Metaphors

   Given my life-long relationship with words (from Winnie the Pooh to Joseph Campbell), I'm eternally enraptured with the mystery of metaphors.
    As in what makes the dynamic "work."
    For example:
    There is Donald Trump.
     Or how we've gone from ancient pornography uncovered amid the ruins of Pompeii to "clips" of diverse sex on various internet "sites". (Google free porn)
     Or the matter of Yeats' "Slouching to Bethlehem" as Yin to the Yang of "Casey Jones daughter was deaf and dumb/ and the hair on her poontang was as thick as your thumb/ and if you hit her on the belly/ she went rum-diddley-dum-dum-yum yum!"
     Or Hebron as the new Warsaw ghetto.
     Anyhow...
     No matter where you look, white whales and metaphors lurk.
      At which point, the ghost of as long-dead editor emerges to howl, "So what? Your average reader won't get It!"
      To which I can only reply, "Who says I get It?"
.     Because I sure as hell don't.
      Which brings us to an apt metaphor to "cover" America's greed-driven health care system.
       My personal favorites?
       Another neighborhood bake sale in response to the devastating cost of a local kid's losing battle with terminal cancer.
       Or Florida Governor Rick Scott's fiscal butt fuck of low income health care in the Sunshine State,
       Or the mean-spirited legacy of Scott's "politically active" Republican hack-appointees responsible for governing Broward Health - one of  the nation's ten largest public health care system.
       Or the South Florida Sun-Sentinel's  journalistic impotence in covering the egregious doings of public health care in their own backyard.  
       For example,concerning the above*:
                           North Broward Hospital District
                             A metaphor of the Scott Years
                            2011                   2017 projected
Adjusted 
   admissions        122,327              121,010
Tax Revenue         $154,450,148     $145,198,762
Per adj. admit       $1,263                $1,200
Patient Revenue   $913,553,096      $1,088,153,931
All Patient Care
  Revenue             $1,068,003,244   $1,233,352,693
Surplus                 $97,404,407       $19,572,886
Per adj. admit       $796                   $162            (80%)
Margin                  9.1                      1.6
And Under WTF:
Uninsured Care
  Costs
  Bad Debt            $376,700,276      $408,245,104
  Indigent Care      $350,252,811      $151,358,476
  Total                   $726,953,087      $559,603,580
  Tax Revenue      $154,450,148       $145,198,761
  "Reimbursed"  
  Per $1 charged   21.2 cents           25.9 cents          

District Avg
Daily Patients       874                     858             (2%)
   Medicare
   Traditional         203                      195             (4%)
   Medicaid
   Traditional         158                       112             (29%)
   Private Insured  360                       461              28%
   Compensated    722                       768              6%
   Uninsured         153                        90              (41%)
   

Facts & Fart Machines

  

