Los Angeles Times: Lack of record access drives up costs at L.A. hospitals for poor

L.A.’s safety-net hospitals are scrambling to match others nationally that use electronic records and integrated systems to manage care for low-income patients and cut costly hospitalizations.


November 25, 2011|By Noam N. Levey, Los Angeles Times

The emergency room at White Memorial Medical Center on Los Angeles’ Eastside was buzzing when paramedics arrived on a Friday night with an elderly man slurring his words and complaining of aching bones.

The nurse in the receiving bay immediately ran through standard triage questions: “Are you diabetic? Do you have high blood pressure? Are you allergic to any medications?” Each drew the same response: “I don’t know.”

The hospital and doctors had no record of the man or his medical history. And with their only guide a piece of crumpled paper they found tucked into the man’s pants that seemed to indicate he might have had cancer, doctors had to order a full diagnostic work-up, including blood tests and an EKG to check his heart.

It was another night of high-priced detective work at one of America’s urban hospitals.

“We’re mostly flying blind here,” said Dr. Brian Johnston, the senior emergency room physician at White Memorial, shaking his head at the high costs generated by the lack of records and unnecessary testing.

Waste bedevils much of America’s fragmented healthcare system, driving up already skyrocketing costs. As health spending overwhelms government budgets, the stakes are especially high for safety-net institutions like White Memorial that serve the country’s poorest patients, largely at taxpayer expense.

The best safety-net systems — in Denver, Dallas, New York and elsewhere — have found ways to practice medicine more efficiently, using electronic records and integrated systems to manage care for low-income patients and cut costly hospitalizations.

In Los Angeles, Chicago and many other cities, local healthcare officials are now scrambling to catch up.

“There is really no system of care here,” said Allen Miller, a Los Angeles consultant who is working with private hospitals, clinics and physicians on a potentially trailblazing initiative to link together medical providers that care for some of Los Angeles County’s neediest patients.

“We think by working together, there are ways to provide the right care and spend less money,” he said.

White Memorial, a nonprofit hospital founded in 1913 by the Seventh-day Adventist Church, is on the front lines of that campaign.

The sprawling medical center rises out of the heart of Latino Los Angeles, almost literally in the shadow of the county’s mammoth public hospital just east of downtown.

For nearly a century, the two institutions have served the same communities of immigrants and other Angelenos without private insurance or without access to the upscale hospitals on the city’s Westside.

They often serve the same patients. On a recent Tuesday, 38 of the 270 people seen at White Memorial had also received care at L.A. County/USC Medical Center in the last year, according to hospital data.

But doctors and nurses at the two hospitals have no way of knowing which tests were run or what treatment was provided because they cannot access each other’s computer systems.

Nor can they see what care patients might have received at the 70 other acute-care hospitals or at any of the thousands of doctors’ offices and clinics around the county.

Patients, many of whom don’t speak English, often have difficulty providing guidance.

In the White Memorial emergency room, doctors and nurses tell stories of people who can’t explain big scars on their chests, or even drug allergies or recent blood tests.

“We end up repeating an unbelievable amount of medical tests and other things that probably have been done somewhere else,” said Dr. Juan Barrio, who directs White Memorial’s internal medicine internship program.

Nationally, most emergency doctors reported in a recent survey by the American College of Emergency Physicians that at least a quarter of their patients had gotten tests that could have been avoided with better access to medical records.

Adding to the inefficiency, White Memorial and many other hospitals that care for low-income patients have few resources to ensure that their patients are getting needed care once they leave the hospital.

That can lead to complications at home and costly trips back to the emergency room. Studies show that poor patients are much more likely to end up back in the hospital.

At a place like White Memorial, where about 85% of the patients are on Medicaid, Medicare or some other government health insurance program, the cost of that waste is borne directly by taxpayers.

A thousand miles away, Denver Health, which every year provides care to a third of that city’s 600,000 residents, has shown there are ways to reduce the waste.

The nationally acclaimed safety-net system has developed a network of neighborhood and school-based clinics where patients go for checkups, vaccinations and other routine care, a critical tool in reducing expensive hospitalizations.

