Hospitals as Covid-19 Disease Vectors

"For example, we are learning that hospitals might be the main Covid-19 carriers, as they are rapidly populated by infected patients, facilitating transmission to uninfected patients. Patients are transported by our regional system,1 which also contributes to spreading the disease as its ambulances and personnel rapidly become vectors. Health workers are asymptomatic carriers or sick without surveillance; some might die, including young people, which increases the stress of those on the front line."

From a recent journal article by practitioners in and near Bergamot, Italy.

What’s a Hospitalist?

Last week, I participated in a discussion of primary care provider supply on KCUR, Kansas City's local public radio affiliate.  I was pleased to participate and enjoyed the conversation with my fellow panelist, Dr. Michael Munger and with our host Gina Kaufman.  I suppose I was invited to participate because I just won't be quiet about primary care provider supply, medical school education, Kaiser Permanente's recent announcement of its decision to fix the broken pipeline of primary care providers representative of and responsive to communities with the greatest shortages by opening a proprietary medical school in southern California and on and on.

Today, I want to focus on a point made later in the radio program when listener call-in questions were fielded.  One self-described "older"  caller disparaged the rise of hospitalists and the use of hospitalists in places where they were previously unknown, including rural settings. Forgive me KCUR host Gina Kaufman, but the most interesting thing about the whole exchange with the call-in listener was that you did not seem to know who or what a hospitalist is until, apparently, you were guided to some understanding by someone in the studio.  I note this without dismay for two reasons.  First, unless and until you have experienced a hospitalization for something other than scheduled elective surgery or a planned normal birth, you may not have been introduced to the new normal: acute in-patient care delivered by a physician typically previously unknown to you, a provider often employed by the hospital itself, and a provider you are unlikely to ever encounter again outside of an acute care in-patient setting. Or, it could have been that the use of hospitalists in America's acute care in-patient facilities is so widespread that the term has become obsolete to lay people, though recognized inside baseball as the fastest growing medical specialty. Either way, the caller's point was that quality care should not be based on a system of strangers treating strangers. The easy answer to that is that electronic medical records will make us all strangers no more and that care by strangers is cost effective. 

Whatever you make of the alleged impersonalism of modern health care, the caller may have been on to something in noting that there is an ongoing problem with the hand off between hospitalist provided hospital based acute care and the ongoing treatment and monitoring of things like chronic disease required of community based medicine. Our hand offs are problematic. Less expensive care in the in-patient acute care setting under the hospitalist  combined  with the costs of poorly integrated transitions to community based care on discharge can lead to higher community care based expenses along with the cost of unnecessary human suffering pushed elsewhere.  So much of our health care system is financed and delivered under principles designed to push costs elsewhere in the system rather than acknowledge that poorly integrated care costs us all but costs some of us more than others.

So, whether you are in the "What's a hospitalist?" camp  or the  "You can see someone beside a hospitalist during an acute care admission?" camp, we all ought to be interested in valuing and prioritizing the hand off from acute in-patient care to community based care, where the real rubber meets the road

X-posted at Prawfsblawg.


Hospitals v. Insurers: Mississippi Version

I love the movie Cowboys & Aliens for its retro edge.  The story is ever the same, though the players may be altered slightly.

And so it is with the epic battles between hospitals and insurers over network participation and rates. I tell my students these battles are among the hardest fought and most continuous in all of health care contracting, whether or not what is going on behind the scenes is glimpsed by the public.

Occasional public glimpses over the bare-knuckled negotiations between hospitals and insurers occur when the negotiations threaten to blow up and plan enrollees are informed of impending changes to hospital "in-network" provider status. The issue can become quite heated.  People develop considerable loyalties to specific in-patient facilities, loyalties cultivated between and among friends and acquaintances (giving a whole new meaning to the idea of hospital "network"). You can read about a thought experiment probing patient acute care hospital selection here:  It may come as little surprise, then, to see Connecticut's Stamford Hospital, apparently trying to harness patient loyalty in opposition to the breakdown of their negotiations with Blue Cross & Blue Shield here:

What is going on in Mississippi takes one of these same kinds of disputes and writes it large. Negotiations have apparently broken down between the Blue Cross Blue Shield Network and Hospital Management Associates for-profit hospital chain over the in-network or out-of-network status of ten HMA facilities. After BCBS dropped these hospitals from their network, Governor Phil Bryant issued an executive order temporarily (for a maximum of 60 days) reinstating these ten HMA facilities into the BCBS network on contract terms based on the old contract rates. Yes, the facilities appear to have been commandeered and hospital-insurer contract rates have been set by the Governor.

