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Saturday, July 11, 2020

Health Care Reform Articles - July 11, 2020



The Moral Determinants of Health

Donald M. Berwick, MD, MPP1 - JAMA Network - June 12, 2020
he source of what the philosopher Immanuel Kant called “the moral law within” may be mysterious, but its role in the social order is not. In any nation short of dictatorship some form of moral compact, implicit or explicit, should be the basis of a just society. Without a common sense of what is “right,” groups fracture and the fragments wander. Science and knowledge can guide action; they do not cause action.
No scientific doubt exists that, mostly, circumstances outside health care nurture or impair health. Except for a few clinical preventive services, most hospitals and physician offices are repair shops, trying to correct the damage of causes collectively denoted “social determinants of health.” Marmot1 has summarized these in 6 categories: conditions of birth and early childhood, education, work, the social circumstances of elders, a collection of elements of community resilience (such as transportation, housing, security, and a sense of community self-efficacy), and, cross-cutting all, what he calls “fairness,” which generally amounts to a sufficient redistribution of wealth and income to ensure social and economic security and basic equity. Galea2 has cataloged social determinants at a somewhat finer grain, calling out, for example, gun violence, loneliness, environmental toxins, and a dozen more causes.
The power of these societal factors is enormous compared with the power of health care to counteract them. One common metaphor for social and health disparities is the “subway map” view of life expectancy, showing the expected life span of people who reside in the neighborhood of a train or subway stop. From midtown Manhattan to the South Bronx in New York City, life expectancy declines by 10 years: 6 months for every minute on the subway. Between the Chicago Loop and west side of the city, the difference in life expectancy is 16 years. At a population level, no existing or conceivable medical intervention comes within an order of magnitude of the effect of place on health. Marmot also estimated if the population were free of heart disease, human life expectancy would increase by 4 years,1 barely 25% of the effect associated with living in the richer parts of Chicago instead of the poorer ones.
How do humans invest in their own vitality and longevity? The answer seems illogical. In wealthy nations, science points to social causes, but most economic investments are nowhere near those causes. Vast, expensive repair shops (such as medical centers and emergency services) are hard at work, but minimal facilities are available to prevent the damage. In the US at the moment, 40 million people are hungry, almost 600 000 are homeless, 2.3 million are in prisons and jails with minimal health services (70% of whom experience mental illness or substance abuse), 40 million live in poverty, 40% of elders live in loneliness, and public transport in cities is decaying. Today, everywhere, as the murder of George Floyd and the subsequent protests make clear yet again, deep structural racism continues its chronic, destructive work. In recent weeks, people in their streets across the US, many moved perhaps by the “moral law within,” have been protesting against vast, cruel, and seemingly endless racial prejudice and inequality.
Decades of research on the true causes of ill health, a long series of pedigreed reports, and voices of public health advocacy have not changed this underinvestment in actual human well-being. Two possible sources of funds seem logically possible: either (a) raise taxes to allow governments to improve social determinants, or (b) shift some substantial fraction of health expenditures from an overbuilt, high-priced, wasteful, and frankly confiscatory system of hospitals and specialty care toward addressing social determinants instead. Either is logically possible, but neither is politically possible, at least not so far.
Neither will happen unless and until an attack on racism and other social determinants of health is motivated by an embrace of the moral determinants of health, including, most crucially, a strong sense of social solidarity in the US. “Solidarity” would mean that individuals in the US legitimately and properly can depend on each other for helping to secure the basic circumstances of healthy lives, no less than they depend legitimately on each other to secure the nation’s defense. If that were the moral imperative, government—the primary expression of shared responsibility—would defend and improve health just as energetically as it defends territorial integrity.
Imagine, for a moment, that the moral law within commanded shared endeavor for securing the health of communities. Imagine, further, that the healing professions together saw themselves as bearers of that news and leaders of that change. What would the physicians, nurses, and institutions of US health care insist on and help lead, as an agenda for action? A short list follows, the first-order elements of a morally guided campaign for better health.
  • US ratification of the basic human rights treaties and conventions of the international community. The US, alone among western democracies, has not ratified a long list of basic United Nations agreements on human rights, including the International Covenant on Economic, Social and Cultural Rights, the Convention on the Elimination of All Forms of Discrimination Against Women, the Convention on the Rights of the Child, the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families, and the Convention on the Rights of Persons with Disabilities.
