The hospital environment in the United States is quickly changing nationally and exponentially more rapidly in Pennsylvania. According to Moody analysts from a Modern Healthcare article by Alex Kacik, hospitals are successfully lowering their operational expenses but not as quickly as their revenue is dropping. The implications of that statement are onerous. There are only so many ways to cut until you reach rock bottom as an organization and the point of no return. Shrinking to greatness is typically not considered a viable option to survival.

The statistics from 2017 are very telling as expense growth was cut by 5.7% but revenue has only grown by 4.6% and that was in spite of the numerous mergers and acquisitions that have taken place. In fact, with 13 M&A transactions, Pennsylvania was the most active merger and acquisition state nationally followed by Georgia and Texas at nine and eight each. In the year 2000, there were approximately 122 independent community hospitals in Pennsylvania and now there are just 36 with several of these hospitals hanging by a proverbial economic thread.

Without getting too deeply into the financial woods, Medicie and Medicaid payments as a percentage of gross hospital revenue increased slightly, but higher paying commercial insurances have gone down by 33.9%. In a financial structure where less than 3% of net patient revenue came from capitated and risk-based contracting in 2017 and 41% from DRG’s (Diagnostic Related Groups), 28% from fee schedules and 17% from the actual charge master or list price, based on a traditional operating model, there is no clear pathway for small and rural hospitals to remain viable.

Add to these economic challenges, the 2868 total number of retail clinics in the United States supported by Minute Clinic, Walgreens, The Little Clinic, Walmart, Target and dozens of other smaller corporations as well as an exponential growth in free-standing surgi-centers and independent physician-based clinics, and hospitals must take additional aggressive steps to change their business model.

In the Modern Healthcare article, Lyndean Bric, President of Advis Group, a healthcare consulting firm, states that hospitals must find ways to grow volumes, be creative, and do things differently than they have by looking to monetize assets and seek out non traditional revenue.

What if your hospital could afford to have its own Innovation Officer, and creativity could be added to your C-suite agenda at every meeting? With experience in the latest “Omics” research, expertise and connectivity in Integrative Medicine, and other cash income producing innovations, we can change the way a community utilizes their local hospital facilities while generating significant financial gains to their bottom line.

Although some of the areas that we may recommend may seem a little like “driving in front of your headlights” to the traditionally trained C-suite executive, each of them comes with a proven track record of success from multiple settings. Ultimately, the hospitals that work with us have experienced new levels of community acceptance and involvement that helps to reposition them as true partners with their patient base on a level that drives increased volumes and patient revenue.

Be it cash paying integrative treatments, pharmacogenomics testing, human longevity, federal and state grant opportunities, new technologies for treating depression, opioid testing labs, the creation of a 501©3 Foundation, mobile imaging, polypharmacy, or just creative supply chain payment methodologies, we hav experience, knowledge, and connectivity in all of these areas and because of that can bring the right people to the table to make “creative things” happen in an economically viable way for you and your organization.

Full disclosure. I was never physically molested by a person of the cloth. I’ve been verbally abused, but most of us have had that experience sometime from someone in power regardless of our faith.

When I was a pre-teen and wanted to be a priest, my Italian grandfather used to tell me regularly that I shouldn’t be so “impressed” by them. He used to say, “Nicky, the Pope is just an old man.” When he said that, I was worried that he’d be going straight to hell, but I’m pretty sure now that wouldn’t have been a problem.

When President Kennedy was killed, I was a complete wreck because I had read that he ate bacon for breakfast that Friday morning. At that time, that was also a “Hell” infraction. Of course that was before I had heard about his other extracurricular activities. Naivety can be a wonderful protector.

A decade after that, my dear Italian grandmother died. To say she was religious would literally be “the understatement of the year.” As a young woman, she had made a Pilgrimage to Assisi and even had a tattoo on her right arm that the participants received for making the last mile up the mountain to the Church of St. Francis on her knees.

Grandma died and the new priest pulled up to the funeral home in a white Mercedes. He came inside to talk to my dad about her funeral, and then this happened. “Mr. Jacobs, I don’t care if she came to church every day of the year, I won’t do this funeral mass unless you pay me $100 upfront.” (That’s $580.06 now.)

Two years later my dad died. He had been suffering from lung cancer and didn’t make it to church very often because of that. During that time, he received last rites from another new priest.

Except for that meeting, they were not well acquainted. During the sermon at my father’s funeral, the priest said, “Charlie, snuck into heaven through the back door” because he wasn’t attending church regularly. Then his entire sermon was a lecture about abortion. Nothing about my dad.