    Based on a long-standing policy, the North Broward Hospital District's governing board of Commissioners allows members of the public to voice their concerns at the start of every regular commission meeting.
    For three minutes.
    However...
    Since former Commission Chair David DiPietro was removed from his post by Florida Gov. Rick Scott, the new Commission Chair Rocky Rodriguez and his fellow District Commissioners have refused to respond to my questions regarding current District budgetary and policy matters impacting both hospital patients and the tax-paying public.
    So it was that I attended the regular monthly meeting of the Distict Commission on May 25 with a fart machine.
    Why?
    In anticipation of the Commissioners' refusal to answer my questions as a District taxpayer.
    The fart machine worked.
   Which led District officials to:
    (1) Order me to silence the fart machine - which I refused/.
    (2) Order me to leave the Commion meeting - which I refused.
    (3) Request two Fort Lauderale Police officers to order me to leave the meeting - an order which I declined to comply.   
     Faced with  the threat of arrest and jail, I surrendered my fart machine to the current District Commission Chair Rocky Rodriguez, a grossly obese Cuban refugee who's found a meaning and purpose to life in food, real estate and the Republican party.  
    However...
    For the record, I have obtained a new fart machine for the future gatherings of the North Broward Hospital District Commissioners.
    Call it a metaphorical demand for accountability based on the disturbing budgetary anomalies below:
          North Broward Hospital District
                        Official Budget
       (Expenditures Per adjusted admission)
                                        2011          2016            CPI 
Adjusted admissions     122,327      117,856
Tax Revenue                  $1,263        $1,160         (8%)
Gross Charges                 $30,918      $34,097        10%      
Deductions:          
Bad Debt                        ($3,079)     ($3,612)         8%
Charity Care                   ($2,863)     ($1,273)       (55%)
Third Party/Other           ($18,067)   ($21,418)     (5%)
Total Deductions            ($24,010)   ($26,303 )      9%
Reimbursement
 Medicare                         $1,527        $1,610          5%
 Medicaid                         $937           $402            (57%)
 Private Insurance            $4,495        $5,782          29%
Total Revenue                 $9,018         $10,319        14% 
Total Expenses               ($7,801)      ($10,372)       33%
Total Surplus (Loss)      $1,217        ($53)            (104%) 
Source - North Broward Hospital District
                                  *10 months of current fiscal year
      Okay.
      That the above data vexes me suggests, after my 78 years on this lonely planet, I still believe there are rational answers to the Five W's and H posed by the nano-second of my life in a 15 billion year-old universe. (Who, what, why, where, when and how.)
      True.
      Like  even our late Lord and Savior Jesus Christ died asking questions on the cross.
      So what makes me so special?
      Other than my ego.
      Coupled with the quantum improbability of my life.
      Anyhow...
      On a personal note, my story involves a life-long battle between my frontal lobe and my amygdala. 
       But then I AM a product of a culture that believes in the notion of Good vs. Evil, diverse Alphas and Omegas, and the absolute superiority of this year's all-new Whatever over last year's obsolete.
       How else could anyone explain the meaning-in-the-metaphor of Candidate Trump, the State of Israel, vaginal deodorant, or Amerika uber alles?      
       Which brings us back to the WTF inherent in what we blithely call the American Health Care System.
        Accompanied  by the righteous braaaaak of a fart machine.
        All in the name of accountability by Browad Health's governing Board of Commissioners.
        Because, as one of the nation's ten largest public health care systems,  the North Broward Hospital District suffers from an epidemic of anomalies. 
        Consider, for example.the absurd Persian Market  in the following Charge-v-Cost "spread" for an Emergency Room visit by a Broward citizen in need of critical are:
                Level 4 ER visit - Average Charge v Cost
                Broward      Memorial   Plantation   Holy
                Medical       Regional     General       Cross
Charge    $722             $639            $1,964         $1,408
Cost         $187             $356            $164            $233
         As purveyors of bullshit as well as health care, hospital officials and Chamber of Commerce types love to boast of the so-called Free Market at allegedly work in America's health care system.
         As if some poor bastard slammed by a heart attack has both the time and ability to shop for the "best" ER with the fastest and the mostest level of care.
        The ultimate free market lunacy?
         Broward County highways are festooned with giant billboards alleging "average waiting times" at Ajax Medical Center or Acme General.
         And so on.
         Which suggest it's only a matter of time before hospital billboards will include the average price they charge for various medical services.
         Because the "sticker price" numbers are already there.
         Even though their "spread" is worse than used car lot.
         Like:
                Medical Service - Congestive Heart Failure
                Broward       Memorial       Plantation      Holy                                   Medical        Regional         General         Cross
2007        $90,589        $62,103          $67,632         $74,445
2014        $89,924        $103,100        $178,587       $64,641
Increase     (1%)             66%             64%             (13%)
            Which explains the findings of Florida Gov. Scott's Commission on Healthcare and Hospital Funding released earlier this year.
            "Healthcare," the Governor's Commission reported, "is not a free market system.
            "Hospital utilization data indicate that more than 70% of all all hospital admissions in Florida during 2013 were covered by a government-sponsored resorce. (i.e Medicare, Medicaid, VA/Tricare or other.)"
              Which suggests hospital care in Broward County is a poster child for - GASP - socialized medicine.
              And then, we have from the January issue of Health Affairs magazine in 2006:
              "Asked by a a Wall Street Journal reporter to explain how U.S. hospitals price their services, William McGowan, cjoef financial officer of the University of California, Davis, Health System and thirty-year veteran of hospital financing responded, 'There is no  method too this madness. As we went through the years, we had the cockamamie formulas, We multiplied our costs to set our charges."
             Which explains the "cockamamie" dynamics at work in the following:
               Diagnostic Cardiac Catheterization - Outpatient
                       Broward    Memorial     Plantation    Holy
                       Medical     Regional       General       Cross
Average:  
Charge            $10,641     $9,168          $8,658         $22,719  
Cost                $1,589       $1,402          $553            $2,606
               Again, Broward features three Persian Market public hospitals that serve as designated ER Trauma Centers:                      
                    ER patients requiring immediate life-saving care
                 Broward Medical   Memorial Regional Broward North  
                      2005     2014      2005  2014        2005       2014
White            2,150    4,788     NA    2,700        2,037      3,981
Avg. Charge  $3,871  $7,819   NA    $15,544    $3,331    $7,451 
Black            4,007    7,760     NA     1,433        1,800      3,437
Avg. Charge  $3,298  $8,086   NA    $15,752    $2,846    $7,450 
Hispanic        820       1,451     NA    1,011        790         1,350
Avg. Charge  $3,684  $7,801   NA    $16,221    $3,143    $8,296
                And speaking of the above Chargemaster-generated ER anomalies as grist for a Special Grand Jury...
                                         Emergency Room Trends 
                                             Broward                Plantation
                                              Medical                 General
          Severity -               2005        2014         2005       2015
          Minor &
          Low/Moderate
          White                      4,017      5,713           3,450     302 
          Avg. Charge            $578       $320           $1,960   $1,545
          Black                       7,326      9,929         18,102    4,891
          Avg. Charge            $530       $391           $1,625   $1,220
          Hispanic                  1,425      2,051          2,167     337
          Avg. Charge            $535       $484           $1,77     $1,759
          High Severity        
          Non Immediate
          & Immediate Care
          White                      5,757      11,902        248        1,932
          Avg. Charge            $2,972    $5,885        $6,211   $13,148
          Black                      10,848     24,770        874        14,126
          Avg. Charge            $2,536    $4,719        $6,196   $11,083  
          Hispanic                  2,241      5,264          128        1,566
          Avg. Charge            $2,756    $5,115        $6,166   $12,362
                  Of course...
                  Data alone are like blips on a radar screen. or a distant explosion.
                 And thus, the above (data) require an explanation as to their meaning and relevance for both taxpayers and patients. 
                  This is certainly the case with the data and trends for Broward General (a tax-funded public facility) and Plantation General (a for profit hospital scheduled to relocate to a more upscale location with far fewer minority residents).  
                  Trouble is...
                  We have here are arcane data filled with mysteries 
equal to the miracle of  transubstantiation in the conversion of common wine to the Blood of Christ.         
                   Or the North Broward Hospital District's legal expenses  versus the cost of  blood:
               Costs             2008                    2015
               Lawyers        $2,488,334          $9,965,535
               Blood            $10,126,809        $12,217,896
                   Which is a metaphor from hell.
                   And speaking of metaphors, ponder the numbers and trends below - not that any of District's politically-appointed governing Board of Commissioners might grasp the significance of this data tsunami.
                         