  • Realization in statute of health care as a human right in the US. The number of uninsured individuals in the US is 30 million and increasing. No other wealthy nation on earth tolerates that.
  • Restoring US leadership to reverse climate change. The US is nearly alone in its withdrawal from the Paris Agreement.
  • Achieving radical reform of the US criminal justice system. The US has by far the highest incarceration rate in the world, and it imprisons people of color at 5 to 7 times the rate of white persons.
  • Ending policies of exclusion and achieving compassionate immigration reform. State-sponsored violence, child abuse, and family separation due to US policies remain widespread at the southern border. Congress has failed repeatedly to enact immigration reform.
  • Ending hunger and homelessness in the US. These are completely addressable issues.
  • Restoring order, dignity, and equity to US democratic institutions and ensuring the right of every single person’s vote to count equally. Science is under attack within crucial US agencies, voter suppression tactics continue, and the Electoral College, in which the weight of a citizen’s vote varies by a factor of 70 from state to state, is profoundly undemocratic.3
To many US physicians and nurses who trained for, are committed to, and are experienced in addressing health problems in individual patients, this campaign list may seem out of character. However, if the moral law within dictated that the shared goal was health, and if logic counseled that science should be the guide to investment and that the endeavor must be communal, not just individual, then the list above would be a clear and rational to-do list to get started on well-being. The agenda includes, but is by no means restricted to, ensuring care for patients with illness and disease, no matter how they acquired their health conditions. But it ranges broadly into the most toxic current social circumstances, including institutional racism, that make people—especially people of color and of lower income—become ill and injured in the first place. It is an agenda for fixing the horrors of the subway map.
No sufficient source of power exists to achieve the investments required other than discovery of the moral law within, with all its “awe and wonder,” as Kant wrote. The status quo is simply too strong. The vested interests in the health care system are too deep, proud, and understandably self-righteous; the economic and lobbying forces of the investment community and multinational corporations are too dominant; and the political cards are too stacked against profound change.
The moral force of professional leadership can also be powerful, once grounded and mobilized. A difficult question follows: ought the health professions and their institutions take on this redirection? To use a recent vernacular, what is health care’s “lane”?
Honest and compassionate people disagree about health care’s proper role in improving social conditions, countering inequity, and fighting against structural racism. Some say it should remain focused on the traditional: caring for illness. Others (this author among them) believe that it is important and appropriate to expand the role of physicians and health care organizations into demanding and supporting societal reform.
The angry, despairing victims of inequity, and their supporters, marching in the streets of the US despair in part because they and their parents and their grandparents and generations before have been waiting far too long. They find no moral law in evidence, no social contract bilaterally intact. They do not believe in promises of change, because for too long people remain hungry and homeless, with the doors of justice so long closed.
What specific actions can individuals and organizations take toward the morally guided campaign sketched above? Physicians, nurses, and other health care professionals can speak out, write opinion pieces, work with community organizations devoted to the issues listed, and, most important of all, vote and ensure that colleagues vote on election days. Organizations can also act: they can contact local criminal justice authorities and develop programs to ensure proper care for incarcerated people and create paths of reentry to work and society for people leaving incarceration. They can identify needs for housing and food security in local communities, set goals for improvement, and manage progress as for any health improvement project. They can pay all staff wages sufficient for healthy living, which is far above legal minimum wages. They can lobby harder for universal health insurance coverage and US participation in human rights conventions than for the usual agendas of better reimbursement and regulatory relief. They can examine and work against implicit and structural racism. They can do whatever it takes to ensure universal voter turnout for the entire health care workforce.
Healers are called to heal. When the fabric of communities upon which health depends is torn, then healers are called to mend it. The moral law within insists so. Improving the social determinants of health will be brought at last to a boil only by the heat of the moral determinants of health.
https://jamanetwork.com/journals/jama/fullarticle/2767353 

