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CSA Online First is a weekly blog featuring insights from CSA members themselves.

Edited by Rita Agarwal, MD, FAAP, with contributions from CSA’s Committee on Professional and Public Communications, Online First is a place where knowledge and opinion from any one of our 3200 plus physician-anesthesiologist members can be shared, discussed and deliberated to advance the specialty of anesthesiology, the practice of medicine and society in general.

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A Hospital Too Far, Part II - Bleeding Anesthesia at Good Samaritan Hospital (San Jose), The High Price of Free

by
  • Chow, Harrison, MD
| Oct 07, 2019

Harrison_ChowRecently at a party, a friend talked about her son’s admission to UC-Berkeley (“Cal” for the locals and alums) Computer Science department, truly a Willy Wonka-like Golden Ticket[1] admission to one of the premier computer science programs on the planet. When is he starting? Which six-figure tech job is he planning to start after graduation?

“That’s the crazy thing, he’s worried about Berkeley and all of the activists, he doesn’t want to deal with that,” said his mom, “Anybody got any suggestions?” The party grew a bit silent, in a mix of respect and curiosity. What kid turns down a Willy Wonka Golden Ticket and a chance to make his mom happy?  

The conversation turned to the rough layout of Cal. And back to demonstrations and protests in the 1970s and 1980s. South campus is the home of administration and liberal arts, Sproul Plaza, Telegraph Avenue, and nearby People’s Park. Where the ubiquitous demonstrations occur.   This is the land of the free.

The north campus, however, is a quiet cousin to the rowdy south campus. The Northside is the hard sciences; engineering, computers, chemistry, physics and biology.  The North campus is the STEM-side of town. The future-Tesla-engineer side of town. The lucrative side of town.

“Just stay on the Northside,” we all advised.

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We live in a STEM world. Engineers of any background, computer scientists, geneticists, physicians (the bioengineers of the human body) are all running in short demand in an American education system that has failed to anticipate and educate sufficient people to fill the crazed hiring demand. The shortage is so severe that engineers and physicians are recruited from around the world to the US.

This is very much the world in which Good Samaritan Hospital of San Jose lies, just down the freeway from Stanford University and UCSF, Genentech, and surrounded by eBay, Netflix, Apple, Google, amongst myriad of other transformational tech companies.

My practice lies in the heart of Silicon Valley, a hub of the STEM universe that is the SF Bay Area. If you have a STEM brain and want to work at a STEM corporation, a STEM salary awaits you. This simple economic formula, a mining of educational and individual talent, has fueled a world that places a premium on STEM. 

Valley employers are lined up to hire you, because they are selling your brain and creativity in packages that people want and need to buy (think iPhone, Facebook, cancer drugs, robotic surgery). The fervent growth of the local STEM economy has resulted in the most expensive housing market and cost of living in the US, with a family house in this area costing 2 million dollars plus.

Since I’ve been at suburban Good Samaritan (Good Sam) Hospital, first as part of the longtime GAS group and now as part of Vituity Anesthesia (formerly CEP), there has been considerable interest and pressure to merge with the sister HCA (Hospital Care of America) facility Regional Medical Center, located in the less affluent downtown San Jose.

Shortly after we merged into Vituity a little over three years ago, HCA put out a Request for Proposal (RFP) for anesthesia services at Regional Medical Center, with some significant stipulations. No hospital stipend. No stipend for MediCare/MediCal patient base. No stipend for 24/7 in-house trauma call. No stipend for 24/7 in-house OB call on a slow service. That’s 6-7 anesthesiologists for free. Take it or leave it.    

But somebody didn’t get the memo – that highly educated STEM minds have a STEM price tag. 

The existing group at RMC just walked out. Vituity ended up with an undesirable contract with almost no lead time and inadequate staffing. Locums were hired, and partners encouraged to cross-credential and work at both facilities.  Work hours increased, vacation decreased, and finally income decreased to cover ongoing losses. The practice increasingly miserable.

Now burdened with cross-town charity care, the anesthesia medical staff from the Good Samaritan Hospital started to leave, one here and one there, seemingly a new person leaving or retiring every couple of months. At first, we would have a retirement party dinner (a longstanding GAS tradition), and then a retirement cocktail as these became more frequent, now the people leaving to other practices has reached such a torrent that people now leave with a conciliatory mass e-mail. Sad, the loss of our culture.

In this case following the money is instructive. RMC patients are often uninsured or covered by public insurance vehicles such as MediCal and Medicare. Comprehensive hospital services, such as trauma coverage, mandated by Santa Clara County, also vastly underpay providers.  