Of course, this is already in federal district court.  Whether the Mississippi Patient Protection Act of 1995 requirement that insurers provide "reasonable access to care with minimum inconvenience" means that BCBS cannot walk away from what it says is a losing deal remains to be seen.  The real back story is that BCBS holds a near monpoly in some of  Mississippi's health insurance markets. You can see 2010 data on health insurance market concentration (looking at the individual insurance market) here:  And at least three of the hospitals are sole acute care providers in their rural settings, deeply dependent on reimbursement from BCBS.

This Mississippi story tells a tale of health insurance market concentration.  And it tells a story of the stark vulnerability of rural hospitals who need all the reimbursement they can get.  "Narrow networks" may be the topic of the month, when discussing cost-containment measures in the ACA but the possibility of non-existent rural networks has been out there for some time because of the high incidence of uninsurance in rural populations.

Governor Bryant is a well-spoken opponent of Medicaid expansion in Mississippi. In January he told a reporter, "I would rather pay extra to Blue Cross [to help cover uncompensated costs for the uninsured], rather than have to raise taxes to pay for additional Medicaid recipients." (You can read the text of that interview here:

It is beginning to look as if he may get his chance.

Do We Even Need Hospitals Anymore?

Cross posted at


You may have also received an invitation to participate in tomorrow's
"Future of the Hospital" forecasting game.  (An open invitation is
found here: 
for those among you who have yet to register.) Sponsored by the
California Health Care Foundation and others, this twenty four hour
competition looks like an attempt to crowdsource the question: "Do we
even need hospitals any more?" 

This is a very good question.

Intrigued, I have explored the forecasting game's website, twitter
feed, "challenge" posts and decided to register.  Why this one? I
receive invitations to a number of such "let's re-invent health care
before  we become obsolete" type events. I occasionally participate by
helping formulate questions. 

But this is the first time I would like to help brainstorm answers
in this format. The difference is the series of smart questions posted
under the first challenge: "Construct a 21st century safety-net system
that is fair, economically sustainable and delivers high-quality
emergency care services to all in need." This challenge includes these

  • Should hospital relocations and closures be stopped through the
    legal or political systems?  What if minority communities could sue to
    prevent a hospital closure?
  • What if the drop in operating EDs
    across the country is a positive sign of market forces at work, creating
    a more efficient healthcare system?
  • Could EMTALA (the
    act that requires hospitals to provide care to anyone needing emergency
    health treatment regardless of citizenship, legal status or ability to
    pay) be strengthened to restrict closures in medically underserved

This is great stuff, much of it resonant of the 2006 Institute of Medicine's study on challenges facing 21st century hospitals.

Hospital closures — whether full closures or partial closures such
as  stand alone Emergency Department closures — are complex and, often,
emotionally fraught.  Whoever said every divorce, from the perspective
of family life, is the death of a civilization might have known a thing
or two about community hospital closures. In a secular society, schools
and hospitals often substitute as the institutions where all of our
paths eventually cross at transcendent moments of our lives — birth,
death, life-threatening illness. Hospitals, while primarily health care
institutions, are also civic institutions.

As a result, in the throes of a pending closure, it can be a
challenge to address the larger questions about efficiency, the changing
nature of hospital delivered care, and equity. I look forward to the
forecasting game's insights. As a warm up,  I offer here a few thoughts
on the topic of permission to close a hospital.

Permissive hospital closings are the inverse of the long-debated
hospital building certificate of need ("CON") process.  In some states
— but no longer on the federal level — a hospital's advance permitting
to build requires a determination of need. A CON is not required in
California, for example, but is required in New York.  There is
considerable diversity of approach in between the hands-off wild wild
west approach and the fairly searching scrutiny required in some states.
Just as you might imagine, this means hospitals are often built on spec
as it were in some states, in anticipation of demographic trends, and
then have to be re-purposed as other kinds of facilities.  There are
risks.  In other places, it can be arduous to open a hospital,
essentially protecting market share for long-established institutions. 
There are risks to harm to competition in these places.

In these different contexts, you can see that requiring permission
for full or partial hospital closure might seem more or less consistent
with that jurisdiction's thinking about hospitals as public goods. All
of this is further complicated by the fact that, though the majority of
hospitals in the United States are not for profit, states like
California have substantial for profit hospital chain presence.

Add to this mix the reality that some parts of the country are
over-supplied with acute care hospital beds (and their attendant
hospital-based medical specialty providers) and some are under-supplied
and realize that tomorrow's forecasting game ought to be lively.

Reinvent community hospitals for the 21st century? I'm game.