues, management of life threatening agitation in the ICU, and increasingly one of the leading thinkers on issues relating to the ethical and financial aspects of futile medical care in the ICU (he has just edited a fascinating book on the latter subject: Three Patients: International Perspective on Intensive Care at the End of Life, ISBN # 0-7923-7671-4). I thought the readers of Cryonet might find the following tale interesting not only in its own right, but as guide for putting into perspective what life in the cryonics community is like versus what it is like in the everyday world of medicine (at least so far). Local Medical Politics by David Crippen, MD, FCCM Sit back and relax and spend some time reading this. It's going to give you a good view of current medical politics involving "private practice" in the USA. There is a medical drama unfolding over at one of the big trauma centers here in town worthy of anything on Chicago Hope. I don't think this is privileged information because I saw a blurb in the Pittsburgh Post about it yesterday and my wife is peripherally involved (as an employee). In order to fully savor this story, it's necessary to understand some of the background and how it applies to medical economics then and now. Disclaimer: as I relate this story, keep in mind that it is freely permeated with my own biases and those of my wife who claims to have inside information. This is a very big and well established hospital across the river from the University of Pittsburgh Medical Center (UPMC). This hospital is affiliated with another academic major medical center in the Philadelphia, and all their staff have academic credentials from that center. For the sake of this story, we'll call it Pittsburgh's Greatest Hospital (PGH). Like UPMC, PGH is a Level One trauma Center with helicopter programs and they have extensive specialty and subspecialty residency programs. There are well over a thousand acute care beds.It not a big stretch to tell you that this is a "good" hospital and patients get good care there. In the 80s and 90s, PGH was known as a fairly "rich" facility. They wheeled and dealed in Pennsylvania medical power mongering and their upper crust wore power suits with suspenders and flew around in Lear jets.Their natural enemy was UPMC, and the power boards from each facility met frequently to get one up on the other. Dirty tricks were a weekly sacrament on both sides. And all the hospitals were making money on the side with shrewd stock market manipulations. They were all riding the crest of the dot com excesses that everyone knew had hollow bottoms but no one thought could ever really "crash". But they did crash, in mid-90s and not only did they crash, the bottom fell out of a lot of other stock related things as well and hospitals found out they had lost a LOT of money and they had no way to make any of it back. Add to this the progressive decrease in reimbursements and the handwriting was on the wall. Accordingly, it became incumbent on PGH to start holding their finances a lot closer to their vest and they started taking a hard look at what was real and what was fantasy. These hard looks discovered that some of the upper crust may have been playing fast and loose with money. Shortly thereafter, some of these upper crust were banished to the minors and it hit the papers that when you scratched through the veneer of opulence, PGH was essentially broke. The elaborate house of cards fell quickly and there was serious question that PGH's creditors would strip and abandon. These were uneasy times for the many employees of that facility. As they cut to the bone, Unions developed a foothold, ending their ability to prioritize. Priority at that point went to the most powerful, not the most beneficial. Debt increased exponentially. They stopped paying their bills, credit vanished and all dealings with vendors were cash and carry. Then as the darkest hour approached, a ray of light appeared on the horizon. A surprise deal was fashioned between PGH and a Peripheral Pittsburgh Hospital (PPH), not known to possess the kind of money it would take to sit down at the PGH table and play. In fact PPH didn't have two nickels to rub together. The deal was financed by Highball Health Insurance, who had plenty of money, and was looking to form a united front of hospitals to effectively compete against the UPMC evil empire, the tentacles of whom relentlessly entwined all the marginal and broke hospitals in the area, stripping them and developing conduits to the mother ship. UPMC has it's own health care insurance scheme. SO.....PGH and PPH entered into a consortium, fueled by Highball money, that put them back in the game. It has been several years now and they are all said to be doing well. The hospital wards and ORs are full. Between UPMC and Highball, they had the market in Pittsburgh effectively cornered and they fought like cats and dogs to stiff the other. the other hospitals in town fight over the crumbs. PGH wonks, having learned a few things from this trial resolved to become more