The Merits of Medicare for All Have Been Proven by This Pandemic

By Sonali Kolhatkar - Independent Media Institute - July 7, 2020

A pandemic is not the time to be having discussions about how to design a national health care system. The fact that the United States, which has 4 percent of the world’s population, leads the world with 25 percent of all coronavirus infections, indicates at a glance that something about our nation’s health care is irredeemably broken. In just a few months, more than 40 million Americans became unemployed in a country where a majority are expected to obtain health care through employer-provided insurance. Even the New York Times has pointed out that, “Nothing illuminates the problems with an employer-based health care system quite like massive unemployment in the middle of a highly contagious and potentially deadly disease outbreak.”
The Times has hardly been a champion of the nationalized health care system that progressive activists have demanded for years. The unimaginably large (and growing) death toll from COVID-19 should notbe, as the paper’s editorial board member Jeneen Interlandi says, “an opportunity to look at health care reform with fresh eyes—and to maybe, finally, rebuild the nation’s health care system in a way that works for all Americans.” We, as a nation, should have figured this out a long time ago.
As Dr. Anthony Fauci, the nation’s leading infectious disease expert, pointed out at a recent Senate hearing, left unchecked the coronavirus could spread to 100,000 people per day. Republican Senator Rand Paul was not happy with this grim assessment, instead demanding that the scientist instead offer up “more optimism” to the American people about the disease. But that is precisely how opponents of a single-payer health care system have painted our deeply flawed employer-based system for many years—with a veneer of positivity that was never matched by reality.
As FiveThirtyEight points out in examining pre-pandemic surveys of health care, “Americans tend to have a much rosier view of the health care they personally receive than the health care system in general or the cost of health care.” This should come as no surprise given the massive amount of propaganda that health insurers have paid for to convince people that the current system is good enough. However, no amount of optimism is going to help us survive the current COVID-19 crisis. There is no rosy way to view tens of thousands of dead Americans—especially in contrast with other nations that have managed to control the outbreak. In the words of one New Zealand health expert, “It really does feel like the U.S. has given up.”
In Arizona, one of the new hotspots of the disease, health care providers have taken to rationing health care—in a manner reminiscent of many developing nations or socialist regimes that the United States has criticized in the past. One report explained that Arizona’s rationing plan, “would see patients rated on a scoring system to determine who should be prioritized based on the severity of their condition.” In Houston, Texas, which is considered another COVID-19 epicenter, pediatricians are now taking on adult patients as hospital beds fill up to capacity.
There is little to no information about how the nation’s uninsured are expected to pay for COVID-19 treatments if they are hospitalized. Contrast that with a nation like the UK where there’s no question about any other entity besides the National Health Service (NHS) picking up the tab for any and all patients. During the current crisis, the UK government has even recruited all private hospitals to bolster the NHS’s capacity, forcing them to place lives over profits. Imagine the United States ever taking such a step to prioritize the health care of Americans!
The Wall Street Journal, aghast that a free-market system of the type that it has relentlessly promoted has not worked in the realm of health care, declared in an op-ed, “Rationing Care Is a Surrender to Death.” But op-ed writer Allen C. Guelzo, a fellow of the right-wing think tank Heritage Foundation, had no answers beyond standard capitalism pablum saying vaguely that we need to, “Improvise, innovate, imagine.”
It’s not just our health care in the form of treatments and hospitalizations that is showing itself to be wholly inadequate in the face of a pandemic. The pharmaceutical industry, which has also preyed upon Americans for far too long, is charging outrageous prices for drugs that taxpayers paid to help them develop. Amidst the worst medical crisis in modern history, the drug manufacturer Gilead has set the price for remdesivir—a drug that has shown modest success in COVID-19 treatment—at a whopping $3,120 per patient. Infuriatingly, that same company, which made good use of U.S. tax dollars in its research and development, is licensing the drug to generic manufacturers outside the U.S. to produce remdesivir at a substantially lower cost to non-American patients.
The shocking extent of the coronavirus crisis in the United States is explained in large part by a libertarian economic approach. It is the same sort of approach that successive administrations have taken in addressing our health care needs and can be boiled down to the adage, “survival of the fittest.” Rather than imposing rules and regulations to protect Americans through a nationalized health care system and an aggressive cost-control mechanism for lifesaving drugs, Americans have been left at the mercy of their employers, health insurance and pharmaceutical companies, and private hospitals. Similarly, instead of taking a strong federal approach to controlling the spread of the coronavirus as other nations have successfully done, the Trump administration has washed its hands of any responsibility for the virus’ spread. An absence of strong federal guidelines on how people need to protect themselves has resulted in a culture war of comical proportions where Fox News-fed Republicans claim that rules requiring protective face masks are akin to “practicing the devil’s laws.”
Such hyperbolic language is reminiscent of the hysteria over so-called “death panels” in the early years of the Obama administration. That phrase was used to cast the most modest of government regulations of our health care system as a scenario where dispassionate committees of technocrats would decide who gets to live or die. Never mind that such a description was a more apt one for our existing system of care where corporate executives decide which treatments to pay for and which to forego.
Just as progressives were right more than a decade ago that a single-payer or Medicare for All system was best poised to meet our health care needs, that same rallying cry for such a universal and free health care plan remains more relevant and appropriate than ever. Even the New York Times agrees, admitting perhaps a bit reluctantly that, “A single-payer system in which one entity (usually the federal government) covers every citizen regardless of age or employment status, could work.” But is it too late?
Had the nation gone down a different path in 2008 or anytime in the decade following it, we would have been better poised to take on the current crisis. There is little comfort to be had in being right on the issue of health care under our current grim circumstances.
This article was produced by Economy for All, a project of the Independent Media Institute.
https://www.pressenza.com/2020/07/the-merits-of-medicare-for-all-have-been-proven-by-this-pandemic/ 

Coronavirus Live Updates: Early Reopenings Drive U.S. Case Surge

The country recorded its sixth single-day record in 10 days with almost 60,000 cases on Thursday. U.S. immigration officials have helped spread the virus, a Times investigation found.
Right Now
Tokyo reported a daily record of new cases amid an outbreak connected to the city’s nightlife districts.

Here’s what you need to know:

Like ‘a Bus Accident a Day’: Hospitals Strain Under New Flood of Covid-19 Patients

I.C.U. units are reaching capacity. Nurses are falling sick, contributing to shortages. The new coronavirus spikes are challenging hospitals across the United States.
By Kimiko de Freytas-Tamura, Shawn Hubler, Hailey Fuchs and David Montgomery - NYT = July 9, 2020

