The Crockett Hospital’s Painful Demise

June 30, 2017 was a sad day for Crockett, Texas, our neighbor just 47 miles to the west. Little River Healthcare ended its management affiliation with the Houston County Hospital District that Friday, effectively shuttering the Crockett hospital. Nearly 200 employees are affected by the closure.

The simple sign taped on the front door said, “HOSPITAL CLOSED” and directed people to either call 911 in an emergency or to go to Palestine Regional Medical Center, the closest hospital 39 miles away.*

Though this seemed like a sudden event, in many ways it was a slow death over many years. The 49-bed Crockett hospital – most recently known as Timberlands Healthcare, under the management of Little River Healthcare since April 18, 2016 – had danced with several management partners over the last several years. Little River Healthcare didn’t even last 15 months. 

Prior to Little River Healthcare, CHC (Community Hospital Corporation) was brought in June 1, 2015 to run the Crockett hospital for an interim period after the hospital’s messy divorce from East Texas Medical Center (ETMC) in Tyler. ETMC ran the hospital for 10 years. ETMC claimed to have invested $27 million in facility and technology upgrades in Crockett, but for a hospital in the 21st century, that was a paltry amount when spread out over 10 years. 

So why didn’t Little River Healthcare succeed?

According to published news reports, Little River Healthcare blamed Blue Cross and Blue Shield for not paying $32 million it was owed; BCBS would not comment. Little River stated that when it took over the Crockett hospital, the hospital had been “cash flow negative for a long time,” but that they thought they could turn it around.

It was a helluva lot to turn around. Payroll alone was $1.5 million per month. To keep the hospital running in its current state would have cost $2.7 million per month. The Houston County Hospital District board had already increased property taxes to the max amount and even borrowed money in an attempt to keep the hospital afloat. 

LRH Co-Owner Ryan Downton was quoted as saying, “We came to the conclusion the patient volume just isn’t there in the town anymore.” The problem was not volume; it was reimbursement. You can double or triple the number of patients you see, but if you don’t get paid adequately, you are just digging a deeper hole.

Crockett is a dying town. According to the Census Bureau, its population is around 6,500 and shrinking. 39% of the population is living in poverty. Only half of those 16 years of age and older are employed. A mere 17.2% of the population 25 years and older has a bachelor’s degree or higher (and 22.4% don’t even have a high school diploma). 27.4% of the population under the age of 65 has no health insurance. In today’s medical climate, no hospital can survive with this demographic. No hospital district can squeeze enough taxes and reimbursement out of an uneducated, poverty-stricken, unemployed, and under- or un-insured demographic to keep a hospital afloat.

What happened in Crockett is, unfortunately, not unusual. At least 15 rural hospitals have closed across Texas over the last several years. Dozens of counties in Texas have just a single physician – or none at all.

I grieve for Crockett. My brother and his wife live there. I have had the privilege of treating many dear patients from Crockett over the years. We share a compassionate state representative, Trent Ashby, whose rural upbringing cannot be far from his mind in a situation like this. Trent has said he is “committed to working with all of the involved stakeholders to mitigate the loss of existing jobs and help move forward with a plan to increase access to healthcare in our area of the state.” I don’t doubt it one bit. But to be honest, there’s not much he can do. CHI St. Luke’s Health Memorial Lufkin leadership was over in Crockett even before the closing to assist some with employment, but even they can’t come close to softening the impact of nearly 200 jobs lost.

Ultimately, this falls far too heavily on the shoulders of the local Houston County Hospital District board to find a solution. They can’t pull money out of thin air or tax property any higher. And they certainly can’t get paid for healthcare when no insurance coverage or safety net exists. I hope the hospital district board can reassess and reallocate resources to focus on providing comprehensive primary care and prevention services to the citizens of Houston County, at a minimum. They also need to strengthen relationships with surrounding regional hospitals to provide higher level of care services where needed. 

Those of us outside Houston County need to open our eyes. Without a much deeper, systemic and national change in how we allocate and pay for healthcare in this country, what just happened in Crockett is going to be replicated in more and more communities around the country. Let’s help Crockett, but don’t think it can’t happen to us.