                                Broward Medical Center
                                          2000                    2016          CPI %
Adjusted admissions       29,554                 42,151                %
Surplus (Loss)                 $26,470,029        $27,160,258
Per adj. admit                   $997                    $644            
Gross Charges                  $842,550,528      $1,869,517,490
Per adj. admit                   $28,509               $44,353             56%
Deductions/Costs
 Bad Debt                        ($73,997,000)     ($173,611,601)
 Per adj, admit                 ($2,503)              ($3,974)              59%
 Indigent Care                  ($112,026,698)   ($118,959,485)
 Per adj. admit                 ($3,791)              ($2,723)             (28%)
 Other                              ($483,771,990)   ($1,027,911,172)  
 Per adj. admit                 ($16,369)            ($23,528)            44%
Reimbursed
Medicare                         $37,993,797         $81,080,853
Medicaid                         $31,103,932         $59,529,164
Managed Care                $77,101,892          $1,027,911,172  
Other                              $26,555,222         ($3,276,608)
Tax Revenue                  $39,588,385          $43,025,063
Grants                             $1,675,622            $755,009
DSH                                None                     $20,890,015
Net Reimbursement       $214,018,849        $422,811,145
Per adj. admit                 $7,242                   $9,115               26% FTEs                               2,046                     2,957                45%   Salaries                           $83,896,658          $175,711,584
Benefits                          $16,604,486          $52,054,015
Total                               $100,501,144        $227,765,599
Per Employee                 $49,120                 $77,026             58%
Licensed Beds                744                        716
Avg. Daily Census          355                        410                    15%
Occupancy Rate             48%                       57%
Uninsured                        88                          54                     (39%)
Medicare                         86                          79                     (8%)
Medicare HMO/PPO      30                          40                      33%
Medicaid                         76                          105                    38%
Medicaid HMO/PPO      10                          25                      150%
Other Insured                  65                          107                    65%
Admissions                      21,848                  27,116                24%
ER Admissions                12,567                  18,954                51%
ER Visits                         66,069                   123,154             86%
Outpatient Visits             191,948                 217,608             13%
Surgical Operations         9,036                    11,779               30%
Cardiac Cath                   1,684                     1,382               (22%)
MRIs                               3,081                     5,992                 94%
CT Scans                         17,576                   43,245               146%
Lab                                  889,016                 1,624,513          83%