TAMPA — As states across the American South and West grapple with shortages of vital testing equipment and a key antiviral drug, hospitals are being flooded with coronavirus patients, forcing them to cancel elective surgeries and discharge patients early, and doctors worry that the escalating hospital crunch may last much longer than in earlier-hit areas like New York.
Even as regular wards are being converted into intensive care units and long-term care facilities open for patients still too sick to go home, doctors say they are barely managing.
Hospitals are scrambling to call back nurses and recruit new doctors. Florida Gov. Ron DeSantis announced he was sending 100 nurses to help out Jackson Health System in Miami, which said it had already hired 80 extra nurses in the past two weeks. Jackson Memorial, its flagship hospital, has only 28 I.C.U. beds, out of a total of 234, available.
“When hospitals and health care assistants talk about surge capacity, they’re often talking about a single event,” said John Sinnott, chairman of internal medicine at the University of South Florida and chief epidemiologist at Tampa General Hospital. “But what we’re having now is the equivalent of a bus accident a day, every day, and it just keeps adding.”
Florida is struggling with one of the worst outbreaks in the country, along with Texas, California and Arizona: 43 intensive care units in 21 Florida counties have hit capacity and have no beds available.
In South Carolina, National Guard troops are being called in soon to help insert intravenous lines and check blood pressure. Roper St. Francis Healthcare in Charleston saw a 65 percent increase in coronavirus patients in a single day.
Dr. Christopher McLain, the hospital’s chief physician officer, said he has begun each day on his knees in prayer and often begins meetings the same way, asking the Lord how to respond to the pandemic. “We’re already at a severe condition,” he said.
In Mississippi, five of the state’s largest hospitals have already run out of I.C.U. beds for critical patients, Dr. Thomas Dobbs, the state health officer, said on Thursday. “Mississippi hospitals cannot take care of Mississippi patients,” he said.
Texas Gov. Greg Abbott on Thursday ordered an increase in hospital bed capacity for dozens of counties, extending a ban on elective procedures to new corners of the state in an effort to assist hospitals dealing with the outbreak.
Mr. Abbott directed hospitals to “postpone surgeries and procedures that are not immediately, medically necessary.” The governor had already done so in hard-hit urban counties that include San Antonio, Dallas, Houston and Austin.
At the 463-bed hospital operated by Eisenhower Health in Rancho Mirage, Calif., east of Los Angeles, the coronavirus case count has gone from less than a dozen in May to 77 this week. Most of the 34 intensive care beds are full, nearly half of them occupied by people who have been infected.
“I’m glad some of you are sheltered from what unbridled Covid-19 looks like. It’s a hell show,” a doctor at the hospital, Dr. Richard Loftus, posted to a Facebook physician group after a computer trainer at the hospital turned out to be infected.
Dr. Diego Maselli Caceres at University Hospital in San Antonio, Texas, said he has watched a sevenfold surge of Covid-19 patients needing intensive care over the past month, filling up three floors of the hospital instead of one. His workload has increased to 15 hours a day, he said.
“You get bombarded with multiple calls at the same time,” he said, referring to the “code blue” warnings from overhead speakers that send doctors and nurses rushing to save a patient in distress.
“You hear the calls and you’re running from one end to the other, just like putting out fires, and you’re trying to help as much as you can. It gets overwhelming.”
Hospital bed capacity, including in I.C.U.s, is generally used to gauge a region’s health care infrastructure and the preparedness of its hospitals to respond to the coronavirus. Data showing I.C.U.s at full or near capacity have made headlines recently, but health experts say that attention to capacity does not paint an entirely accurate picture of the severity of the pandemic.
Regular beds are easily converted into I.C.U. capability, doctors and hospital experts say. The bigger challenge is having enough advanced practice nurses who are qualified to care for such patients and equipment such as ventilators.
Hospitals can “pivot enough space,” said Jay Wolfson, professor of public health at the University of South Florida. “The trick is going to be staffing. If you get people burned out, they get sick, then you lose critical care personnel.”
At the Medical University of South Carolina in Charleston, emergency room waiting times can last up to four hours before patients are seen by a physician. The hospital has set up large white tents outside to allow for social distancing, but patients are increasingly leaving the site before their treatment, unwilling to endure the wait.
As physicians and nurses fall ill with the coronavirus, much like their patients, fewer and fewer staff members have been available to accommodate the burgeoning number of sick people at their doorstep. Some emergency room doctors have taken on extra shifts, and the hospital plans to implement a new system where some doctors will be on-call, even on their days off, to respond to the surge.
Mohamed Ibrahim Ali, a critical care doctor at AdventHealth North Pinellas near St. Petersburg, Fla., one of the hospitals that have no more available I.C.U. beds, said that the system was clogged up by patients, sent from nursing homes, who had recovered but had not yet received the all-clear. He said nursing homes have refused to accept residents back unless they have tested negative, a period that could take days.
Roopa Ganga, an infectious disease specialist at two hospitals near Tampa, said that they lacked sufficient supplies of remdesivir, the antiviral drug, forcing her to choose which patients needed it the most. Patients were also being discharged “aggressively” — perhaps too early, she said. They sometimes return a few days later, she said, their symptoms worsened.
“About five people came back in one week last week,” she said. “That is making me feel like, you know, you got to slow down.”
Dr. Wolfson, from the University of South Florida, said health authorities and public officials needed to collaborate better to bypass regulations that bar out-of-state nurses from working in Florida. New York’s Covid-19 crisis in the spring was aided by a number of health workers from outside the state.
“It’s political inertia,” he said. “It takes somebody in a position of significant political stature to say, ‘Let’s do this.’ Florida has always been afraid that people were going to come into the state and take their jobs. Now we need all the help we can get.”
Traveling nurses were brought in to the Eisenhower Health hospital in California’s Riverside County. It was necessary, said Dr. Alan Williamson, the chief medical officer, because the 3-to-1 nurse-to-patient ratio is much higher even for Covid-19 patients who are not in the intensive care beds. It has been a challenge, said Dr. Williamson, because Eisenhower is competing with two other hospitals in the area that are using the same nurse registries to find help.
Texas is experiencing one of the fastest growing coronavirus caseloads in the country, with new cases exceeding 10,000 one day this week. At the Texas Medical Center hospitals in Houston, the average daily rate of new Covid-19 hospitalizations was 360, nearly double the rate of just two weeks ago.
“The hospitals are full,” said Dr. Esmaeil Porsa, president and chief executive officer of the county’s two-hospital public health system, Harris Health. “We have been over capacity for a couple of weeks.”
In Corpus Christi, Texas, one of the state’s fastest spreading outbreaks has pushed hospitals to convert floors to treat Covid-19 patients as they scramble to find extra staff, especially nurses.
“Are we strained? You bet we are,” said Barbara Canales, the top official in the surrounding county, adding that hospitals were asking the state of Texas for help on staffing.
The county, of 360,000 people, saw hospitalizations surge in the last few weeks, to 300 on Wednesday, up from fewer than 20 in the middle of June.
Doctors and nurses interviewed said the current spike is unlike anything they have ever dealt with.
Rick Stern, a veteran oncology nurse who works with the Covid-19 patients at Eisenhower Health, said the job is a constant churn of gloves, gowns, masks, face shields and heart-wrenching misery.
His first day in the unit, he said, he watched a cancer patient who had become infected die in the space of 15 hours. At times during this surge, he said, as many as three patients a day have died on his ward; he personally has lost three so far.
One of his current patients is 35.
“I’ve had experience with death,” he said, “but this is different. These people aren’t ready to go yet.”
https://www.nytimes.com/2020/07/09/us/coronavirus-hospitals-capacity.html?action=click&module=Top%20Stories&pgtype=Homepage