And Denver Health’s extensive electronic data system allows doctors and nurses to access patients’ medical records anywhere in the system, reducing costly errors and duplication.

The initiatives have helped Denver Health hold costs for many medical procedures far below those at other Denver hospitals, according to Colorado Hospital Assn. data. And last year, Denver Health bested more than 100 other leading academic medical centers in a measure of how many patients survived under hospital care.

There are immense challenges to replicating those results in Los Angeles County, where dozens of independent private hospitals work alongside the massive county health system to provide care to about 5 million people who either lack insurance or rely on the publicly funded Medicaid program.

But in an unusual partnership sparked by the healthcare law President Obama signed last year, White Memorial is now working with two other major safety-net hospitals and the county’s largest chain of nonprofit health clinics to try to create the kind of integrated system that is cutting costs and improving quality in Denver.

Clinic operator AltaMed; Hollywood Presbyterian Medical Center; Citrus Valley Health Partners, a hospital in the San Gabriel Valley east of Los Angeles; and White Memorial plan to begin sharing medical records in a year.

And by 2013, they hope to be able to begin managing care for thousands of patients by using AltaMed’s clinics and a network of independent private physicians, instead of expensive emergency rooms and hospital wards.

At the same time, the new partnership is talking with the county health system, which is working on its own streamlining efforts, about sharing more records to cut down on duplicative services.

The cooperative venture is still in its early stages. But health officials in the nation’s most populous county say they have no choice.

“There aren’t enough beds here. There aren’t enough doctors…. And there isn’t enough money,” said Elvia Foulke, Citrus Valley’s chief operating officer. “We have to figure out a way to care for these people more rationally. We just have to.”

The Washington Post: Supercommittee announces failure in effort to tame debt


By Lori Montgomery and Paul Kane, Published: November 21

A special congressional committee created to try to curb the national debt abandoned its work and conceded failure Monday, the latest setback in a long effort by Washington to overcome ideological differences and stem the rising tide of red ink.

In a joint statement issued hours before a midnight deadline, the Democratic and Republican leaders of the panel said that they were “deeply disappointed” by their inability to reach an agreement and that they hope for progress in the months ahead.

“Despite our inability to bridge the committee’s significant differences, we end this process united in our belief that the nation’s fiscal crisis must be addressed and that we cannot leave it for the next generation to solve,” said the statement from Rep. Jeb Hensarling (R-Tex.) and Sen. Patty Murray (D-Wash.). “We remain hopeful that Congress can build on this committee’s work and can find a way to tackle this issue in a way that works for the American people and our economy.”

The collapse of the “supercommittee” offered fresh evidence of partisan gridlock and legislative dysfunction as policymakers gird for the 2012 elections with the White House and Congress up for grabs.

The breakdown left the nation facing the prospect of automatic reductions to government agency budgets in January 2013 — an outcome that both parties agree could damage the military and government services such as law enforcement, food inspection and transportation safety.

Some GOP lawmakers immediately issued statements vowing to stop the Pentagon cuts. But President Obama sought to block that effort, threatening Monday to veto any legislation aimed at softening the impact of the cuts unless Congress approves a broader debt-reduction plan. Obama urged lawmakers to revisit that task as soon as they return from the Thanksgiving break.

“Already, some in Congress are trying to undo these automatic spending cuts. My message to them is simple: No,” the president said in a televised statement that marked his reentry into the debt debate after weeks of keeping his distance as Congress flailed.

“There will be no easy off-ramps on this one. We need to keep the pressure up to compromise, not turn off the pressure,” he said. “The only way these spending cuts will not take place is if Congress gets back to work and agrees on a balanced plan to reduce the deficit by at least $1.2 trillion. . . . They’ve still got a year to figure it out.”

Congressional leaders in both parties pledged to press on. But in statements issued Monday, they spent more time blaming one another for the political paralysis that has nearly shut down the government twice this year and that in August pushed the U.S. Treasury to the brink of defaulting on the national debt. Although the supercommittee’s failure will not result in an immediate calamity, analysts said it probably will further erode public confidence in Washington — particularly in Congress, which already is held in historically low regard.