                 And finally...
                 A word about the scourge of  Socialized Medicine.
                 The Dark Side  of the American Healthcare system.
                  Which so many politicians and lobbyists for Big Health would have us believe -- even though healthcare in America has been "socialized" for years.
                   Via government programs like Medicare and Medicaid.
                   And most recently, a national health insurance program called Obamacare by its opponents..
                   All of which suggests healthcare in America is already pretty damn socialized  by billions of tax dollars.
                    Anyhow...
                    Time now to close with a mega dose of irony.
                     Coupled with the shameless abuse of the English language.
                      Like right here in Broward County, the non-profit Cleveland Clinic is the county's most profitable hospital.
                     With earnings to revenue numbers like:
                      Net Operating Revenue -      $276,910,861
                      Total Bottom Line Surplus -  $80,421,706 
                      Which comes to "earnings" like 29%
                      Versus Broward's soon-to-be relocated for-profit Plantation General.
                       With earnings-to-revenue numbers like: 
                       Net Operating Revenue -  $369,891,371
                       Total Profit -                      $11,090,935
                        Which comes to "earnings" like 3%
                       Compared to Plantation's future neighbor Westside Regional.
                       With earnings-to-revenue numbers like:
                        Net Operating Revenue -  $186,587,600
                       Total Profit -                       $29,089,726
                       Which comes to "earnings" like 16% 
                        Oh yes.
                        Let's not forget the South Broward Hospital District's Memorial West.
                        With earnings to revenue numbers like:
                         Net Operating Revenue -  $442,389,455
                        Total Profit -                       $91,822,486
                        Which comes to "earnings" like 21%
                        Which ain't all that bad for government work!