efficient. One of the things they learned was that they didn't want to have anything to do with independent contractor physician groups. This is an expensive way to provide health care. Independent contractor are always trying to renegotiate for more money. And they're always pushing to stiff the hospital for subsidies and concessions that cost money and eat up resources. SO PGH progressively (and successfully) moved to make all their physicians hospital employees. In fact (I am told by my wife) that most of the surgeons that attend there are groups bought and owned by the hospital. The holdouts continue under the gun. But the anesthesiology group, Pittsburgh's Greatest Hospital's Anesthesiologists (PGHA), remained a big holdout. Rugged individualists all, they refused to be owned by anyone and told the hospital in so many words that they would stay independent or walk. Now, this is a BIG anesthesia group, about 125 employees. So it would be a major hassle to replace them so PGH started a war of attrition, putting the squeeze on them for a "better" hospital deal. The hospital pointed out that all the equipment they were using were provided by the hospital and the CRNAs (Certified Registered Nurse Anesthetists) who were hospital employees. The anesthesiologists were getting essentially free use of all these things but were not paying the hospital a nickel for it since they both billed separately. So the hospital browbeat the anesthesiologists into a deal where they would have to take on the CRNAs an PGHA employees. PGHA would have to pay the CRNAs salary, benefits, put with personnel headaches, call-offs, deal with crazies and all that. And so it came to pass that all the CRNAs were let go from the hospital and hired by PGHA. This deal included a raise and sign-on bonus to keep financial parity with what other CRNAs were making around town (mainly at UPMC). This was a BIG financial hit for PGHA. Naturally, being a bunch of doctors protecting their income, the CRNAs were worked harder and got fewer benefits compared to their deal as hospital employees (my wife assures me). After this evil deal was made, the money squeeze intensified for the doctors, as you can imagine. The jaundiced eye of PGHA perused the available resources to see what could be squeezed harder. Lo and behold, it was discovered that the reimbursement for anesthesia by Highball Insurance was in some sense lacking (compared to what, I don't know). So PGHA went back to the hospital and complained that they weren't keeping up with their income and needed more money.The additional expenses of buying the CRNAs exceeded their ability to make a living. (It was unclear whether their profit or their working margin was involved) That revelation was greeted by stone faces. "Sorry, you guys wanted to remain free and so you are. If you had become our employees like we asked you to, CRNAs would have been the hospital's problem and you would have actually made out better in the long run" "You made this bed; sleep in it". And so, hardballs were pitched. The next tack was to inform the hospital that after May 2, 2002, PGHA would no longer be giving anesthesia for patients indemnified by Highball insurance (since the reimbursement thereof did not meet the real expenses involved). This tack put the hospital in a serious bind. Their contract with PGHA mandated an exclusive right of PGHA to give anesthesia and the hospital was not allowed to bring locum tenens gas passers to make up the deficit.There was no way the hospital could fire PGHA and replace them by May 1, 2002. The surgeons squealed like pigs in hot oil. And so, as of today they are both, metaphorically speaking, standing out there in the hot sun daring the other to draw and fire first. The hospital says this is the first volley in the campaign to end independent contractors.PGH says that they MUST own everyone they deal with or they won't be able to survive in a cut throat reimbursement climate where small hassles cost large quantities of money. They say, and I believe it will come to pass, that they have the resources to win any war of attrition with "private" physician groups. PGH says the reimbursement from Highball doesn't cover their expenses and every minute they give gas under Highball is a minute they lose money. Therefore, they cannot continue under the present rules or they will go bankrupt and their 125 employees (including my wife) will be out in the street. As of the first part of this week, the hospital has allegedly approached some of the PGHA employees about "crossing the line" as it were and doing locum tenens for Highball patients after May 2. Yesterday, PHGA filed suit against the hospital for breaking their contract. the sun is getting hot and the onlookers are accumulating. One of them is eventually going to have to draw and the other will have to follow. Who is left standing has profound consequences for how health care is delivered in Pittsburgh and by expansion the rest of the country. David Crippen, MD, FCCM Rate This Message: http://www.cryonet.org/cgi-bin/rate.cgi?msg=18949