The scale of our collective progress can be measured against a timeline of vaccine milestones. The polio vaccine brought hope to millions of families from America to Zambia. Up until the mid-Twentieth Century, few could imagine the eradication of smallpox, but a global vaccination campaign against the disease starting in the 1960s ushered in an era of new possibilities for billions. And the roll-out over the past week of the first-ever approved malaria vaccine may mark another landmark: the moment when children across Africa have been given hope in the form of a tool that can help them escape a plague that kills 500,000 of them each year.

A future where malaria is eliminated as a public health threat in the African continent may remain out of reach for the immediate future, but that shouldn’t stop us from working to fulfil our dreams of a malaria-free Africa. As it has with other diseases, the introduction of a new vaccine has the potential to catalyze innovation and create new opportunities for economic growth.

If the malaria vaccines enter the immunization schedule of most African countries over the next year, as planned, the steady stride of the region’s economic power may accelerate. When more children survive past their 5^th birthday and the strain on health systems is reduced, that’s not only intrinsically valuable, it’s a good thing for economic growth.

Healthy children fuel healthy economies

With the coming decades expected to see the ascendance of several African markets as global economic players, malaria vaccination could be a catalyst to sustained development in the region. This serves as a benefit for nations around the world, including the U.S.

Yet, one of the most immediate ways to derail Africa’s economic potential is to hamper the very immunization programs that have delivered the most impressive returns on health investments, both in Africa and globally. That’s what is on the line later this year when Gavi, the alliance responsible for financing the delivery of more than 19 different vaccines to low-and-middle-income countries, is set to have its funding reauthorized by the U.S. and several other governments.

Gavi has written the playbook for creating an investment-driven approach to providing emerging markets with the immunization infrastructure they need to thrive. In the 24 years since its founding, the alliance has vaccinated half of the world’s children. That alone is a remarkable achievement, but the alliance has matched humanitarian outcomes with powerful financial results: Its model has proven so successful that $1 of investment in Gavi yields $54 in health savings among its beneficiary countries. Peer-reviewed research has shown a strong link between child survival rates from vaccine-preventable diseases and GDP growth.

As investments of U.S. taxpayer funds go, few if any can rival the return that Gavi brings for the roughly $300 million committed to it by the American government each year. Looking beyond the direct impact on lives saved – nearly 18 million children and counting – global immunization programs supported by Gavi have strengthened health systems in many of the most vulnerable countries of the world. These are the very places where deadly disease outbreaks have the greatest chance of growing undetected until they are uncontainable.

Continuing support for routine immunization is essential

Gavi funding helps protect Americans by blunting the relentless pace of viruses and bacteria to evolve beyond our control. Better immunization against known threats, more sophisticated early-detection systems in disease hot zones, new vaccine manufacturing capacity closer to the likely sources of outbreaks, and hospital systems that are less burdened by increasingly preventable maladies like malaria – these are the building blocks that Gavi has helped put in place to foster a healthier future for all of us.

At a time when disinformation further erodes trust in the institutions tasked with protecting public health and the spread of disease is supercharged by climate change, the value of Gavi’s time-tested model deserves to be acknowledged through funding replenishment later this year. This would send an unmistakable message to the world that we can still fulfill the hopes and dreams of billions of people by providing the lifesaving vaccines they need to have a shot at a more prosperous, peaceful future.

The post A Gateway to Growth in Africa appeared first on Medika Life.

For most of last year, St. Agnes Medical Center, based in Fresno, California, looked like a white knight poised to rescue smaller Madera Community Hospital from financial ruin.

Now, with the nonprofit Madera, California, hospital bankrupt and shuttered, St. Agnes looms as a dark knight, pushing to liquidate the hospital to get a loan it made to Madera paid back — even if that means dashing the hopes of the community activists, political leaders, and health care officials that the hospital can still reopen.

A pivotal moment in the case could come July 25, when a bankruptcy judge in Fresno will hear arguments on whether the Madera hospital should be allowed to spend its dwindling cash reserves on things such as building maintenance, security, utilities, and the salaries of its three top executives.