 

Broward Health - Where the buck stops

  With an annual budget of nearly $2 billion, the tax-funded North Broward Hospital District (dba Broward Health) is governed by a handful of politically appointed Commissioners chosen by Fla. Gov. Rick Scott for the membership in the local Republican party -- rather their knowledge of health care (of which they have little, or none).
 Attention District patients and taxpayers - below are the current governing board members of one of the nation's ten largest public health care systems:
 Chair - Rocky Rodriguez, realtor
             1700 NE 18 Street, Fort Lauderdale, 33316
              954 568 4822
Members -
             Maureen Canada, yacht basin owner
             2521 NE 31 Court, Lighthouse Point, 13064
             954 946 6090
             Joel Gustafson, retired lawyer-lobbyist
             100 S. Birch Road, Fort Lauderdale, 33316
             954 463 6900
             Sheela Van Hoose, lobbyist
             1631 NE 28 Avenue, Pompano Beach
             954 438 8066
             Christopher Ure, branch bank employee
             2770 stirrup Lane, Weston 33331
             954 349 2640  

District Doctor Dollars

     The recent demand for access to Broward Health financial records from Florida Attorney General* Pam Bondi begs certain questions.
    Like:
    What is the difference between a financial relationship, compensation, and enrichment?
    And between the three, which is taxable and which is not?
    Specially, as noted in her letter to Broward Health Attorney Linda Bauman, Bondi's demands are based "upon North Broward Hospital District (dba Broward Healh) having entered into financial relationships with physicians that violated the Physician Self-Referral Law, 42 U.S.C 1395nn, the Florida Anti-Kickback Statute 456.054, Florida Statutes and False Claims  Act 678.081 et seq., Florida Statutes."    
      Specifically, in her 3/10/2016 letter to Ms. Bauman, Attorney General Bondi seeks District records involving nine (9)"physicians whose contracts (with the District) Florida contends were improper and in violation of the Self Referral Law".
   Below are the nine physicians cited in Bondi's letter - and the District-paid (taxpayer) cost of their services:
                                               2010                2016
                                               Spent              (Budget) 
    George Caldwell                  $2,025,461      $1,483,664
   Michael Chizner                   $762,387         $1,024,639
   Violetta McCormack              $1,236,425     $1,112,248
   Hector Rodriguez-Cortez      $769,044        $647,809
   Rudolph Roskos                   $803,109        $645,907
   John Rozanski                      $976,172        $939,067
   Ashok Sharma                      $1,683,368     $1,532,947
   Erol Yoldas                           $2,368,505     $2,111,298
   Shazia Zafar                         $957,375        0
      Source: Commission-approved District Budgets
 
     NOTE - In the interest of full disclosure, I was involved in numerous hospital issues during my four years as a policy analyst employed by and answering directly to then Attorney General Robert A. Butterworth. JKdeG

Where's the Grand Jury?