*Will Johnson, Senior Reporter for the Messenger News in Grapeland, and Caleb Beames with KTRE-TV have done an excellent job reporting on the hospital closure, and I am indebted to them for some of the details and quotes in this column.

What I Would Like to See in Healthcare Reform (Part 2)

Last month, I wrote about the bloated, incredibly inefficient federal bureaucracy that eats up hundreds of billions of dollars annually in administrative costs. I mentioned that Obamacare was not, in my opinion, true healthcare reform and did not address these inefficiencies; rather, it simply added people to the rolls of a broken system.

In this column, I am not intending to argue for or against Obamacare or whether we “repeal and replace” or go with “Obamacare Lite”, whatever that might be. I am simply pointing out areas where I see daily a burden for both patients and providers. My dream would be for simplification of much of the process of valuing, coding, and billing for healthcare services. Whether any of these thoughts are achievable or affordable, I don’t know.

Let’s start with that dreaded hospital bill. Medical billing is indecipherable. Even patients with advanced degrees can spend hours trying to interpret the bill they receive for a hospital stay. And that bill is obscenely higher than what either the hospital or the providers are going to get paid. What’s ironic is that bill often has no correlation with the actual cost of the care received or the value that the federal government (or the insurance company) places on that care. We must simplify how we charge for medical care and how hospitals and providers get paid. Unfortunately, the only patients who get stuck with the full, inflated bill are those without insurance – the ones who can least afford to pay it. That is unethical.

The overall cost of care (and your bill) is determined by coding every aspect of care, from the Kleenex and bedpan to the heart valve. For every cancer patient I treat, there are dozens of separate codes submitted for reimbursement covering all different aspects of planning, designing, QA’ing, and delivering treatment. I have no doubt that much of that could be combined into, say, a fixed reimbursement for treating prostate cancer. The problem is, when the government wants to bundle procedures together, they do it to cut overall reimbursement immensely. We still do the work; we deserve to get paid. Why can’t we work out a way to simplify, cut administrative costs, and make it a win-win both for the providers and the payors?

Along the same lines, consider a simple office visit to the doctor. The complexity required to determine whether I get paid a level 2 or level 3 office visit – which reimburse only $25 and $50 – is outrageous. These so-called Evaluation and Management (E&M) codes – and there are many of them – are based on four different possible levels of complexity of three aspects of the patient encounter: history, examination, and medical decision-making. Take history, for example. The proper level of complexity is determined by the presence or absence of documentation for four sub-elements: chief complaint, history of present illness, review of systems, and past, family, and/or social history. Do you see where I am going with this? Documentation of these encounters (consultations, follow up office visits) often takes longer than the encounter itself! And, any "error" in billing is considered fraud and abuse. It is common to hear patients complain that their doctor never looked at them, but was always looking at the computer screen. We need to simplify coding and put physicians back face-to-face with their patients.

Then there is the ever-increasing burden of deductibles and co-pays. We have such a mishmash of healthcare plans, each with their own deductibles and co-pays, that it is virtually impossible to keep it all straight. At the beginning of every year, doctors’ offices and hospitals cringe. Did a patient change insurance plans, or did their insurance lapse? What about the deductible for the new year? What about co-pays? More than half of Americans have less than $1,000 in savings. Deductibles for individuals enrolled in the lowest-priced Obamacare health plans will average more than $6,000 in 2017. Can the majority of Americans afford that? Certainly not! This is an unfair burden both on patients and on providers, who end up providing that care for free. Why? Most of it gets written off, but only after we spend a lot of personnel time and effort proving we try to bill for what we can’t collect in order to avoid the appearance of fraud and abuse. Those patients who are forced to pay may rack up credit card debt, get sent to a collection agency, and/or go bankrupt. Some go without the care they need rather than add to their debt. I truly believe co-pays and deductibles are a vestige of a bygone era. I would like to see the dollars saved by decreasing the administrative burden of healthcare go to actually paying hospitals and providers what they deserve and earn, and do away with co-pays and deductibles. There should be one price for a procedure or encounter, and that cost should be paid 100% by insurance.

