(Blue Dog 4 October 2001)

Hospitals at the Edge
Part II: What the doctors say

by Bruce Jackson
 

Buffalo’s hospitals are in crisis. There isn’t enough money to provide many essential services, specialists are leaving or retiring and aren’t being replaced, and UB’s medical school is in disarray. A few optimists urge us to hang on until the High Street Corridor is completed a decade or so from now, at which time, they say, all will be well again. Be that as it may, right now things are bad. A blue-ribbon task force of rich white males, none of whom has any health care experience, has been set up to study the problem.

I asked several physicians—a group deliberately excluded by the organizers of the health care task force—for their sense of what went wrong, where things are, and where things are going. What follows are just two of the responses, both from highly-regarded practitioners.

Dr. Howard A. Lippes:

(Dr. Lippes is and internist an endocrinologist currently practicing in Buffalo.)

Perhaps the most painful wound inflicted on providers and patients is the deterioration of all area hospitals. For the Kaleida, Catholic and ECMC hospitals you can blame:
 

1. The big three HMOs  (Independent Health, Community Blue, and to a lesser extent Univera) who have underpaid or in many instances not paid the hospitals.

2. The Medicare balanced billing act of 1997.  This legislation has had a profoundly negative impact on hospitals nationally, especially larger urban “teaching” hospitals.

3. The leadership and management of our hospitals. The leadership at the Kaleida system seems to be guilty of the greatest mismanagement and it is not surprising that they are in the worst financial shape.  These are the folks responsible for signing contracts with the HMOs. These are the same people who stood by when they must have seen that the HMOs weren’t paying their bills. Were they incompetent or is there some other explanation for their dealings with the HMOs? These are the folks who are responsible for the shortage of nurses and support staff, as well as the failure to maintain infrastructure and vital equipment.  At same time these same hospital administrators have told us that our hospitals are functioning well and that they expect the hospital to be “in the black” by next fiscal quarter. Of course no one believes them anymore.

4. Some blame should be assigned to the leadership at the medical school. The medical school’s involvement in the community’s health care and particularly the state of local hospitals is complex.  The relationship between the medical school and the community hospitals must be viewed from the perspective that SUNY at Buffalo school of Medicine and biomedical sciences has NO University hospital (unlike the other state medical schools and unlike most excellent medical schools).  It was our WNY hospitals that provided the salaries and support for the majority of the clinical faculty of the medical school. At the last faculty meeting I attended (about 2 years ago) the Dean, John Wright (since dismissed as dean) stated that 100 faculty had left the medical school without replacement.  Some clinical departments have almost no faculty left (I have been told that there is only one member of the department of Radiology).  While clinical departments have been decimated what has the medical school administration said or done? Most of the damage occurred during the administration of Dean John Naughton, but since his departure things seem to have only gotten worse.  A detailed investigation into all aspects of “the faculty practice” plan would be very interesting indeed.

5 Finally, what have the physicians of WNY done except complain?  We have stood by silently as conditions at the hospitals worsened year by year and we have watch colleagues in the medical school retire early or leave town, while there have been no replacements.  What has the Erie county medical society said or done? What about leadership in individual hospital medical staff?  Actually, there have been a few voices of protest. Sadly, too few and too faint.

In considering the state of WNY hospitals let’s not leave out the Buffalo Veterans Hospital.  The VA had been the source of funding for a very large number of the medical school faculty.  The shift in demographics has resulted in the central VA sending resources to hospitals in the retirement communities in the south and southwest, and at the expense of the Buffalo VA.  More faculty and research dollars sent to Florida and the Carolinas. How does this affect you if you are patient at the Buffalo General hospital?  Consider who is training the intern or resident called to attend you in the middle of the night or in a crisis. Consider that many VA faculty were part time and received the balance of support from one of the other community hospitals where they would attend patients and teach students and house staff. Often, these were the doctors who spent some time doing research and were called to see the most complicated cases. Most of these academic faculty have gone.

The low reimbursement rates from HMOs in WNY have taken on a new dimension. We now have the distinction of having the lowest (or nearly the lowest) rates in the country. For the most part doctors are still very well paid (there are some significant disparities here) and so it is hard for non-physicians to get too upset about doctors getting paid less. However, the current rates have resulted in community doctors leaving WNY.  More worrisome is that no new doctors are coming to replace those leaving or retiring early.  We already have severe shortages in some specialties and I fear that this problem is going to get a lot worse. The directors for Health Now (aka Blue Cross) and IHA are often quoted in the Buffalo News and they say that physicians in WNY are inefficient or even down right out of step with doctors in other communities. Health Now says that patients in WNY are admitted to hospital more often, stay in hospital longer and are operated on more frequently than patients in other communities (such as Portland, Oregon). This is undoubtedly true, and Health Now officials use this as the reason that they cannot raise payment rates to hospitals and doctors.  What Health Now will not tell you is that WNYorkers are older, more indigent, fatter and smoke more tobacco than say, residents of Portland, Oregon. On most national indicators of Quality of Health administered, WNY doctors and hospital usually garner an “average” score.  Given the circumstances in WNY, in which doctors and nurses work, I think that the doctors and nurses have performed admirably.