The hospital wants to run a skeletal operation while it seeks a buyer and develops a reopening plan. But the federal bankruptcy court in Fresno has authorized it to spend money only through July 29. If the judge doesn’t think the hospital has a viable plan, he may refuse an extension, which would likely mean liquidation.

Problems like Madera’s are common among other small, financially challenged hospitals in California and nationwide. They typically have low patient volumes and rely disproportionately on payments from Medicaid and Medicare, which constrains revenue and makes it difficult to attract talent or invest in cutting-edge equipment. Add to the mix a crushing surge in expenses stemming from the covid-19 pandemic, and dozens of such facilities are struggling to survive. Two others, both in California, have filed for bankruptcy this year.

Yet Madera had problems that were all of its own making. The hospital made money on patients insured by Medi-Cal, the state safety-net insurance program that pays notoriously low rates, according to financial data filed with state regulators. But it lost money on its commercially insured patients due to low volume and bad deals with insurance providers. It also failed to seek covid relief funds in a timely manner. A state hospital bailout fund came too late.

Plus, Madera had no backup plan when St. Agnes and its parent company, the hospital chain Trinity Health, walked away from a proposed merger with the troubled hospital late last year, giving virtually no notice and scant explanation. Their move shocked and infuriated officials, former employees, and community advocates in Madera and Sacramento.

In a brief December press release, St. Agnes and Trinity blamed their decision on “complex circumstances” and “additional conditions” imposed by state Attorney General Rob Bonta. But industry experts said Bonta had agreed to most of what St. Agnes asked for and were baffled as to why they walked away from the deal.

The spectacle of St. Agnes and Trinity now pushing in court for the liquidation of tiny Madera has drawn Bonta’s ire.

“For Trinity, it was always about profit, not the health of the Madera community,” Bonta told KFF Health News in a statement. “They are now attempting to use their position as Madera’s biggest creditor to extract every dollar possible, instead of keeping the community’s interests at heart.”

Bonta said his office had “offered maximum flexibility to Trinity in recognition of Madera’s financial circumstances.”

An agricultural area of 2,150 square miles and home to nearly 160,000 people, Madera County is 60% Hispanic, and more than one-fifth of its residents live below the poverty line, according to census data.

A Community Left in the Lurch

Jennifer Lara, a former Madera Community Hospital nursing assistant, said she and colleagues had been looking forward to positive change after the anticipated merger with St. Agnes. “We were floored when we found out the hospital was closing,” she said. “We didn’t think anything other than the hospital continuing on was going to happen.”

St. Agnes and Trinity declined to comment. The longtime CEO of St. Agnes, Nancy Hollingsworth, retired in May amid a reorganization that made the hospital part of a regional group based in Idaho. It’s unclear whether her departure was related to the collapse of the Madera deal. Hollingsworth could not be reached for comment.

St. Agnes’ considerable leverage in the bankruptcy case is the result of a $15.4 million loan it extended to Madera during merger talks last year. Madera has since repaid $8 million, leaving a debt of over $7 million, which still makes St. Agnes its largest creditor.

St. Agnes, one of 88 hospitals belonging to Trinity, a multistate, Catholic, nonprofit health system headquartered in Livonia, Michigan, argued in a recent bankruptcy court filing that Madera still has made no significant progress finding a buyer, more than four months after filing for Chapter 11 bankruptcy protection on March 10, and should not be allowed to continue spending money “without a serious path forward to either sell or mothball the hospital.”

The hospital has been talking to three potential partners, “one of whom is late to the game,” said Riley Walter, Madera’s bankruptcy lawyer.

Mohammad Ashraf, a cardiologist and member of the executive committee of Madera’s medical staff, said the first two entities in question, whom he declined to identify, are management service organizations, not hospital groups. “They don’t want to spend any money to buy it. They just want to run it,” he said.

Without a convincing strategy for the future of Madera Community Hospital, the end of the bankruptcy case could come quickly.

Ranjit S. Rajpal, a Madera cardiologist for over 40 years, said the closure of the hospital is bad news for patients who need time-sensitive care, such as for heart attacks, strokes, or other traumas, and who now must travel greater distances to get it.