What about insurance companies? In the best of circumstances, they pay fairly and quickly. But too often they can and do delay patient care and prevent patients from getting the care they need in a timely manner, if at all. They do this through a process called precertification or prior authorization (read: denial). And sometimes when they do give prior authorization, they still deny payment. This ought to be illegal. But it happens without recourse because the state insurance regulations are written in favor of the insurance companies. We need to loosen the precertification grip on the practice of medicine, and we need to be able to hold insurance companies accountable to their agreements. A preauthorization is a contract to pay.

The two hospitals in Lufkin (Woodland Heights Medical Center and CHI St. Luke’s Health Memorial) have spent tens of millions of dollars on electronic health records, not to mention what individual and group physician practices have spent, all mandated by the federal government. To what end? This was supposed to be about “quality”, but that emperor had no clothes. There is precious little improvement in communication between providers and hospitals than before electronic health records. The various doctor’s offices use a number of different vendors, and each hospital uses their own separate vendor. None of them share information with each other. I dream of a truly universal electronic health record language with seamless interconnectivity between offices and hospitals, but I sure don’t want to live through the incredible expense, time and effort it would take to get there. But I do dream.

Finally, let’s talk about rights. I have never felt that free or universal healthcare was a “right”. Hear me out. No one has a "right" to healthcare without some responsibility. That responsibility may be in purchasing insurance, but that is not the only way to contribute. The most glaring, but not the only, example is smoking. Half of long-term smokers will die of a smoking-related illness. If you smoke, the rest of us are burdened with some (or all) of your healthcare costs. On average, a pack of cigarettes in the US costs a smoker $5.51, while the combined medical costs and productivity losses attributable to each pack are approximately $18.05, according to researchers. This is where consumption taxes are attractive, but only if the tax truly goes to help offset the cost of healthcare. How we balance rights and responsibilities in healthcare is a good subject for a doctoral dissertation.

As well all hear about and read about proposed healthcare changes over the next year or two, look for what they are really trying to change, and ask yourself, are they really improving the system, or are they just trying to squeeze more people under a broken umbrella? Can they do both? Let’s hope they try.

History and Medicine in Angelina County

I recently came into possession of Angelina County Medical Society meeting minutes dating back 80 years, from 1936 to 1954. These archives were kept by Dr. W. D. Thames. A walk down medical memory lane with these records is remarkable. Some facts are simply mundane. For example, dues in 1936 were $10.50 per member - $488 in today’s dollar. That makes our current County Medical Society dues of $100 seem like a bargain.

More fascinating to me is that even though the practice of medicine has changed profoundly over the last 80 years, little of the economics and politics of being a physician has changed. For example, charity care issues were documented back in 1937. We struggle with that today. The physician-patient relationship – what today would be assessed by patient satisfaction scores – was the topic of lectures in 1938.

The broad legislative issues on the table today are hardly different than those in 1938 when a Legislative Committee was appointed. Scope of practice issues with optometrists and chiropractors were discussed way back in 1941. In 1953, Dr. Arnett “encouraged members of our society to join the American Association of Physicians and surgeons, which is a political organization of doctors. Its purpose is to stop socialized medicine.” (What would they say now?)

Some issues from the past seem frankly quaint today. In 1952, Dr. Arnett was to appoint a committee to investigate a physician who took out an ad in the Lufkin Daily News, apparently quite the no-no at the time. The next month’s minutes document how that physician “apologized and said it wouldn’t happen again”. The Society even had a secret ballot to vote whether he was guilty or not guilty of advertising. He was acquitted on a 9 to 2 vote.

Admirably, the Angelina County Medical Society minutes also contain notable evidence of community involvement and civic leadership. In January, 1940, the Society was holding joint meetings with city and county officials and the Chamber of Commerce directors to discuss a federal aid program for the building of a county hospital. It was these very discussions that spurred local industry leaders to join together to build a new hospital. The legend we pass down is that in 1941, Arthur Temple, Sr., President of Southern Pine Lumber Company, W.C. Trout, President of Lufkin Foundry & Machine Company, E.L. Kurth, President of Southland Paper Mills, and Col. Cal C. Chambers, President of Texas Foundries, along with ten other businesses and industries, joined resources, refused federal funds, and raised one million dollars to build the non-profit Memorial Hospital (now CHI St. Luke’s Health Memorial). But we have forgotten the groundwork was laid the previous year by the healthcare community, the city and county leaders, and the Chamber of Commerce, all working together. Such cooperation and leadership can still take place today.