At a scathing news conference, New York Mayor Michael R. Bloomberg (I) blamed Obama and lawmakers in both parties for the stalemate, calling the supercommittee collapse a “damning indictment of Washington’s inability to govern this country.”

Sen. Olympia J. Snowe (Maine), a moderate Republican, called the panel “a monumental waste of time and opportunity” that “represents yet another regrettable milestone in Congress’s steady march toward abject in­effectiveness.”

“It paints a portrait of dysfunction that further crystallizes for the American people their government’s incapacity for producing solutions to our major challenges,” Snowe said in a statement.

The supercommittee was created during this summer’s showdown over the federal debt limit, part of a two-stage strategy to restrain borrowing by at least $2.2 trillion over the next decade. About $1 trillion in savings was identified up front in the form of limits on spending that Congress appropriates annually. The committee was tasked with finding the rest, with the threat of $1.2 trillion in across-the-board cuts as an incentive to compromise.

Appointed by the four congressional leaders, the 12-member panel was given extraordinarily broad power to act. Any part of the budget was fair game. And if a majority of supercommittee members agreed on a plan, the House and the Senate would have to take it up for a vote without making changes.

Senate Minority Leader Mitch McConnell (Ky.) said Republicans considered the panel a “golden opportunity to change the direction of the nation’s fiscal trajectory and create a better environment for job growth.” In the end, however, the hard work of panel members was thwarted by the same political pressures that prevented Obama from sealing a far-reaching deficit deal this summer that he was negotiating with House Speaker John A. Boehner (R-Ohio).

Although Republicans offered to raise taxes by $300 billion over the next decade, they insisted on conditions that all but guaranteed that the wealthy would not be hit hard. And Democrats refused to agree to deep cuts in spending on health care for the poor and the elderly unless the rich were forced to make greater sacrifices.

By late last week, hope for a deal had all but faded, leaving panel members to spend a desultory weekend talking with their aides and trekking to TV studios for recrimination-filled appearances on Sunday talk shows. On Monday, several members took one last stab.

“Both sides are feeling angst and greater angst at the possibility of no agreement,” Sen. Max Baucus (D-Mont.) said as he left a midday meeting in the office of Sen. John F. Kerry (D-Mass.). “So they’re working harder, more creatively, to see what can be accomplished.”

In addition to Baucus and Kerry, the bipartisan huddle included Rep. Chris Van Hollen (D-Md.) and three Republicans: Rep. Fred Upton (Mich.) and Sens. Jon Kyl (Ariz.) and Rob Portman (Ohio).

Although the last-minute talks offered a ray of hope — a high school civics class from Georgia on a tour of the Capitol spent 40 minutes waiting outside Kerry’s office — aides to both parties said a deal was never close. But as late as 4:40 p.m., Kerry was still hoping for a bargain.

“Well, I can’t go into the details of it,” the senator told a TV reporter. “It’s sort of a last-ditch effort to try to see if we could find a way to solve America’s problem here.”

Kerry said the negotiators were “waiting for the chairs to speak” about whether the latest proposal would fly. Five minutes later, Murray and Hensarling issued their statement pulling the plug.

“I’m deeply disappointed with this outcome. We all are. This was an historic moment to do something big, bold, and balanced that demanded shared sacrifice to put our country first,” Kerry said later in a written statement.

“It’s too easy just to say that Washington is broken or Congress is broken,” he said. “These issues aren’t going away; in fact they are becoming more urgent.”

Reuters – Supreme Court agrees to hear Obama healthcare law


1:29pm EST

By James Vicini

WASHINGTON | Mon Nov 14, 2011 5:14pm EST

WASHINGTON (Reuters) – The Supreme Court agreed on Monday to decide the fate of President Barack Obama’s healthcare law, with an election-year ruling due by July on the healthcare system’s biggest overhaul in nearly 50 years.

The decision had been widely expected since late September, when the Obama administration asked the country’s highest court to uphold the centerpiece insurance provision and 26 states separately asked that the entire law be struck down.

The justices in a brief order agreed to hear the appeals. At the heart of the legal battle is whether the Congress overstepped its powers by requiring all Americans to buy health insurance by 2014 or pay a penalty, a provision known as the individual mandate.