Elite Hospitals Have an Epidemic of Greed

How the University of Pittsburgh Medical Center and “charitable” hospital systems like it put making money ahead of service to the public.

by Phillip Longman and Udit Thakur - Washington Monthly - July/August 2020

In early March, public health officials issued warnings about what the spreading coronavirus could mean for the Pittsburgh region. Debra Bogen, director of the health department for surrounding Allegheny County, forecast that between 40 to 60 percent of the adults in western Pennsylvania could come down with COVID-19 unless strong mitigation measures were taken. The Harvard Global Health Institute predicted that Pittsburgh-area hospitals could need between 480 to 720 percent more beds than were currently available. Meanwhile, federal officials, ranging from the surgeon general of the United States to scientists at the Centers for Disease Control and Prevention, warned that hospitals would spread the contagion further if they continued performing non-urgent care. 
Check out the complete Washington Monthly hospital rankings here. Heeding this expert advice, Pennsylvania Governor Tom Wolf issued an executive order on March 19 requiring all the state’s hospitals and doctors to stop performing elective procedures. Such surgeries are highly lucrative. But hospitals understood the gravity of the situation, or at least recognized Wolf’s authority. Systems throughout the state quickly complied. 
Except one. 
In their headquarters atop the 64-story former U.S. Steel Tower in downtown Pittsburgh, executives of the University of Pittsburgh Medical Center (UPMC), a $21 billion hospital chain and health insurer, took a different course. Ignoring not only the governor’s order but also an open protest letter signed by 291 of their own doctors, UPMC decided on March 20 that the 40 hospitals they control would continue conducting elective surgeries. 
At a press conference, UPMC tried to justify its decision by asserting that there were only five known COVID-19 cases in the Pittsburgh area at the time, and that, despite insufficient numbers of tests, they were monitoring the situation closely. They also argued that they weren’t technically violating the governor’s order because the elective procedures weren’t really elective, at least as they used the term. “ ‘Elective’ commonly means scheduled cases, but scheduled does not mean unnecessary,” Donald Yealy, UPMC’s chair of emergency medicine, said. Bogen disputed those semantics. “We ask that UPMC, like all the other health care providers in our community, begin to address this request from the governor and from us,” she said. The Pittsburgh Post–Gazette, the city’s leading newspaper, lambasted UPMC for its decision. The hospital system, they wrote, was “endangering lives by continuing to perform elective surgeries despite pleas by state and local health officials to postpone them.” 
It wasn’t as if UPMC’s managers could not afford to do the right thing. Though chartered by the state of Pennsylvania as a nonprofit, charitable institution affiliated with the University of Pittsburgh’s medical school, UPMC has morphed over the past three decades into a money-making machine. According to its latest financial statement, the corporation commands reserves amounting to $5.5 billion in unrestricted cash and investments. Nor are UPMC’s executives hurting for money. In 2018, UPMC President and CEO Jeffrey Romoff, who has said he seeks to make UPMC “the Amazon of health care,” took home $8.54 million, while 33 other executives each earned more than $1 million. As the editors of the Post–Gazette wrote, “This cannot be a medical decision. It’s a greed decision.”
The tense relationship between UPMC and its surrounding communities has been building for years. A wide range of voices—from civil rights and labor leaders to local politicians and Pennsylvania’s attorney general—have long accused the corporation of shirking its civic responsibilities, jeopardizing access to health care for millions of local residents, stripping doctors of their independence, and leaving rank-and-file health care workers struggling to make a living wage. 
Pittsburgh, however, is not the only city with growing acrimony surrounding a nonprofit hospital. Most major metropolitan areas of the United States now feature large medical systems, typically affiliated with a local university, that wield extraordinary economic and political power. These institutions typically enjoy high margins because they face little competition, having spent the last several decades buying up, and often shutting down, rival hospitals. They are then able to charge monopoly prices for highly lucrative specialty treatments while downplaying medical services, like mental health and primary care, that don’t pay well. They advertise these high-end treatments to rich medical tourists from across the world, offering them deluxe accommodations, while ignoring the poor and working-class residents who live, quite literally, next door. 
Legally, however, these institutions are still considered charities. That’s despite not just negligent attitudes toward their communities, but also their bottom lines. Many major academic medical centers make big profits. According to a study published in Health Affairs, seven of the 10 most profitable hospitals in United States are officially “nonprofits.” An analysis by Axios of 31 prominent nonprofit hospital systems found that their margins are on par with some pharmaceutical corporations and medical device makers, and well beyond those of insurers and drug distributors.
These corporations have escaped intensive countrywide (if not local) scrutiny because they enjoy strong national reputations, based mostly on the specialized procedures they practice. UPMC’s flagship hospital, Presbyterian Shadyside, regularly appears on U.S. News & World Report’s “honor roll” of the top 20 hospitals in America and draws in well-heeled patients from around the world with procedures like angioplasties and pacemaker implants. But as a rule, these same institutions tend to do poorly on measures that people in their surrounding communities rightly consider part of the mission of charitable institutions. Presbyterian Shadyside, for example, treats a disproportionately large number of wealthy patients relative to the demographics of its surrounding community. Partly as a result, in the Washington Monthly and Lown Institute’s “Hospitals for America” rankings, which give weight not just to clinical excellence but also to public service (see page 14), UPMC’s Presbyterian Shadyside scores poorly. Out of 3,285 hospitals ranked nationwide, it places 3,138 for civic leadership and 2,424 overall. 