Another more poignant event occurred in February, 1954. Then President Dr. Gail Medford “read a letter from the Negro Chamber of Commerce wanting help from the Angelina County Medical Society in their plan to improve sanitary conditions in the colored community. Drs. Taylor and Spivey, City and County health officers, were appointed to work with the colored organization.” We cringe now, thinking about Jim Crow segregation and disparities in neighborhood services and conditions. But do we recognize similar disparities in healthcare today? Are we addressing the needs of the indigent, uninsured and underserved populations among us? Is the medical community as approachable today as it apparently was in the segregated 1950s?

Technology has revolutionized healthcare over the last eighty years. But technology cannot replace the heart. Let us not forget our calling, our oath, and our love for the patient. The practice of medicine should never be just a job. It is a profession.

I invite everyone to the Salute to Healthcare banquet on Thursday, November 10, 2016. Help us recognize and honor those in our community who set the standard in healthcare and who are true to the calling – the profession – of medicine. Call the Chamber at 634-6644 for ticket information.

Lung Cancer Screening Saves Lives

For more than 50 years now, we have known the dangers of smoking. That smoking causes heart disease, emphysema, and lung and other cancers is not in dispute. For fifty years, we did not have an effective screening tool for lung cancer.

Now we do.

Medical imaging has improved so much that we are now able to do computerized tomography (CT) scans with significantly lower dose to the patient and at a low enough cost to warrant widespread use as a screening tool. Not everyone needs a scan, of course. But smokers who are at high risk of developing lung cancer now have an option for screening, much like mammography for early detection of breast cancer.

In 2011, the results of the National Lung Screening Trial (NLST) were published in the New England Journal of Medicine, arguably the foremost medical journal in the world. This trial screened current or former heavy smokers aged 55 to 74 with low-dose CT scanning of the chest and compared it to standard chest x-ray. The NLST primary trial results show 20 percent fewer lung cancer deaths among trial participants screened with CT compared to those who got screened with chest x-rays. This is huge news, because we haven’t cured a lot of lung cancer over the last 50 years! Based on these results, the Centers for Medicare & Medicaid Services (CMS) decided in 2015 to start paying for the procedure on January 1, 2016.

According to the American Cancer Society, in 2016 an estimated 224,390 people in the U.S. (117,920 men and 106,470 women) will be diagnosed with, and 158,080 men and women will die of, cancer of the lung and bronchus, the leading single cancer killer in the U.S. If everyone who was eligible got screened, more than 30,000 deaths from lung cancer could be averted every year.

There are more than 94 million current and former smokers in the U.S. at high risk for lung cancer. In 2014, an estimated 18.1 percent, or 40 million U.S. adults, were current cigarette smokers. Unfortunately, smoking rates in East Texas are higher than state and national averages. That means a lot of East Texans are eligible to be screened.

Starting last fall, CHI St. Luke’s Health Memorial began offering low-dose CT lung cancer screening to eligible patients. Medicare covers ages 55-77 (commercial insurance 55-80, but Aetna 55-79). Even within those age ranges, an eligible patient must be a current smoker (or quit no more than 15 years) with at least a 30 pack-year history of smoking (for example, smoking 1 pack per day for 30 years, or 2 packs per day for 15 years). And, eligible patients must have no symptoms of lung cancer (such as coughing up blood or unexplained weight loss of more than 15 pounds in the last year). If lung cancer is suspected, a standard CT chest should be done.

Finally,  Medicare requires “shared decision making” on the risks and benefits of lung cancer screening, which means you must meet face to face with your primary care provider to get an order for screening.

Since we started screening at CHI St. Luke’s Health Memorial, more than 70 patients have been screened. Six abnormalities have been found (including an incidental kidney mass), and two lung cancers have been diagnosed. Those two cancer patients’ lives may have been saved by screening; only time will tell.

Of course, the best way to prevent lung cancer is by not smoking. Ever. Quit if you do smoke. And if you meet the criteria listed above, talk to your doctor about getting screened for lung cancer. If you have questions, feel free to contact the Temple Cancer Center at (936) 639-7466 for more information.