Later in my life I went to work for a Catholic Hospital. There I met several nuns who, when you looked into their eyes, you could literally see heaven. They used to say, “Don’t go to those priests for confession. Some of them are very bad people.” I should have listened.

As it turned out, several of those priests were exposed in the Altoona/Johnstown predator report. Some of those ladies must have known and had no where to go because even the DA’s of that era along with the monsignors, bishops, cardinals, and the Vatican have been implicated.

Many of my Catholic friends will point out to me that the church is not solely its leadership, but its members. It is also a human organization run by humans with human flaws. No human organization is perfect. They will say they are members based on their personal faith. So by lumping all members with these criminals I am basically accusing all of them who continue to remain faithful to the teachings of the church of the same crimes.

That is certainly not my intent. Just like I didn’t accuse my Penn State friends of being part of the Sandusky scandal. What I am saying, however, is that these heinous crimes should be punished to the full extent of the law. The statute of limitations should be lifted. Judges should not be able to take donations as potential hush money from those related to the church, and, for God and the kids’ sake, let priests get married, or at least screen out the pedophiles. Let women enter the priesthood. These were illicit sex rings run with the knowledge of church leadership.

As Blood Sweat and Tears used to sing… I pray there ain’t no hell. (Because it’s gonna be full of unholy men.)

Many of us are proud of our fathers, and with Father’s Day fast approaching, we’re definitely expecting to see posts praising our dads. OK, so, here you go.

My dad was relatively short in stature at about 5’6,” but incredibly tall in my eyes. Although Dad held jobs that usually preferred a college education, and he didn’t have one, he was one of the smartest men I’ve ever been around. Whenever something interested him, he attacked it with wild abandon. When it was iron furnaces and cannonballs, we traveled all around our area seeking cannon balls with bent coat hangers or twigs as dowsing rods. When he became enamored with electronics, we got to play with every type of electronic analytical machine that he could buy used. (We didn’t have much money.)

Dad dove into bees, not literally, and learned all about them. Then, as he reached his 40s, he turned to our community. First he decided that any peaceful little community should have gray squirrels so he drove back and forth to Jeannette, where a friend would live-catch squirrels for him. He populated our little town with these frisky bushy tailed devils. He loved to watch them, but, unfortunately, our neighbors loved to shoot and eat them.

After his squirrel adventures, dad turned to getting water and sewage into our little village, then a bridge, and finally, a Coal and Coke Museum. During his work days, he was able to convince an entire community along the Mon River to work together to bring in the Pittsburgh Wind Symphony for summer concerts.

To say that he didn’t teach me a lot would be a bona fide distortion. Every night he’d drill me in recitation of vocabulary words. We had a large box of vocabulary words that he practiced with me, words that won’t appear in this column because they are too obtuse. His charge to me was that I’d learn five new obscure words from the lexicon each and every day, use them in sentences until I was comfortable with them so I’d get a great score on my College Board exam. (That worked in English but not so much in math.)

Dad also taught me to spade a garden, control copperheads that were about to strike me with a two pronged snake stick, shoot rats at the local dump, identify all poisonous plants, recycle bottles, make compost piles, shovel coal into the coal bin, stoke a coal fired furnace and then empty the ashes from that furnace, solder, use a hand saw, pound nails, change the oil and do body work on a car, and most importantly, avoid physical harm by outsmarting my potential opponents. He taught me how to make money from a lemonade stand, from grass cutting, and running errands for retired people. He also taught me how to manage my paper route like a business. He would sit with me and go over my collections, explain how to approach the two deadbeats on my route and how to up-sale my customers into getting the Sunday paper.

Our grade school was only a few blocks away, but I always begged my parents to allow me to periodically take my lunch to school.

Dad wanted me to feel special, so he bought white lunch bags. I was the only kid in the school who ever had a white lunch bag. He also encouraged my imagination by buying me little tablets and making sure I always had lots of pens and pencils.

He bought me my first bike and car but then taught me how to save for the second of each. Above all he taught me how to be a good, loving, kind, resourceful, provider and Father.

Dad smoked until 1960, but he died in 1975 from lung cancer. It was an outrageous loss for my family and for the world. Love ya, Dad.

When asked what the most perplexing thing was about humanity, the Dali Lama replied, “Man. Because he sacrifices his health in order to make money. Then he sacrifices money to recuperate his health. And then he is so anxious about the future that he does not enjoy the present; the result being that he does not live in the present or the future; he lives as if he is never going to die, and then dies having never really lived.”

