Dr. Daines' unexpected death

I learned this morning that Dr. Richard Daines has died. He served as New York State Health Commissioner until last December.

I last saw Dr. Daines on December 13 when he was in Syracuse to address the University Hill Corporation. It may have been his last public address as Commissioner.

A student of history, Dr. Daines gave a thoughtful and insightful lecture. He cited the names of various New York counties through which he traveled as Commissioner, and for each name he recalled a part of New York history involving civil rights, commerce, or technological innovation. He concluded his remarks by advocating that New York, consistent with its remarkable history, has an opportunity to take a leadership role in addressing the needs and challenges of health care.

After the talk, Dr. Daines told me had not yet decided what he would do after leaving the Department of Health. I read last week that he had been named a visiting scholar at the New York Academy of Medicine.

To get a sense of the man, read the New York Times profile that accompanied his appointment as Health Commissioner in 2007. Dr. Daines unexpected passing is such a shock and a sadness.

The Urban League & Syracuse history

A fellow employee asked me last week when I was planning to write "your February letter." She meant, was I going to write about Black History Month? I didn't have a topic, but as we talked, I said, "February is not over yet."

When I checked this blog, I realized I have never written an entry specifically about Black History Month. I have posted comments about civil rights and racial equality but not about Black History Month.

That very day I received a call from an old friend, Leon Modeste, who was President and CEO of the Urban League of Onondaga County for 15 years (1979 to 1994). Now a resident of Albany, GA, Mr. Modeste was a big part of Syracuse -- and of Syracuse black history.

I had found my topic for Black History Month.

I am sorry to say the Urban League no longer exists in Onondaga County. It shut down more than a decade ago, the victim of budget cuts, a leadership gap, and inconsistent community support.

I worked with Mr. Modeste in the League for many years. He will celebrate his 85th birthday later this year. We reminisced about the people we worked with and issues we encountered in recent Syracuse history. He recalled Andrew Willis, his immediate predecessor as Urban League CEO, who played an active role in desegregating the city schools, something that happened in Syracuse only in the 1970's, despite Brown v. Board of Education, 1954.

We talked about Dennis Dowdell, Sr., who founded the League in Syracuse in the 1960's, working with local employers and civic leaders during a time of black frustration and white worry. Mr. Dowdell was honored with the League's Harriet Tubman Award in 1988.

We remembered other figures from Syracuse's history, such as League Board members Elijah Huling, Jr., Harriet McDowell, the Rt. Rev. Ned Cole, Mary (Mitzie) Cooper, Charles Chappell, Jr., the Rev. Sherman Cummings, Charles Anderson, Larry Harmon, Dr. Bruce Leslie - and so many more. See Charles Anderson's op-ed article in today's Post Standard.

And the issues of the day! The Landmark Theater pepper spray incident. The civilian review board. Fair access to housing. Jobs and training. The importance of family life. Mr. Modeste was outspoken when he perceived injustice or hypocrisy.

The League offered a number of programs, balancing funding among a complex of local and government sources. I remember us calling then-State Senator Tarky Lombardi, Jr., who helped many times to keep state funds flowing during various budget shortfalls and cutbacks for programs the state had contracted with the League to provide.

There were programs in the city schools. One service encouraged students with after-school tutoring, involving parents. The Urban League honored a different family each year at an annual awards ceremony, respecting the decency and determination of family accomplishments.

The League helped educate and assist first-time mortgage applicants. And it was part of the community's cultural life with fashion shows and fundraisers. The photo, above, is from the Urban League's 25th anniversary dinner in 1989. That's an embarrassingly youthful me, next to Mr. Modeste.

Two years ago Mr. Modeste and Mr. Willis donated pictures, papers and other documents from the old Urban League to the Onondaga County Public Library.

Thanks to the prompt from a co-worker -- and a fortuitous call from Mr. Modeste -- I am able to post this commentary during Black History Month, just barely.

More support for Community & Upstate

In a post on Thursday, I wrote:

Last week Community General's board of directors approved a resolution that accepted Upstate’s offer to acquire our hospital and its affiliated companies . . .

You read it here first. Today the Post-Standard reported on the Board's decision, based on my memo to employees, which you can read by clicking here.

The combination of Community with Upstate University Hospital has also been supported by the Auxiliary to Community General Hospital. Click here to see the Auxiliary's endorsement.

Are stand-alones an endangered species?

Today we read in the Post Standard that Auburn Memorial Hospital, Oneida Healthcare Center and probably "every hospital within 100 miles" is interested in some form of stronger affiliation with a larger health system.

In a very public way Community General Hospital has been pursuing its strategy of affiliating with another, stronger hospital since 2009.

The newspaper quotes Gary Fitzgerald, President of the Iroquois Healthcare Association:

Our region has a lot of . . . stand-alone hospitals. They just can’t afford to stay completely independent without exploring other options . . .