And the closure will exacerbate existing health inequities for people who face challenges getting care because of immigration status, language barriers, lack of transportation, or other socioeconomic factors, he said. “Those disparities will be compounded as time goes by.”

Community leaders and the hospital’s leadership hold out hope for reopening. The hospital has applied for $80 million from California’s new, $300 million loan fund for distressed hospitals. Hospital leaders must produce a reopening plan by July 31, but even if it does, it’s unlikely to get the full requested amount: Sixteen hospitals have already applied for loans totaling over $385 million, said Joe DeAnda, spokesperson for the California State Treasurer’s Office.

“They’re not going to give a quarter of their total fund to one hospital that doesn’t even have a partner,” said Glenn Melnick, a health economist at the University of Southern California who authored an analysis commissioned by the AG’s office of the proposed St. Agnes-Madera merger. “Eighteen months ago, the ask would have been a lot smaller.”

Even if Madera Community Hospital finds a viable partner and gets the funding it needs, reopening would be daunting and expensive. The hospital would need to hire hundreds of nurses, technicians, and other staffers in a tight and expensive health care labor market and find a way to avoid the financial problems that landed it in bankruptcy.

“Some things an acute care hospital offers are profitable, and others are not,” said Jay Varney, Madera County’s administrative officer, whose role is akin to a CEO. “It doesn’t make much sense to have it reopen like it was and have it go bankrupt again.”

‘Running Out of Time’

Reopening the facility with all the services it provided before is not the only option. Baldwin Moy, an attorney for California Rural Legal Assistance, a community advocacy group, said he and colleagues have been arguing for the court to allow Madera additional time either to find a buyer or for the county “to put together a package that can reopen the emergency room with some stripped-down clinical operation.” But, Moy said, they are “running out of time.”

Karen Paolinelli, the hospital’s CEO, said the current suitors are interested in reopening it as an acute care facility that “may or may not have all services that were previously offered by Madera Hospital on day one.”

If the hospital can hold out for a few more months, it says, it can collect $23.5 million owed by the state for “provider fees,” and possibly an additional $10 million from the Federal Emergency Management Agency. Those payments would more than cover the hospital’s entire debt of $30 million. But the amount and timing of payments are unclear.

Paolinelli, voicing a common industry complaint, said the hospital has a disproportionately high number of Medi-Cal patients and Medi-Cal rates do not cover the cost of providing care. But state data shows that Madera received enough supplemental payments to earn nearly $15 million from Medi-Cal in 2021, though it lost over $11 million treating Medicare patients. Madera also lost about $6.8 million on commercially insured patients in 2021, the state data shows. Commercial insurance payments covered only 59.5% of what it cost to care for those patients. That compares with a statewide average of 156%, according to Melnick.

Paolinelli said Madera tried to negotiate better rates with commercial health plans but “does not have much leverage with the payors.” She added that many residents of Madera who get commercial insurance through their employers choose Kaiser Permanente, whose nearest acute care hospital is in Fresno, 20 miles away.

State Democratic Sen. Anna Caballero, whose district includes parts of Madera, Merced, and Fresno counties, said that if Madera Community Hospital were to successfully reopen, more people with commercial insurance would have to choose it over other hospitals outside the county, which they had not been doing frequently.

“The county and the city may need to say, ‘If you need hospitalization, you need to go to Madera, and there will be no copay, but if you go out of the county, there’s a copay you have to pay,’” Caballero said.

But with no clear path to reopening yet in sight, Caballero said, that discussion is premature.

Melissa Montalvo covers Latino communities for The Fresno Bee as part of the Central Valley News Collaborative, a partnership that includes The Fresno Bee, Vida en el Valle, Valley Public Radio, and Radio Bilingüe. This article is part of the Central Valley News Collaborative, which is supported by the Central Valley Community Foundation with technology and training support from Microsoft Corp.

Bernard J. Wolfson: bwolfson@kff.org, @bjwolfson

The post Giant Health System Almost Saved a Community Hospital. Now, It Wants to ‘Extract Every Dollar’ appeared first on Medika Life.

