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    

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