How did this happen, and what can we do about it? By examining the evolution of UPMC’s culture and business practices, we get a case study in the creeping corporatization of America’s “nonprofit” health care sector and the steps needed to once again make it serve the public interest. 
UPMC’s origins trace to the 1920s, when local industrialists and civic leaders looked for ways to help Pittsburgh overcome its image as a social and cultural backwater. Toward this end, they focused on creating a teaching hospital for the University of Pittsburgh’s medical school that they hoped would attract more talented doctors and students. Through heavy investment, they succeeded. By the early 1950s, Pitt’s medical center had attracted the right physicians and was becoming world famous. The most renowned member of its faculty was the virologist Jonas Salk, who along with his close colleagues pioneered the polio vaccine. 
The hospital continued to rise throughout the latter half of the 20th century, with broad benefits for Pittsburgh’s residents. The medical center created jobs both for high-paid professionals and for rank-and-file health care workers. That included a large share of African American women who, though grossly underpaid, found employment at the medical center as nurse’s aides, food service workers, and cleaning staff. During the late 1960s, the medical center partnered with local foundations and the federal government’s “Model Cities” initiative to create the highly successful Freedom House ambulance service, which focused on creating a career path for low-income black youths to become middle-class medical technicians. Moreover, many residents, including substantial numbers who lacked insurance, gained access to a modern, highly sophisticated hospital system.
But over time, UPMC’s relationship with the surrounding community became increasingly fraught. An early flash point came in 1970 when Coretta Scott King, widow of the slain civil rights leader Dr. Martin Luther King, came to the medical center to rally support for striking hospital workers, as she had previously done at Johns Hopkins Hospital in Baltimore. Before a large crowd she argued, “The truth is that the large majority of hospital workers are black, most of them women. Their campaign for a union is part and parcel of the struggle going on everywhere for dignity.” But even in a strong union town, her efforts were to no avail. The hospital broke the union. To this day, UPMC’s labor force remains un-unionized, and many of its workers still protest that they do not receive a living wage. “We’re understaffed, underpaid,” Nila Payton, an administrative aide, says. “We do not have affordable health care even though we work for the health system.” 
During the 1980s, the medical center’s power relative to other local institutions grew stronger and stronger. One reason was the collapse of the local steel industry. But another was the medical center’s own rapid expansion into lucrative lines of specialty medicine, particularly  leading-edge operations like liver transplants, that gave it huge financial leverage. 
UPMC President and CEO Jeffrey Romoff has said he seeks to make UPMC “the Amazon of health care.” In 2018 he took home $8.54 million, while 33 other executives each earned more than $1 million. A key figure in that transformation was Thomas Detre, a psychiatrist who became a powerful hospital administrator. According to a corporate history of UPMC by Mary Brignano entitled “Beyond the Bounds,” Detre raised eyebrows when he arrived in Pittsburgh for his habit of “chain-smoking Marlboros through an ebony holder” and his tendency to wear a topcoat draped around his shoulders. Detre built his own fiefdom within the University of Pittsburgh based initially on his ability to raise large amounts of grant money from the National Institutes of Health, and later by forming a cancer center that brought in huge revenue streams. By controlling so much money, Detre was able to consolidate power from other parts of the university into a stand-alone corporation that came to be known as UPMC, with himself in charge. 
The other key figure was Jeffrey Romoff, UPMC’s current president. A brash and outspoken Bronx native, Romoff emerged as UPMC’s leader after Detre suffered a heart attack in 1992. In a lecture to the faculty of the University of Pittsburgh’s medical school in 1995, he set the tone for his administration by articulating his vision for the future of American health care. “At the heart of the matter is the conversion of health care from social good to a commodity,” he told the assembled doctors and professors.
To increase UPMC’s profits, Romoff moved aggressively to acquire free-standing outpatient facilities, such as surgery centers, particularly in Pittsburgh’s affluent suburbs. Then he started buying up local community hospitals and independent doctor’s practices, converting them into referral networks for UPMC’s main medical center. UPMC’s empire now stretches across Pennsylvania and even includes dozens of foreign ventures, from Ireland and Italy to Kazakhstan and China. 
At least some of UPMC’s acquisitions include hospitals that combine clinical excellence with strong community services. McKeesport Hospital, founded in 1894 in what was then a great hub of steel production, was acquired by UPMC in 1998. Unlike UPMC’s flagship hospital, Presbyterian Shadyside, this small community hospital scores exceptionally high in the Washington Monthly hospital rankings because it manages the rare feat of achieving strong medical outcomes while treating a local patient population deeply threatened by poverty and other adverse socioeconomic determinants of health. It’s proof that, when it wants to, UPMC can manage socially responsible hospitals.