There’s a famous scene from the 1991 movie “City Slickers” where the Jack Palance character, Curly, seated comfortably on the back of a beautiful horse, looks over at Mitch, played by Billy Crystal, and says, “Do you know what the secret of life is?” Then he holds up his gloved index finger and says, “One thing. Just one thing.” To which Mitch responds, “What, your finger?” Curly, with a cigarette hanging from his lips continues to stare at him and repeats, “One thing, just one thing. You stick to that and everything else don’t mean @#$%.” Mitch then replies,”That’s great, but what’s the one thing?” And Curly replies, “That’s what you gotta figure out.”

I spent some time honing in on what that was for me, and about 10 years ago, I heard someone describe a happy friend as a person who was living a purpose driven life, and it hit me. That’s where I’ve found happiness.

True happiness for me seems only to come from living a purpose driven life, but that’s not always easy, and plenty of things can get in the way.

Behavioral scientists have long known that our neurons are set by the age of 2 or 3. In my case, a friend once observed, “You always try to deliver the impossible on a platinum platter, and people just get used to it. So, you kind of make your life your own personal hell by always trying to exceed everyone’s expectations.”

The bad news is that, now that I’ve figured it out, I still have trouble trying not to focus on always making people happy all the time. It’s not easy, but its also not impossible. I always have to remind myself that it is not my circus and they are not my monkeys. We all have to figure out our personal vulnerabilities.

I’ve wanted to have bumper stickers made saying, “We’re all messed up,” because we are all messed up in our own way, and it’s up to us to either try to figure it out or get someone to help us figure things out. Otherwise, we just drive ourselves and everyone else bonkers. If we can recognize our personal flaws, we might be able to stop doing some of the destructive things we do to ourselves while we’re on this journey.

But the point of this article wasn’t to concentrate on either my story or Mitch’s. It was to get you to try to figure out your stories, your “one thing.” It’s just a matter of deciding what that one thing is that makes you tick, or purr, or sing. Sometimes, it’s simply about honing in on the beauty of that one thing, and that, my friends, takes focus. It also takes thought, honesty, and discipline.

OK, so 3-year-old Pete was sitting in his little “reward for pooping on the potty” electric car, and he thought the battery was dead because all he heard when he pushed on the ignition switch was click, click. Anyway, according to my daughter, he sat back, shook his head and said, “Son of a *%^#. This is messed up.” When his folks corrected him, he looked down and said it again under his breath. Fortunately, I wasn’t there because, as indicated above, I just want him to love me, but when she told me, I thought, “You got that right, kid. This is messed up!” So, let’s fix it.

President Trump indicated at his press conference on the pharmaceutical industry that a “tangled web of special interests” has conspired to keep drug prices high at the expense of American consumers.

Today I received an email reflecting the latest information about pharmacy costs for emergency rooms in the United States. The information was collected by IBM Watson’s Health Redbook which contains product information on more than 200,000 prescription and non-prescription drugs plus 8 of the 10 most frequently used emergency department drugs.

As a former hospital CEO, one of my most challenging aspects of budget season was predicting drug costs for the following year. Well, as most of us in the business know and Watson confirmed, within the past ten years, emergency department drugs have seen price increases of 50 percent or more.

Because I am neither a physician nor a pharmacist, many of these drugs mean little or nothing to me in terms of use or frequency of use, but as you will see, some of the more recognizable ones that are the most often used have had significant increases. Here’s just a few of them.

Ketoralac: 153 percent price increase (oral)

Morphine: 77 percent increase (injectable)

Albuterol: 69 percent increase

Hydromorphone: 81 percent increase (injectable)

Acetaminophen/Oxycodone: 90 percent increase

Lidocaine: 59 percent increase

Besides these drugs, another significant change has occurred that impacts thousands of patients annually. Depending on the manufacturer and quantity ordered, intravenous sodium chloride has increased in price by a whopping 162 to 328 percent.

What’s happening?

The pharmaceutical industry is a for-profit participant in what can only be described as the medical-industrial complex, and when you query them, they indicate that they have increased costs in producing their drugs, hence their higher costs to us, but their recent profits have been excellent.

I am also not an expert in the healthcare supply chain, but when it comes to things like IVs of saline solution increasing exponentially in cost, my head says, “Follow the money.” And following the money usually leads to lobbyists and politicians.