Last week Community General's board of directors approved a resolution that accepted Upstate’s offer to acquire our hospital and its affiliated companies. This represents progress in defining Community's future role in Central New York.

The board action is good news for the community that we serve, as well as our medical staff and hospital employees.

We are fortunate to have the opportunity to become part of SUNY Upstate's health system.

Upstate's important "eds and meds" role

In the discussion about the economic benefit of SUNY Upstate Medical University, an executive from Columbia University weighed in yesterday in the opinion pages of the Post-Standard.

Willaim Eimecke, Director of Executive Education at Columbia University’s School of International and Public Affairs, noted the "Brookings Institution recently concluded that the best strategy for stimulating the Central New York economy is investment in its educational and medical institutions; Upstate Medical (University) is both."

Dr. Eimecke urged that elected officials who seek to balance budget cuts with job creation should see SUNY Upstate and other teaching centers "as an investment, not just a cost."

Click here to read the full text of "Cutting health care in Upstate New York creates more pain than gain."

Scale and efficiency

At the CNYHSA meeting last month, there was one comment by a physician. Dr. Douglas Tucker works for MVP health plan so he was actually speaking as an insurer, rather than as a physician.

Dr. Tucker said that the acquisition of Community by Upstate would be “a catastrophe” because patient services at Upstate cost more than at Community. As a result, he asserted, the combined hospital would be more expensive for the community-at-large.

He wasn't speaking about hospital costs. He was talking about what insurers pay hospitals for care given to their beneficiaries. (Hospitals aren't able to disclose what we are paid by insurance companies. To do so would violate antitrust laws.)

Is Dr. Tucker's concern a valid one? Will the combination of Community and Upstate help or hurt the cost of care over the next five or ten or 15 years?

First, let's be clear about Community's prospects as an independent community hospital. They are not great, as has been widely reported, unless we become part of a larger hospital system.

So why are Community's prospects "not great" as a stand-alone, community hospital? There are several reasons. A loss of cases in profit-making services. A limited ability to cost-shift to private insurers when there is underpayment from government payers. The ever rising costs of the hospital business. And fewer physicians who replace themselves when they leave practice.

Community has lost profitable cases to free-standing ambulatory surgery centers. This profit-making volume helps a hospital like ours subsidize the money-losing services, such as medicine, psychiatry, and 24/7 emergency services.

Over the years some ambulatory surgery cases have migrated away from the hospital in favor of free-standing ambulatory surgery centers, which are typically owned by physicians. Why do physicians need the additional revenue? Because their incomes have been frozen or otherwise restricted for a number of years.

What about insurers, such as Dr. Tucker represents? Arguably, insurers have been paying more than their fair share to hospitals, given the increasing statutory and regulatory controls on Medicare and Medicaid. Like other hospitals, Community relies on private insurers to make up the difference. But private payers do not make up all the difference, and there is a limit to this cost-shift. Dave Oliker, MVP’s President, recently called the cost-shift a hidden tax.

With this pressure on hospital revenues, we have also seen hospital fixed costs going up. Hospitals shoulder the added cost of services no longer provided by private doctors (such as 24/7 hospitalist service). We've seen higher costs due to federally-mandated electronic medical records (EMRs). And there are greater capital costs as hospitals construct private rooms (the emerging standard) and update medical technology.

Add to that the problems of doctor practices. Many older physicians do not replace themselves when they leave practice. A shrinking supply of doctors means hospitals scramble to buy medical practices as a way of replenishing physicians (and not incidentally, as a way to avoid competing with doctors for ambulatory surgery cases).

Community has been clear about what it wants from its affiliation with a larger hospital system: we seek to spread the fixed costs over a bigger base of operations, we seek to avoid duplicate and costly capital investment, we seek an integrated delivery system, and we seek better access to capital. Upstate provides these things.

The question about hospital system efficiency cannot be answered by looking at the hospital payment rates negotiated last year by the health insurers. Those rates represent the embedded costs of the old system. We are talking about future costs of a reconfigured system. Scale and efficiency are everything in the future system – only the larger, more efficient, and well integrated health care organizations will weather the storm.

Community General Hospital cannot build such a system. So we will join one.

We believe that Upstate’s investment in Community is a cost-effective way to best use the expensive assets in which this community has already invested.

We believe the combination with Upstate will foster a more efficient hospital system in the coming years -- and for decades.

LICH implications for Community?

A report in today's New York Times suggests that a takeover of Long Island College Hospital (LICH) by SUNY Downstate Medical Center might not happen. New York State is reportedly reconsidering its award of HEAL grant funds that were expected to be part of the overall financial transaction.

The Downstate-LICH transaction has some similarities to the proposed acquisition of Community General Hospital by SUNY Upstate Medical University. So a logical question is: does today's report about LICH have implications for Community?