Most of us assume that discharge is up to our treating physician or surgeon to decide when it’s appropriate for us to go home and what sort of in-home treatment or rehab we should have prescribed as part of our aftercare. We are, in that regard, totally in the dark because the day of discharge has been taken out of your physician’s hands and is controlled by a codebook; the DRGs are an all-payer guide with one section, another, the MS-DRGs, for Medicare patients.

What is this mysterious acronym? The acronym stands for Diagnosis Related Groups, a plan for codes for illnesses and procedures related to them. These codes (there are 740) are mandates for discharge, and physicians must abide by them unless there are extenuating medical circumstances.

Ask the older women in your family how long they remained in hospital after the birth of their children. Today, women may remain for one day or 48 hours. Previously, women may have been patients in the hospital for up to 10 days after childbirth. The DRGs changed all of that.

Specialized medical practices such as those for reproductive medicine have begun providing professional articles to assist physicians in coding and reimbursement. Patients who may wish to peruse the reimbursement rates for orthopedic procedures can find this information here. But note that there is no agreement among hospitals that would indicate they all bill at the same rate. Essentially, the patient is on their own when it comes to cost because of a lack of transparency.

The DRGs aren’t something new because the codes were designed and implemented as part of the prospective payment system for Medicare in 1983. How effective has it been at attaining its primary goal, and have there been problems with its design and utilization over the years? Psychiatrists began expressing their displeasure almost as soon as they saw the coding in 1986.

These issues include the problems of premature discharge, code manipulation, cost-shifting, and equitable patient access to psychiatric services. The potential effects of a DRG payment system on clinical practice are reviewed.

The psychiatrist’s view was relevant to the DRG and its application to psychiatric intervention. Based on limited data on the issue of discharge of psychiatric patients, it was believed that this information was not developed, tested, or applied in psychiatric facilities.

In fact, of the 14 psychiatric diagnostic groupings contained in the initial DRG listing, none were validated in any psychiatric facility, whether in a general hospital, a general hospital’s psychiatric unit, or a private psychiatric facility.

How could anyone, with such flawed data, decide when the discharge of a patient with a psychiatric disorder was appropriate? Considering that the listings were to optimize savings in terms of reimbursement, inappropriately released psychiatric patients would become a burden on local communities, and it was reasonable to assume they would be rehospitalized, potentially at a higher rate. Liaison psychiatry, found to be a cost-effective means of providing care, was not factored into the DRGs.

Another problematic aspect of this coding system is that it’s not uniform in its application for Medicare, Medicaid, and other third-party payment for hospitalization. Code manipulation is present in every form of care under the DRGs.

One aspect of code manipulation (at whose benefit?) is billing practices for reimbursement for patients with multiple disorders. The patient is treated and discharged under one DRG mandate and then re-admitted under another of their illnesses and treated again until that DRG mandate kicks in. Ethical, patient-friendly, or beneficial to the facility’s bottom line? Physicians in one study found this was used particularly with geriatric patients.

Another practice with psychiatric patients is DRG-creep, where a patient is diagnosed with a disorder that pays at a higher rate. When a diagnosis is restricted to a psychiatrist’s independent opinion, who can question this?

Consider another aspect of hospital discharge following DRG guidelines. Where does it indicate any provision for family care, appropriate follow-up services, or placement? If there’s no place for the patient to reside, what do you do, admit them to a rehab facility where another set of DRGs will be initiated? Is this cost-saving for whichever agency is paying for care?

The previous paragraph brought to mind two cases of lengthy hospitalizations. One was for a young woman, about 18, who had been an inpatient in a private psychiatric hospital for five years. I asked what her diagnosis was on discharge. The social worker said, “We’re meeting to decide that today.” That day? What were they using as her diagnosis for all those years? Of course, her wealthy family had private insurance, but didn’t the insurance company demand a working diagnosis? Was it DRG-creep here?

Another is a bizarre case that resulted in active media coverage and a book. It was about the life and hospitalization of Huguette Clark. Fabulously wealthy, she was a patient in a major New York City hospital for 20 years. No DRGs there?

Medical care is still ruled by reimbursement, and the DRGs hold an untenable place in that hierarchy.

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