New Cancer Fighting Technology in Lufkin

Last week, the Temple Cancer Center treated the first patients on our new Elekta Synergy linear accelerator, the first major investment of Memorial since the CHI acquisition. To say, "We got a new piece of equipment" understates the multi-year project of visiting other cancer centers, evaluating manufacturers, specking options, removing an older treatment machine and renovating the vault that houses the linear accelerator, and determining what other hardware and software is required to make this new piece of incredible technology work to treat cancer. No small task!

All told, this project, which also included a Toshiba large bore CT scanner, Vision RT image guided radiation alignment technology and other accessories, topped out at $4.5 million. It is a recognition of the importance of exceptional cancer treatment to our region and a signal that Memorial will remain the regional hub for cancer care in deep East Texas.

So, what does this new technology bring to our deep East Texas region? For our many patients currently being treated with IMRT - intensity modulated radiation therapy - we will be able to deliver their treatment in a fraction of the time it has taken up until now, often less than five minutes per treatment! Standard treatments can go even faster. And, these treatments are often even more precise with less dose to surrounding normal tissues, which will translate to even fewer side effects.

In addition, we will be able to implement a totally new procedure to the region called SBRT - stereotactic body radiosurgery. SBRT delivers high doses or radiation over very short courses - three to five sessions, typically - and requires much finer tuning and more rapid treatment delivery than we were previously able to do. We will start using this technology for small lung cancers first, but I anticipate over time treating cancers in other locations as well. The utility of the technology for lung cancer cannot be overstated. Lung cancer is almost always related to smoking, and heavy smokers often cannot undergo surgery, because they do not have enough normal lung function to survive removal of even a small part of a lung. However, these same patients can often be cured with SBRT. With low-dose CT lung cancer screening, we anticipate finding more early lung cancer; now we have the ability to treat them even if they cannot have surgery, with equal results and less morbidity.

Another site where we plan to implement stereotactic radiosurgery technology is in the brain, where small tumors can be ablated with radiation without having to be removed neurosurgically. Treating tumors such as these in an outpatient setting without having to resort to major chest or brain surgery is a remarkable benefit of this new technology. We will not start using this new technology immediately, however, because any new procedure requires establishment of appropriate protocols, quality assurance procedures, and training, all of which will be implemented over the coming months.

The Temple Cancer Center is also excited that our social worker, Appolonia Ellis, recently completed the Harold P. Freeman Patient Navigation Program, where she learned how to better assist our patients in accessing available services and programs so that they can successfully complete treatment. Patient navigation is fairly new to cancer programs, and we are excited to have the only navigator in the area.

At a time when other industries have announced plans to cut hundreds of jobs or move out of the area altogether, CHI's long term commitment to Lufkin and the Memorial system is reassuring. They are putting their money where there mouth is, so to speak. For that, I am grateful.

Prostate Cancer: How Should We Treat It?

Prostate cancer screening and treatment may be the most divisive issue in oncology today. Oh, we argue about breast cancer, and whether or not women in their 40s should get a mammogram (they should), and how often they should get one (every year). But prostate cancer is even more controversial. That's because prostate cancer is not a single disease with just one way to treat it.

We divide prostate cancer patients into three risk categories: low, intermediate, and high risk. Risk of what? Risk of spreading and killing you, basically.

We place patients in these risk categories based primarily on how high the prostate specific antigen (PSA) blood test is, and how aggressive the prostate cancer biopsy specimen looks under the microscope (the so-called Gleason score). Low risk patients (PSA less than 10, Gleason score 6 or less) have a 90% survival rate at 10 years, which is fantastic. High risk patients on the other hand (mainly those with PSAs greater than 20 or Gleason 8-10) have aggressive cancers and only a 50% survival rate. Finding a prostate cancer when the PSA is lower and the cancer is less aggressive is better. But...

The problem is, we are now finding some cancers so early that they don't even act like a cancer; they will never spread or cause a problem. The conundrum is determining which cancers those are, because we still live with fear of the word "cancer" and assume that something must be done whenever it is diagnosed. Even more problematic, we too often assume that we must have surgery and "cut it out", when that may not be what is best, much less what is needed at all.