Private insurers as well have driven physician and anesthesiologist reimbursement rates in California to the lowest in the nation.   

Worst yet, Tennessee-based HCA, Good Samaritan and Regional Medical Center’s parent company, is notoriously tight-fisted with physicians. Yes, even in Silicon Valley. Seasoned physicians and nurses know that negotiating with HCA is a tough and long path. 

In the months and years after the San Jose physician work-for-free program started, the value proposition for the San Jose HCA anesthesiologists on both campuses has become   work harder, make less, experience more stress, do it because we can make you. Mandated and contractual brute force. How Santa Clara County can expect free physician-level care and how Vituity can attempt to provide it for HCA is an economic and accounting mystery. No amount of hand-wringing meetings or hearings can decode the crypto math. What a deal!?

All this is occurring as the anesthesiologist shortage in California and nationwide has reached near historic levels for our specialty. The policy and C-suite management decisions speak for themselves, loss of the entire Regional anesthesia practice; 10 anesthesiologists (Regional) total and at the date of this article, 12 (possibly 13) anesthesiologists from the Good Samaritan practice.   

Of the roughly 50 anesthesiologists in the HCA anesthesia practices based in San Jose, the HCA - Vituity merger deal has managed to lose over 40% of their core assets, their anesthesiologists. In THREE years. Many just walked, if not ran, away from decades of clinical experience at their practice location.

Lost were not just FTEs, not just numbers on a spreadsheet. Lost were colleagues, young rising clinical stars, medical directors, former Department chairs, performance improvement managers and former presidents of the group. Lost were institutional memory, leadership, and clinical talent. Lost were my friends. Free is never free.

Worst yet, despite all the relentless meetings and money talk, in all the organizational chaos, one essential question is never asked – has anybody died yet as a result of the care disruption?   Nobody ever asks this very simple and essential question. I shudder at the answer. 

One doesn’t need to be a politician or a corporate manager to realize that these decisions have failed the local medical community. Spectacularly so. You can’t get a STEM brain, much less an even scarcer physician and anesthesiologist brain, for free. In the uber-expensive Silicon Valley of all places. 

This isn’t the Southside Berkeley campus, land of the free, a loud and bullying voice and some really, really bad math skills. And those bad math skills, obnoxiously loud as they are, are going to get somebody killed.

On a more positive note, some contractual and management sanity has returned (more to come on that). Hopefully the resignations will stop soon. Maybe we can have a proper retirement party again at a Los Gatos restaurant steakhouse. One can daydream for our genteel culture lost in razor-sharp, unsentimental Silicon Valley.

Free is never truly free. Will economic wonders never cease. Memo to policy makers and management: want to turn things around? Start pricing your contracted brain talent properly.   The zeros are in the wrong place.

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And the Willy Wonka kid? His mother told me he was interested in medicine recently. I just laughed, “take the UC-Berkeley Computer Science Golden ticket” was my quick response. That was my honest advice. No botched e-mail firings by wayward administrative assistants. No mediocre hospital food. Better compensation. No more administrative I.O.Us. and free labor power plays. 

Throughout the Valley, my home, an entire turbocharged, dominant global economy has been born, fueled by STEM education graduates – many organized into the highest performing and most valued companies in the world. Will the jumbled public-private American health care system ever price it’s highly educated STEM minds properly?  I have the San Jose hospitals, in the epicenter of Silicon Valley, as a case study. Nope.

Harrison Chow, M.D. is a frequent contributor to the CSAOF.  He currently is a Vituity partner and staff anesthesiologist and maintains medical privileges at Good Samaritan Hospital (West San Jose) and Regional Medical Center (East San Jose).   He is also a former Department of Anesthesia Chair of Good Samaritan Hospital and is a current Delegate for the Hospital-Based Practice Forum at the California Medical Association.

           


2 comments

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  1. Allen S. Cohen,MD | Oct 07, 2019
    This is one of the best written and best reasoned articles which I have read on the issue of contracting with large entities. The business model of the large hospital conglomerates used to be: pay Anesthesiologists less, and depend upon a never ending stream of young graduates who wish to practice in California to fill-in for the senior physicians who leave. The cost of housing has ended that stream of low cost replacements. I am retiring in the next year or so, and I have no idea who will replace me, and the ever lower paying Anesthesia care which I have provided.
  2. Peter M. Lucas, MD | Oct 07, 2019
    Harrison: Fascinating story. But you left a critically important question unanswered. Why did Vituity respond, and agree to the terrible offer by RMC?

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