In summary, the top three problems can be briefly enumerated as under funded hospitals that are in fiscal disarray, the loss of Medical school faculty to the extent that we could lose accreditation of the school, and a looming shortage of some specialty doctors.

 In a later letter, Dr. Lippes added, “The time for putting a band aid with a ‘happy face’ on Kaleida’s wounds has passed. The same can be said for the other hospitals, too. We need some honesty from boards and hospital administrators before confidence can be restored.”

Dr. F. Fero Sadeghian:

(Dr. Sadeghian, a general and vascular surgeon, was in practice of surgery in the area close to forty years before retiring in 1997.  He served as the president of medical staff at Buffalo General Hospital, and founded and chaired the hospital’s ethics committee.)

Yes, there is a national health problem, but our system seems in far worse shape than others. The exodus of well-respected deeply-rooted and talented doctors in this medical community has reached an alarming level. They are seeking positions in environments more conducive to the practice of their profession, often in neighboring towns. The situation begs the question: why are other medical communities benefiting from them at our cost?

I can only speak about the surgical department at General Hospital where I practiced. We had a cadre of active, well-respected surgical faculty, a mix of volunteer and full-time, who complemented each other well, in almost all surgical specialties, including cardiac, and renal transplant surgery (Buffalo General Hospital and Columbia at the beginning were the only two hospitals designated in NY for heart transplant). The surgical department now is a skeleton of its past. Many of the talented surgeons with deep roots in this community, that the faculty was proud to have trained, are now serving other towns.  Residency and fellowship programs are in trouble, some already eliminated and others are in such danger.

Only a few years ago, BGH was considered a tertiary institution serving many surrounding communities, it served as a last resort for any complex medical problem beyond the scope of such medical communities. It served not only western NY, but the neighboring states as well. Nowadays there is a clear reluctance in such communities to refer their complex problems to BGH because of lack of resources. We are not only losing patients to Cleveland and Rochester but also to smaller communities such as Erie, Pa.

As a physician I never had any hesitation to refer patients who asked my opinion to the medical community in Buffalo, because I knew of the pockets of strength, albeit fragmented, which existed in our medical community that offered excellent care, comparable to any in the country. Today I have to think hard in recommending, since the number of such candidates is dangerously low.

For a city which boasted few years ago to have one of the better state medical schools in the country and a large residency program, it is disturbing to see that its citizens must now depend on the traveling expertise of other states for x-ray interpretation.

Values

There's a lot of huff and puff in Albany and City Hall these days about a casino for Buffalo. Only a few local politicians have had the guts to stand in the way of the gamblers’ and developers' bandwagon now rolling toward the Statler Towers. The casino looks so good, so sweet, so easy: lots of bucks, fast bucks, bucks you can pocket and bank and scoot out of town with. A few real estate developers will surely make a fortune; everything else remains in doubt. The vicious economic and social problems are far down the line, so there's no need to pay them any mind now. Let's talk about the party.

And while they're talking about the casino party they're maintaining brutal silence about the chaos in health care. Health care is far more important to the life of this city than slot machines. Health care is far more important to you and your children and me and my children than the profits made by the developers of the casino and the parking lots it will require.

Instead of frothing about folks around here not playing ball with the casino developers, our local representatives should be dealing with the decline of health care in western New York. Instead of taking health care professionals for granted they should be listening with great care to their ideas and their concerns. Every physician I know passionately echoes the cogent remarks of Dr. Lippes and Dr. Sadeghian.

Instead of telling us that casinos are the secret of urban health, our representatives and power brokers should face the fact that no rational corporate manager is going to locate or expand a corporation in a city where even a rich guy stands a fine chance of being killed by the health system. They should recognize the fact that no young competent physician is going to take a job in a hospital system that spends more energy amputating its own limbs than attending to patients’ needs. They should understand what is going to happen to quality of life in this town when none of the colleges or universities or research organizations can hire top-notch scholars and scientists because nobody smart enough to do that level of research is going to move a family to a town that cannot provide that family adequate health care.

Instead of running like junkies after a fantastic quick fix from slot machines, it’s about time our political and corporate leaders stood still and listened to the people who know what’s really going on. It’s time they looked at the health care mess from the inside as well as the outside. It’s time they stopped the bleeding.
 

Click here for Part I, “Buffalo’s Most Dangerous Neighborhood," which appeared in Blue Dog on September 27.

copyright 2001 Bruce Jackson
 

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