Yes, we over-diagnose and over-treat prostate cancer. Now, I am not a hardliner who says we shouldn't be screening for prostate cancer. Far from it. The American Cancer Society recommends that "men make an informed decision with their doctor about whether to be tested for prostate cancer." How old are you? What health problems do you have?

"Starting at age 50, men should talk to a doctor about the pros and cons of testing so they can decide if testing is the right choice for them. If they are African American or have a father or brother who had prostate cancer before age 65, men should have this talk with a doctor starting at age 45."

Remember, however, that even if you learn you have prostate cancer, you do not necessarily need treatment! Certainly, don't jump in and have major surgery without checking out all your options, including that of observation. On of the oldest statements in medicine is primum non nocere - first, do no harm. That holds true today as much as it did when that ethical concept was included in Hippocratic Oath in the 5th century BC.

If treatment is recommended, we are fortunate at CHI Memorial to offer a very precise form of radiation treatment called Intensity Modulated Radiation Treatment (IMRT) for prostate cancer. This pinpoint, outpatient treatment is every bit as effective as surgery with few side effects. It also does not have the risk of long-term incontinence that comes with surgery.If you or a loved one you know gets diagnosed with prostate cancer, or even just has an elevated PSA, please do not rush to surgery. Certainly, we have skilled surgeons in East Texas, but take your time and get a second opinion to determine 1) whether treatment is the best option, and 2) whether surgery or radiation is a better option for you.

Memorial and Catholic Health Initiatives

In my January column, I wrote that we have an ongoing obligation to provide non-profit care locally so that Memorial’s mission of compassion, established in 1949 by our community forefathers, can continue. I am thrilled that Memorial has strengthened its ability to deliver on that mission by becoming part of Catholic Health Initiatives (CHI), effective June 1. CHI operates 89 hospitals in 18 states, with more on the way.

Much has been written about the transfer of ownership already, so I thought I’d comment on what this transaction is not:

It is not a takeover of physician practice. CHI has committed to preserve existing physician relationships in the community and build new ones. CHI’s relationship model with physicians is very much dependent on the region of the country they are in. Ultimately, improved coordination of care and better patient outcomes have to happen. Quality, efficient care is the focus, not whether or not physicians are independent or employed.

It is not a transfer of care to Houston. In fact, CHI wants to see Memorial become an even stronger hub for healthcare in the region. Of course, we will have increased access to highly sophisticated care through closer ties to CHI St. Luke’s Health in Houston and its affiliations with Baylor College of Medicine and Texas Heart® Institute. That will only strengthen our position in the region and improve the quality of care we deliver locally so that even more health care can remain local. Over the next two to three years, it is CHI’s intent that Memorial will become a part of CHI St. Luke’s Health. In my own area of cancer care, this can only enhance my options for my patients, including improved access to clinical trials.

It is not a drain of money from the local economy. The fact is, Memorial’s board recognized that the landscape of healthcare had so fundamentally changed that maintaining mission in a fiscally responsible way was becoming increasingly challenging without the resources and expertise of a well-capitalized, national partner. Over the next 5 years, CHI will invest more than $1 billion to expand and enhance the southeast Texas region’s health care infrastructure. Memorial, for its part, is guaranteed to see significant capital improvements over the next 6 years.

It is not a change of mission. Having read the Ethical and Religious Directives for Catholic Health Care Services – the guiding document for ethical behavior in health care for Catholic institutions – I can tell you that CHI’s mission and Memorial’s mission mesh beautifully. Both Memorial and CHI share a commitment to putting the health of the people and communities we serve at the center of everything we do. CHI intends to maintain the core health care services and charity care currently provided by Memorial in the East Texas community, which will continue to be overseen by a local board of community and physician leaders. I have the privilege of serving on that board, and I can state with confidence that Memorial’s strong commitment to charity care will continue.

It is not an end of an era. In 1949, our community forefathers got together to establish Memorial Hospital to take care of the people here in deep East Texas. They were compassionate, innovative, and forward-thinking. Their descendants – some in name and all in spirit – have led this health system to maintain that mission for sixty five years. Today, with no less compassion and thought for the future, we have taken a bold step to preserve and advance non-profit care for our region. Here’s to the next 65 years!