Community recently finished a project involving a HEAL grant. Among other things, the grant funds made possible the Center for Orthopedics. The funds were awarded as part of the Berger Commission's recommendations for Community and Van Duyn Home & Hospital. They were not part of the proposed transaction with Upstate. The funds have mostly been expended (and reimbursed).

The Community-Upstate transaction is far smaller, as I understand it, and not as financially complex as Downstate-LICH.

Yesterday Dr. David Smith, President of Upstate Medical University, addressed the Upstate community on the overall subject of state budget cuts, university finances, and plans with Community General.

Dr. Smith reiterated Upstate plans for its acquisition of Community because doing so will help Upstate build capacity and will help “put the right patient in the right bed.”

Doctor and poet

Poetry may not be among today's most prominent art forms (except in popular music). However, poetry is such a part of the human condition, I suspect there are as many people writing today as there ever were, including physician poets.

You may know some of the famous physician poets, such as William Carlos Willaims (Complaint) or John Keats (Ode on a Grecian Urn).

Here is a physician you may know (he practices in Camillus, NY), but you may be surprised to learn about his passion for poetry. Dr. Dave Manfredi is primary care physician with Preventive Medicine Associates, PLLC. His poems have been published in literary and medical journals. One of his poems ("I Come Down in the Morning") was set to music by composer Carter Pann for the Skaneateles Festival (2009).

In “For Zizi” (Voices in Italian Americana), he writes with poignancy about an aged seamstress whose story is implied by the distance between youthful wine making in Sicily and her "life's fulfillment" serving “Dandelion salad to a whole generation of Americans.”

Not surprisingly, Dr. Manfredi writes about health, as well as life and death. He considers personal exercise in “Running” (Rattle) and the experience of disease in “Alzheimer’s” and “Tumor” (both in the Healing Muse).

“Doctor Patient” (Healing Muse) is an affectionate dialogue between the physician and noncompliant patient, “a man comfortable with himself” who kindly refuses to modify lifestyle to reduce health risks.

"Cut back on bread, rice, and pasta,” I say.
His eyebrows raise to unimaginable heights.
“How can that be. . . the staff of life?”

The poem “July” opens with this arresting image . . .

It’s 5 PM, late July on my deck
I sit with my brain in my lap . . .

. . . and concludes with an acceptance of mortality:

The greenery stares at me
Like the transient curio that I am
and I wait patiently to decompose

The existential question is important in Dr. Manfredi's poetry. Here is another example, from “The Grave” (Journal of the American Medical Association), where he sees in the beauty of nature a place of repose:

The grass is comforting and soft,
The green in me is oozing forth
Though I lay resting in my clothes
To its embrace I decompose.

Dr. Smith goes to Community

This morning I was meeting with Dr. David Smith, President of Upstate Medical University. He asked if we could spend a few minutes walking around Community General Hospital, just to see the facility and to meet people.

It was a great suggestion.

On our impromptu walk Dr. Smith had the opportunity to meet and speak with perhaps 80 or 90 people.

He thanked everyone for the work they do and said our work at Community will continue to be important after we join with Upstate.

Dr. Smith commented several times about the good care a member of his family received at Community during a hospitalization two years ago. He spoke about Upstate's teaching mission, about changes in the medical staff bylaws to support the ongoing private practice of medicine here, and about respecting Community's identity within the Upstate system.

There were a number of questions, mostly about jobs but also about the mission of the hospital.

Dr. Smith said that different employment models are under consideration, and he acknowledged the concerns of employees, saying Upstate is working to address the concerns.

One nurse observed that Upstate must be interested in Community's available square footage. Dr. Smith said, "We're interested in the workers. What you do is important. We're interested in keeping 1,100 jobs and in continuing the high quality care you are known for."

Since his walk-through, several employees told me they were impressed with Dr. Smith's friendliness and his uplifting words.

There have been several questions about Upstate's organization, specifically how does Dr. Smith relate to Dr. John McCabe? Many employees have met Dr. McCabe in my employee meetings last year.

Upstate Medical University (UMU) is a large organization, a university, not just a hospital. Part of the State University of New York (SUNY) system, UMU has four colleges, plus University Hospital.

Dr. Smith is the President of SUNY UMU, the entire university. Dr. McCabe is the head of University Hospital. Dr. McCabe's official title is CEO at Upstate University Hospital and Senior Vice President of Hospital Affairs at Upstate Medical University.

Last week, when I met with the Auxiliary to Community General Hospital, one of the Auxiliary board members told me of the time she met Dr. Smith. It was several years ago when he was President of Texas Tech University. She saw him throw out the puck at a hockey game and asked him where he learned to skate. Dr. Smith told her he spent his early childhood in Toronto and learned to skate there. Later, as a student at Cornell University, he was a member of its hockey team.

Dr. Smith is a man of accomplishment. A pediatrician, he is also an avid outdoorsman. And he is a past Commissioner of Health for the State of Texas.