   Okay.
   So the Plan had some "issues" withFederal anti-trust Stark Laws.
   Which resulted in the North Broward Hospital District paying a penalty of nearly $70 million earlier this year.
    Like so many other schemes, the Plan seemed like a good idea at the time.
    Here's how it was supposed to work:
    1.  The tax-funded Hospital District would hire a a bunch of Docs to hondle visits to their offices scattered throughout northern Broward county. .
     2. Unlike the District's four hospitals, the hired Docs would market their services to paying patients - rather than those lacking insurance.
     3. Which would increase the percentage of the District hospitals' paying inpatients.
     So, as the cliche goes...
     Hows that worked out?
     Well, for Starters, the District's hired physician program has been a major money looser from the get-go.
     But, big picture-wise, it gets way, way worse!
     Like:
                          District Employed Physicians
            Fiscal Years         2010                  2016
            Total Visits            227,910             378,220
            Total Employees   218                    403
            Compensation      $35,949,829       $58,973,561
            Per Employee       $164,907           $146,336
            Patient Revenue   $22,732,082
              Per Visit              $100
            Surplus  (Loss)     ($20,763,236)    ($33,332,241)
            (Loss) per Vist       ($91)                 ($88)
                               Four District Hospitals            
            Fiscal Years         2010                  2016 Budget                      Avg. Patient 
               Census              899                    874
            Adjusted 
               Admissions        107,786             109,637
            Total Employees   6,001                 6,057
            Compensation      $456,614,887     $491,945,660 
            Per Employee       $78,090             $81,219
            Total Revenue      $954,401,599     $1,773,723,103
               Per adj. admit    $8,855               $16,178
            Total Expenses    ($877,144,284)  ($1,738,528,718)
               Per adj. admit   ($8,137)            ($15,857)
            Surplus (Loss)      $77,257,315      $35,194,385
            Per Adjusted
                Admission         $717                 $32
      Oh yes.
      Like a proverbial Rube Goldberg machine, the District has a ton of mysterious parts.
      Which leads us to the "Bottom Line" trends for the entire district since FY 2010
                 
      Total North Broward Hospital District                                                     FY 2010           FY 2016
            Surplus (Loss)    $76,866,424     ($59,203,478)*
            Per Adjusted
               admission           $713                 ($748)    ! ! !                                      *First nine months of FY 2016 

                  So where's the Grand Jury?
          Source: North Broward Hospital District Budgets

Calling Horse Shit

   When all else fails and a bad moon's rising, officials running the giant tax-funded North Broward Hospital District will describe their's as a mission from God based on their care for the poor.
   Trouble is, after scraping away all the PR horse shit, it  seems the pony's shrinking.
                 North Broward Hospital District
                   Average Daily Hospital Patient Census   
                Fiscal Year            2010          2016
                Patients                 899           857       (5%)
                Insured                   751           757        8%
                Uninsured               148          100       (32%)
                  Source: North Broward Hospital District
  
   PS - This may be the First of April, but this ain't no April Fool's joke. JKdeG
                                       

Tracking Hospital Finances

   The problem?
   Hospital financial data often involve millions and even billions of dollars.
   Trouble is, most walk-around folk have trouble relating to amounts of this mega sort.
   Which is how and why the American health care industry
developed baselines like:
   Adjusted Admissions
   Adjusted Patient Days
   Each of which enable policy makers to track hospital financial trends over a period of time -- or compare the financial "health" of one hospital to another.
   FYI - Adjusted Admissions and Adjusted Patient Days are produced using a health care industry-wide formula that accounts for BOTH inpatient  and outpatient populations at a given hospital or group of hospitals.
   Here's how it works using the current financial woes at the North Broward Hospital District (dba Broward Health- with a gross annual budget of nearly $4 billion.
                               
                               Broward Health
                        Financial Trends
                            (Per Adjusted Admission)
                                     Total System
            FY                      2013             2016*
            Adjusted
            Admissions       120,046           79,116
            Gross Charges   $31,702          $33,256
            Deductions
            Bad Debt           ($3,065)         ($3,672)
            Charity Care      ($2,711)         ($1,344)
             3rd Party/Other ($18,733)       ($20,659)
            Total                  ($24,509)       ($25,675)

             Reimbursed
             Medicare            $1,552           $1,599
             Medicaid             $794             $408
             Commercial
             Insurance           $4,772           $5,783  
             Other                  $68              ($209)           
             Reimbursed        $7,186          $7,581
             Other Revenue   $1,048           $575
             Total Operating  
                Revenue         $8,234           $8,156
             Non-Operating
               Revenue          $1,754           $829
            Total Revenue   $9,988        $8,985
            Expenses           ($9,498)        ($9,733)
            Surplus               $490             ($748)
                                                            *8 months

           Source: North Broward Hospital District
 
    Bottom line?
    The North Broward Hospital District is suffering from some serious financial health  problems.