What a Hospital Should Be

Healthcare reform may be the most polarizing issue today. Depending on your point of view, you are either eagerly anticipating or just dreading the changes that are happening. Either way, we can all agree there is profound upheaval in the system. We are in the middle of an earthquake waiting for the ground to stop shaking.

While the focus on Obamacare has been on the individual’s access to healthcare, we need to remember that our hospitals are feeling the earth move underneath them as well. When hospitals are merely trying to survive may not the best time to consider what a hospital is and does, but I believe it is exactly when we need to take a step back and focus on mission.

A hospital is, first and foremost, an institution to take care of the sick. The Latin root for hospital is the same root for hospice and hospitality. Hospices in the Middle Ages were way stations for pilgrims who needed a place to rest/ Today, hospices are known for end-of-life care for those on their final journey. And the word hospitality denotes kindness and generosity. What a great family or words! Hospitals should provide comfort for travelers on a journey – a journey from illness to wellness. And that hospitality should be extended to all.

We, as a country, have decided that healthcare is not a universal right, in that not everyone (even under Obamacare) will have free care. Yet, we can’t seem to decide what level of individual responsibility (either in terms of healthy lifestyle choices, like smoking, for example, or huge deductibles which the average person cannot afford) goes along with whatever care we do receive. That leaves us with a broken system of inflated billing and inadequate reimbursement that continues to leave a good number of our sick not only without resources but with outrageous bills.

And, unfortunately, the government is placing more and more burden on the hospital to make sure that patients not only receive high quality care in the hospital, but are taking their medicine and seeing their doctor once they are back at home. The hospital is now supposed to be Big Brother. If a patient is readmitted to the hospital too soon after being discharged, the hospital does not get paid for that stay, even if it was because the patient was noncompliant with their own care outside the hospital. One can argue the fairness of regulations such as this, but all hospitals are required to play the same game now, and some will be better at it than others.

I would argue, some will have better results than others in the new quality outcomes paradigm because they “cherry pick” their patients based on ability to pay. That brings me to my main point: We must not let a divided system of care (non-profit versus for-profit) keep the sick from accessing care.

As a non-profit institution, Memorial has a mission to provide care for all, regardless of ability to pay. In an era of declining reimbursement, for-profit institutions – who report to investors – are increasingly turning away those without insurance (except in emergency situations, where federal law requires care to be administered to stabilize a patient). All hospitals operate on a tight margin, and non-profit hospitals (especially those outside of metropolitan markets) are increasingly feeling the pinch. We in Lufkin have an ongoing obligation to provide non-profit care locally so that OUR mission of compassion in Lufkin can continue. It is what our community forefathers established. It is what hospitality demands.

Giving Thanks!

Thanksgiving is just around the corner, but why wait! I want to send a big thank you to Debbie Jackson, my hardworking co-chair for local enrollment for the American Cancer Society’s CPS-3 study, and to all of the CPS-3 Champions who helped get 423 people enrolled in this amazing cancer prevention study. Our enrollment sites – Memorial Health System of East Texas, Power of Pink!, Lufkin Industries, First Assembly, and the C. L. Simon Recreation Center in Nacogdoches – were fantastic.

Thank you to Becca Chance (along with her powerhouse committee), whose leadership and grace under pressure – and under thunder and lightning! – resulted in another successful Cattle Barons Gala. Thank you to Yana Ogletree and Lindsey Mott with Memorial Health System of East Texas, who hosted an amazing 21^st annual Power of Pink! luncheon. Since 1990, breast cancer deaths in the U.S. have decreased by 27%. Much of that is due to education about mammograms and the importance of screening and early detection.

Today is Election Day. I’m thankful for the right to vote! The most important issue on the ballot today is a constitutional amendment on funding the state's water plan. Voter turnout is expected to be light — below 10 percent of all registered voters — because we just don’t get too excited when actual people aren’t on the ballot. But you need to go vote for Proposition 6. The proposed amendment would authorize the Legislature to withdraw $2 billion from the Rainy Day Fund to begin funding the state’s 50-year water plan. The benefits from a long range planning and economic prosperity standpoint far outweigh and possible downside. And frankly, I think it is poetically appropriate to use a rainy day fund for water planning anyway. Be thankful you can vote, and vote YES on Prop 6.