But McKeesport is the exception. More typical is Braddock Hospital. Located in a predominantly low-income African American suburb of Pittsburgh, Braddock was acquired by UPMC in 1996. It served as the area’s only emergency room and largest source of employment until 2010, when UPMC shut it down. It’s not alone. Since 2008, UPMC has shuttered three additional previously acquired major hospitals. This March, just in time for the pandemic, UPMC closed UPMC Susquehanna Sunbury hospital, in central Pennsylvania. Meanwhile, UPMC is spending $2 billion to build three new specialty hospitals in Pittsburgh, closer to its flagship. 
Romoff has had no problem raising the capital UPMC needs to finance these expansions. Revenue has climbed by nearly $5 billion since 2017, a 30 percent increase. Not only does the corporation have abundant cash flow, but as a nonprofit hospital and technically “charitable” institution, it has access to the tax-exempt municipal bond market. UPMC can also finance its empire building, as well as its generous executive compensation packages, by soliciting tax-deductible donations from individuals, foundations, and corporations, as well as grants from governments. Between 2005 and 2017, the public and private grants received by UPMC totaled $1.27 billion.
Romoff’s business model for UPMC has also included moving it into the health insurance business. UPMC now boasts being the “largest health insurer in Western Pennsylvania” with more than 3.7 million members. Last year, its health insurance division took in roughly $800 million more in premiums and other enrollment revenues than it paid out in medical claims. Even better for UPMC’s bottom line, 40 percent of the medical claims its health care plan does pay out goes for health care performed in UPMC’s own medical facilities, meaning that UPMC is effectively paying itself. 
Romoff and his executives don’t have to justify their business plans and compensation packages to stockholders, because as a nonprofit corporation, UPMC has no stockholders. Its 24-member board, which includes representatives from local banks and businesses that work with UPMC, has theoretical control over policy direction, but has consistently been criticized for its passivity by local politicians, community activists, and Pennsylvania’s attorney general. 
UPMC’s financial power also derives in part from its ability, as a nonprofit institution, to escape paying taxes on its ever-expanding property holdings. The system, as the single largest private employer in the Pittsburgh area, accounts for a dominant share of the local economy. Its exemption from local property taxes costs Pittsburgh’s schools and local-area governments a total of some $40 million per year. For decades, local governments and UPMC sued and countersued and lobbied against each other in the state capital over the fiscal imbalance this creates. Over the last ten years, the battle has reached a fever pitch. It’s become a long-running conflict known in Pittsburgh simply as “the war.”
The war started in 2011 when UPMC demanded that Highmark Blue Cross Blue Shield, one of the biggest insurers in the country, pay it higher rates for care performed in its facilities. By this point, UPMC not only controlled most hospital beds in the greater Pittsburgh area but was also a major insurance company itself. In response, and to try to level the playing field, Highmark purchased a small network of local hospitals in the Pittsburgh area that were not yet under UPMC’s control. 
In retaliation, UPMC sent a certified letter to its patients with Highmark insurance telling them they would need to find a new doctor. Without access to any of UPMC’s pervasive facilities, millions of people throughout western Pennsylvania found their access to health care and choice of doctor deeply constrained. One patient in the middle of cancer treatments had to find a new oncologist. Another with a debilitating autoimmune disease said she was dismissed from UPMC’s Arthritic and Autoimmune Center. A breast cancer survivor had to give up the doctor who had treated her since she was first diagnosed five years before. 
In 2012, state officials managed to negotiate a five-year truce between UPMC and Highmark. But it didn’t last. UPMC continued violating parts of the agreement. When it expired, the system announced that all Highmark enrollees would again be denied access to its system. Indeed, UPMC went further. It decreed that going forward it would require out-of-network patients, including seniors on Highmark Medicare Advantage, to pay all estimated charges up front and in full before receiving treatment for non–emergency room services. 
An analysis of 31 prominent nonprofit hospital systems found that their margins are on par with some pharmaceutical corporations, and well beyond those of insurers and drug distributors. The resulting public outrage prompted Pennsylvania State Attorney General Josh Shapiro to sue UPMC in February 2019, arguing that it “willfully engaged in unfair, fraudulent or deceptive acts or practices,” such as “excessive and unreasonable billing practices inconsistent with its status as a non-profit charity providing healthcare to the public.” UPMC countersued, but after a federal judge threw out its case, the corporation decided to resolve the attorney general’s suit out of court. It agreed to sign a contract with Highmark giving Highmark’s customers in-network access to UPMC doctors and hospitals for another decade. In exchange, UPMC got to keep its tax-exempt, nonprofit designation. 
For now, that may stabilize the situation. But in the wake of the coronavirus, it’s likely that UPMC’s monopoly power will grow still more. For many independent rural and community hospitals in Pennsylvania, which were already losing money or barely getting by, the blow from the pandemic will be mortal. At a media briefing in April, Andrew Carter, president and CEO of the Hospital and Healthsystem Association of Pennsylvania, told reporters that “it won’t take long for some hospitals to collapse.” But not UPMC. While the system’s revenues took a hit after the spreading contagion eventually forced it to postpone many lucrative elective procedures, the situation should prove quite manageable. A memo leaked to the Pittsburgh Post-Gazette dated April 15 showed that UPMC was by then already ramping up to do more elective surgeries. It has told its surgeons to reclassify these procedures with terms such as “urgent,” “cancer,” “unstable,” and “relief from suffering” in reports.