We know that drug companies have made billions of dollars by literally pushing opioids on our population. We consume 80 percent or more of the world’s production of these addictive pain meds. We also know that some of the most prominent supply chain companies were complicit in the illegal distribution of these drugs and were given only a financial slap on the wrist by our government for their involvement.

The current system of getting a new drug to market costs about a billion dollars, and the citizens of the United States are covering much of those research and development costs by paying more for drugs than any other country in the world. Is it a coincidence that the United States allows direct-to- consumer advertising for pharmaceuticals?

Follow the money.

In a private meeting, a top scientist from one of the pharmaceutical companies said to me, “You don’t understand the drug industry in the United States. We’re like the movie industry. We only want the blockbusters, a pill you have to take from age 5 until death that never makes you better.”

The big hammer the United States possess that could control these prices is the purchasing power of the federal government, something President Trump promised to enforce during his campaign. The U.S. government buys more drugs than any other entity in the world, but the President’s pharmacy speech touched on about 50 alternatives to that idea. He never came close to offering to bring that federal clout to the table.

In the EU, drug manufacturers are not permitted to set their own prices.

As securities analyst Ronny Gal, from Sanford C. Bernstein & Company said, “The President’s speech was very, very positive to pharma.” And he added, “We have not seen anything about that speech which should concern investors” in the pharmaceutical industry.

Follow the money.

Nadine Burke Harris, MD, a San Francisco based physician, made a presentation that captured both my attention and my concern, and I’d like to share some of the information from that presentation. Let’s be clear, these are her words, not mine, but if you take a deep dive into her work, it may be a little like the kid who saw his reflection in the water because many of us grew up in an era when several of the “conditions” mentioned in this description were considered normal.

In the mid-1990’s, a discovery was made that exposure to one thing contributed to the cause of seven of the ten most likely causes of death in the United States.  This discovery was known to impact Brain Function, the Immune System, the Hormonal System, and even DNA function. People who were exposed to it had a 20-year difference in life-expectancy with triple the amount of heart disease and lung cancer.  Now, that was a blockbuster discovery, but physicians are still not trained in even the most routine screening for this diagnosis let alone for its treatment.

What was this amazing discovery?  It was Childhood Trauma. The short list of things that fall into this category are abuse, neglect, and dealing with a parent who struggles with Drug and Alcohol Abuse or Mental Illness.

The discovery came from a paper written by Dr. Vince Felitti of Kaiser and Dr. Bob Onda from the Center for Disease Control. It was titled “Adverse Childhood Experience Study,” and over 17,500 adults who were exposed to these adverse experiences were interviewed for this study.  It became known as the ACE study.  This study included people who had been exposed to emotional or sexual abuse, physical or emotional neglect, parental mental illness, substance abuse or dependence, incarceration, separation, or divorce, or domestic violence.  That’s a list that many people can absolutely relate to on many levels.

For every YES checked off on that list, the participants got one point on the ACE score, and then the physicians compared them to health outcomes.  Of those interviewed, 67% of the population had at least one on the ACE score, 12.6% had four or more ACES.

Here’s the discovery. There was a direct response relationship between ACE (Adverse Childhood Experiences) and health outcomes.  The higher the score, the greater the risk and the worse the health outcomes.  Depression was 4.5 times more likely to be present, 3.5 higher risk for lung cancer, and a  3.5 times more likelihood of getting heart disease, but the most dramatic prediction was the incidence of suicidality, this suicide or attempted suicide statistic was 12 times higher.

There are real neurologic reasons why folks who were exposed to childhood diversity were more likely to engage in high-risk behavior, but even if they weren’t engaged in that behavior, they were still more likely to get heart disease or cancer.  You see, when you’re exposed to stress, the body’s stress response system that governs your flight or fight response mechanism ignites, and if that stress is coming at you every day, it evolves from being adaptive and life-saving to maladaptive and health damaging.

The most likely reason this “discovery” hasn’t become more highly promoted within the medical community may be because of something that is not directly evident. The information generated from these 17,500 people may have been marginalized because, as Dr. Harris points out, people may have just thought, “It’s those kids from those neighborhoods.”  The reality, however, is that the participants in the study were 70% Caucasian and 70% college educated. Maybe the study hasn’t been more widely embraced because it truly is “too close to home.”

This is an issue that touches many of us, and it’s easy to look away.  The very real courage must come from our ability to acknowledge this is a real problem and then in taking the steps necessary to deal with it through a multi-disciplinary treatment team that works to reduce impact of adversity through care coordination, counseling, attention to nutrition, holistic interventions, and, when needed, medicine.