Thursday is Salute to Healthcare, the Lufkin/Angelina County Chamber of Commerce’s awards banquet to recognize and thank outstanding leaders throughout the healthcare sector for making Lufkin and Angelina County a better place to live and work. As a physician, I have considered it my highest honor to serve as Chairman of the Chamber board this year. The healthcare sector is now one-fifth of our local economy and drives more jobs and more shopping, retail, and dining dollars than any other industry. Our community can show their support for the healthcare sector not only by coming to the banquet Thursday night, but also by “voting with your feet” when you choose where to go for healthcare. The reimbursement changes that are being implemented at a national level could easily kill what we have here locally if you don’t make the conscious decision to stay here for your healthcare needs. Like anything else, if you don’t use it, you lose it. I applaud the Chamber for starting this event several years ago and for thanking our physicians, nurses, and so many others who help care for us.

Finally, as a cancer doctor, I deal daily with the highs and lows of cancer – celebration and victory for many, but bad news and eventual death for others. I’m thankful I can “be there” for my patients, walking alongside them, no matter which path they are on. You can, too. Comfort is one of my favorite words. Its Latin roots paint a picture of coming along side with strength. Each of us needs to be a source of strength during the holiday season for those around us who are hurting, needy, and hungry. Join in helping others with Community Food Drive, Angel Tree, or other efforts with your church or in the community. And be thankful!

Shop Local, Get Well Local

I have the privilege this year of serving as Chairman of the Board for the Lufkin/Angelina County Chamber of Commerce. The Chamber, along with the City of Lufkin and the Economic Development Partnership, commissioned a retail study that will help us in recruiting even more business to the area. Do you support our local economy by shopping local?

Even more important to our economy, where do you go for your healthcare?

As a physician community leader, I have a unique perspective on the healthcare sector. Across the state level and nationally, healthcare accounts for 11%-12% of a local economy. In the Lufkin area, it is nearly double that at 20%. Over the last 11 years, all other sectors of the economy combined have shown miniscule growth (0.5%). The healthcare sector grew by 36.3% during that same period. 7,424 Lufkin area jobs are directly linked to the healthcare sector, with a direct tie-in of $193.26 million in annual disposable income. It is not an understatement to say that the healthcare sector is a strong driver of Lufkin’s economic growth.

Of course, everyone is a bit nervous about the recent changes at Lufkin Industries and Temple-Inland. In my role with the Chamber, I am grateful for the recent outreach from new leadership from both GE/Lufkin Industries and Georgia Pacific. I urge both companies to continue the legacy left to them of strong involvement with the Chamber, the United Way, and the many other organizations that contribute to our quality of life. But, each of us has a responsibility to our community. Now – more than ever – how we act as individuals will drive our local economy.

We love to tout how much we love Lufkin, then we turn around and head to Houston for healthcare… when our local facilities and personnel are top notch. Those of us who are blessed with jobs and insurance have a responsibility to our community to direct our healthcare dollars locally as much as possible.

Why? Your community non-profit hospital, Memorial Health System of East Texas, has a mission to care for all – even those who do not have insurance or means to pay. For example, the Arthur Temple Sr. Regional Cancer Center has never turned a patient away due to inability to pay. Those Houston hospitals aren’t going to care for our indigent or uninsured, but they are more than happy to take our insurance. MD Anderson, for example, has a history of not even giving appointments without proof of payment up front. When you leave for healthcare services that can be delivered locally, you are diverting resources away that can not only help support local care for all, but improve our local economy. In these times of ever-increasing bureaucracy and ever-tightening reimbursement, we need to consciously support what we have here… or it may go away.

Ah, but then the argument turns to perceived quality of care. A couple of years ago, I looked at our cancer patient population to determine the #1 cause of delay in starting treatment. It was not income level or lack of insurance. It was seeking a second opinion out of town. Ironic, isn’t it, that thinking you need to go somewhere else for treatment might actually hurt you in the long run! Your local healthcare providers are perfectly capable of making the decision of what needs to be treated in the big city, and it is far less than what most people think.

To tweak an expression: “What stays in Lufkin is good for Lufkin.” Shop local? You bet. Stay local for healthcare? Absolutely.