There was a time when America’s leading “nonprofit” hospitals were, in fact, nonprofits. When they were first established, institutions like UPMC, the Cleveland Clinic, and Johns Hopkins combined three public missions: They engaged in medical research; they educated the next generation of doctors; and, in the process, they cared for patients who often could not afford to pay. All of these missions were money losers. And because of that, these institutions were typically viewed, both in public opinion and under law, as charities. Governments supported these charities by granting them charters to operate as nonprofit corporations, and then offered deep direct and indirect subsidies, including sweeping tax exemptions. 
But today, the arguments that have historically justified the public’s mostly unqualified support for these institutions are virtually divorced from reality. Unlike when most of these hospitals were founded, the cost of medical research is now largely covered by government grants (23 percent) and private industry (65 percent). The cost of medical training is largely borne by grants from Medicare and other federal programs that more than reimburse hospitals for graduate medical education programs. Indeed, teaching hospitals make money on the medical services their residents provide.
Finally, the type of medicine now practiced by many elite academic medical centers isn’t focused on the broader health care needs of their surrounding communities. Instead, it’s care delivered almost exclusively to patients with public or private insurance. Indeed, at the largest and most famous academic medical centers, the focus is often on attracting VIPs from around the world who pay top dollar for specialized treatments in luxury surroundings, even as residents in the surrounding neighborhoods see their health care needs go unmet. 
The main campus of the Cleveland Clinic, for example, is surrounded by low-income neighborhoods that are federally designated as “medically underserved areas.” Most lack access even to adequate primary care. Yet the clinic focuses on its services to VIPs, including large contingents from Saudi Arabia’s royal family, who enjoy the privileges of being “Premier Executive Health patients.” These privileges, boasts the clinic’s website, include “personal attention and luxurious suite accommodations found on the exclusive Club Floor of the InterContinental Hotel on Cleveland Clinic’s campus.” Not to be outdone, Johns Hopkins’s main hospital, located in inner-city Baltimore, counters with its newly renovated Marburg Pavilion, which, according to its website, offers “deluxe rooms” with “original wood details,” “patios with view of the medical campus,” “special dining service,” “fine bed linens,” and “specialty bath products.” 
Johns Hopkins’s main hospital, located in inner-city Baltimore, offers “deluxe rooms” with “original wood details,” “patios with view of the medical campus,” “special dining service,” “fine bed linens,” and “specialty bath products.” All these trends have come together to create a new thing in the world: the charitable nonprofit hospital that has morphed into a profit-driven, tax-exempt, publicly subsidized monopolistic corporation focused on lucrative luxury care for the well-to-do. 
What can be done to make these institutions once again serve the public? One powerful potential lever is threatening to take away their nonprofit status and all the gigantic subsidies, tax breaks, charitable contributions, and other privileges that go with it. Nonprofit hospitals, after all, operate under binding charters that require them to serve the public interest. According to the law, they can enjoy the protections of incorporation only so long as they serve some public purpose and not inure to the benefit of any private shareholder or individual. This means that it is well within the statutory powers of state attorneys general to put any nonprofit corporation operating within their states under new management if it fails to act in the public interest, or, alternatively, to strip it of its nonprofit status. It was just such a threat that enabled Josh Shapiro, Pennsylvania’s attorney general, to force UPMC to deal fairly with Highmark customers. 
Legislation sponsored by Dan L. Miller, the Pittsburgh-area state representative, would go further. It would cut off state funding for any nonprofit that failed to adhere to fair labor standards or failed to set aside at least 20 percent of the seats on its governing board to people elected by workers.
Similarly, if a nonprofit hospital acts uncharitably or otherwise fails to produce real community benefits, the federal government has ample statutory authority to yank its nonprofit status and force it to pay federal income taxes. Moreover, both the federal government and the states have all kinds of antitrust and other anti-monopoly laws that, if properly enforced, would put an end to the kind of predatory and anticompetitive business practices that now pervade the world of “nonprofit” corporate medicine. If UPMC or other nonprofit hospitals decided that they wanted to convert to for-profit corporations, they would still need a state license to practice medicine, meaning that governments would still have a lot of power to demand more responsible corporate citizenship. 
Of course, if health care providers like UPMC return to their historic mission, they will need a way to pay their bills. Quality health care and health promotion—the kind that actually improves public health through prevention and helping patients manage chronic conditions—is by its nature a public good. And that means it generally does not, cannot, and should not earn a profit. If we want nonprofit hospitals to operate truly in the public interest, we can’t put them in a position in which they either bend their practice of medicine to maximize revenues or else get eaten by predators who do. Public interest medicine needs public funding, and control. 
In the battle with COVID-19, we are learning how much we owe to the sacrifices of frontline doctors and other health care workers and how much public health depends on everyone having access to quality, affordable health care. But “Medicare for All” or other means of expanding health care coverage won’t get it done if our health care delivery system remains dominated by corporations that put self-enrichment before social mission.
https://washingtonmonthly.com/magazine/july-august-2020/elite-hospitals-have-an-epidemic-of-greed/

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