Legal experts and policy analysts said the healthcare vote may be close on the nine-member court, with five conservatives and four liberals. It could come down to moderate conservative Justice Anthony Kennedy, who often casts the decisive vote.

The law, aiming to provide more than 30 million uninsured Americans with medical coverage, has wide ramifications for company costs and for the health sector, affecting health insurers, drugmakers, device companies and hospitals. 

A decision by July would bring the healthcare issue to the heart of the presidential election campaign. Polls show Americans are deeply divided over the overhaul, Obama’s signature domestic achievement. 

A ruling striking down the law, months before the U.S. elections in November 2012 as Obama seeks another four-year term, would be a huge blow for him legally and politically. 

A ruling upholding the law would vindicate Obama legally, but might make healthcare an even bigger political issue for the leading Republican presidential candidates, all of whom oppose it. 

Also on Monday the administration, in the latest in a string of executive moves to sidestep a divided Congress, announced up to $1 billion for a program to support healthcare innovation to cut costs and improve care. 

The high court could leave in place the entire law, it could strike down the individual insurance mandate or other provisions, it could invalidate the entire law or it could put off a ruling on the mandate until after it has taken effect. 

A Supreme Court spokeswoman said oral arguments would take place in March. There will be a total of 5-1/2 hours of argument. The court would be expected to rule during its current session, which lasts through June. 


White House Communications Director Dan Pfeiffer said the administration was pleased the Supreme Court agreed to hear the case. “We know the Affordable Care Act is constitutional and are confident the Supreme Court will agree,” he said. 

Those challenging the law also voiced optimism. Karen Harned of the National Federation of Independent Business said: “We are confident in the strength of our case and hopeful that we will ultimately prevail. Our nation’s job-creators depend on a decision being reached before the harmful effects of this new law become irreversible.” 

Florida Attorney General Pam Bondi, whose state is leading the challenge to the law, said: “We are hopeful that by June 2012 we will have a decision that protects Americans’ and individuals’ liberties and limits the federal government’s power.” 

BernsteinResearch, which provides investment analysis, predicted the most likely outcomes were the law being upheld or a decision being delayed until 2015. 

Paul Heldman, senior analyst at Potomac Research Group, which provides Washington policy research for the investment community, said he still leaned toward the view that the law’s requirement that individuals buy insurance will be upheld. 

“We continue to have a high level of conviction that the Supreme Court will leave much of the health reform law standing, even if finds unconstitutional the requirement that individuals buy coverage,” he wrote in a recent note. 

After Obama signed the law in March 2010 following a bruising political fight in Congress, the legal battle began, with challenges by more than half of the states and others. The Supreme Court has long been expected to have final say on the law’s constitutionality. 


The administration has said other landmark laws, such as the Social Security Act, the Civil Rights Act and the Voting Rights Act, faced similar legal challenges that all failed. 

The Obama administration in its appeal to the Supreme Court argued that Congress could adopt the insurance purchase requirement under its powers in the U.S. Constitution to regulate interstate commerce.

The 26 states argued that Congress exceeded its powers and that all of the law should be struck down. The group representing independent business took the same position as the states. 

The states also challenged the expansion of Medicaid, a federal-state partnership that provides healthcare to poor Americans, on the grounds Congress unconstitutionally forced the expansion on the states by threatening to withhold funds. 

The dispute reached the Supreme Court after conflicting rulings by U.S. appeals courts. 

Appeals courts in Cincinnati and Washington, D.C., upheld the individual mandate. An appeals court in Atlanta struck it down, but refused to invalidate the rest of the law. An appeals court in Virginia ruled the mandate could not be decided until 2015, when the penalties for not having insurance are imposed. 

The Supreme Court cases are National Federation of Independent Business v. Sebelius, No. 11-393; U.S. Department of Health and Human Services v. Florida, No. 11-398; and Florida v. Department of Health and Human Services, No. 11-400. 

(Additional reporting by Alister Bull and Lewis Krauskopf in New York; Editing by Howard Goller and Eric Beech)