October 3, 2002
New Century Poses Challenge
High costs and staff shortages could impact Cedar's-Sinai's next 100 years.
One hundred years ago, when Cedars-Sinai Medical Center's predecessor, Kaspare Cohn Hospital, opened its doors with 12 beds as Los Angeles' first Jewish hospital, such medical staples as penicillin and insulin remained to be discovered. Life expectancy was 51 years, and the average annual income was $467.
Today, Cedars-Sinai Medical Center exists in a world of dizzying medical developments, where scientists manipulate genes, and doctors are testing a diagnostic camera in a capsule so small that patients can swallow it. Life expectancy has increased by more than 25 years, and in 2000, the country spent $1.3 trillion on health-care costs.
In such an increasingly complex health-care environment, Cedars-Sinai's ability to celebrate a second century will depend on how the medical center, which is also a research and educational institution, navigates a modern set of challenges. The 905-bed facility, like other U.S. hospitals, is facing skyrocketing costs coupled with shrinking insurance reimbursements, staffing shortages and an aging population that will place a severe strain on resources in the future.
"[There are a] myriad of challenges being thrown at the institution ... [which put] a tremendous amount of pressure on all [health-care] organizations," said Thomas M. Priselac, president and chief executive officer of Cedars-Sinai Health System. "We believe that if we [fulfill the strategic objectives supporting] our mission and our vision -- what it is we stand for and what we want to achieve ... we will be able to keep the institution at the leading edge."
Perhaps the most formidable challenge facing Cedars-Sinai is rising health-care costs. New procedures and emerging technologies, while advancing medical care, outpace the payments hospitals receive from insurers and government health plans. Many of these plans pay health-care providers a fixed fee rather than one based on the nature of services rendered. According to the California Healthcare Association, the state has had more than $60 billion in Medicare payment cuts over the last four years. About 45 percent of Cedars-Sinai patients are on Medicare, and another 14 percent are on Medi-Cal.
Compounding the problem of limited payments is the prospect of no payments at all. More than 2 million Los Angeles County residents are uninsured, and Cedars-Sinai will now be caring for an even greater percentage of them.
The Los Angeles County Health Department may deal with a projected $700-800 million deficit over the next three years by converting Harbor-UCLA Medical Center in Torrance and Olive View-UCLA Medical Center in Sylmar into outpatient clinics.
Both currently operate emergency rooms, and like Cedars-Sinai, Harbor-UCLA is one of the county's 13 trauma centers. Eleven community health clinics and four school-based clinics have already been closed as part of county cutbacks. The closures will funnel more uninsured patients to Cedars-Sinai's emergency room and ambulatory care clinic.
Last fiscal year, Cedars-Sinai spent approximately $70 million on uncompensated and under-compensated care and community health programs, Priselac said. "Clearly [these factors present] a financial challenge to the institution.
"However, because we are a not-for-profit community hospital ... we welcome [this challenge], because of our roots and founding, and because of our obligation to the community and our desire to be a community-oriented organization," he said.
Barbara Factor Bentley, board of directors chair, added, "It goes back to our Jewish traditions. When people look up and see the Star of David on the medical center, they know it means quality care for all people."
Providing care requires continually updating and adding to facilities and equipment. Under Cedars-Sinai's Master Facilities Plan, nearly every building on the medical campus is scheduled to undergo renovations and improvements, either to replace facilities lost in the 1994 earthquake or to house expanded programs and services.
Last year saw the opening of a 45-bed neonatal intensive-care unit -- close to 7,000 babies are delivered at the medical center annually -- and a new unit within the department of psychiatry and mental health. This month marks the opening of the S. Mark Taper Foundation Imaging Center, and the commencement of construction on the new North Care Tower to house predominantly intensive-care services.
Philanthropy helps make such growth possible. The medical center's major fund-raising initiative, the Campaign for the 21st Century, has so far raised $322 million of its $500 million goal. Cedars-Sinai also benefits from the efforts of 40 different fund-raising groups. In addition, it receives another $80 million in grants.
However, even with sufficient funding, Cedars-Sinai, as well as other hospitals nationwide, faces the specter of staffing shortages. According to the Joint Commission on Accreditation of Healthcare Organizations, more than 126,000 U.S. nursing positions are currently unfilled, and "that number [is] expected to skyrocket as aging baby boomers begin placing unprecedented demands on America's health-care system." One of the reasons for the national nursing shortage is that nurses are aging. In 2000, 60 percent of registered nurses were over 40.
Dr. Michael Langberg, Cedars-Sinai's chief medical officer, said the medical center isn't feeling the nursing crunch right now. To keep it that way, the medical center has just established the Cedars-Sinai Institute for Professional Nursing Development.
Through a partnership with California State University Los Angeles, the institute will eventually graduate 150 new bachelor's degree nurses annually to help increase the number entering the profession. The hospital will try to persuade institute graduates to stay at Cedars-Sinai by picking up their internship tab if they remain for a specified period of time.
While the nursing shortage has received the most news coverage, shortages of other professionals exist, too. There is a need for hospital personnel such as radiology technicians, computer systems specialists and laboratory personnel, among others.
"We're working hard to create a work environment . . . that makes Cedars-Sinai an attractive place to come to work," Priselac said. He added that the medical center works with other institutions to provide professional training programs and lobbies at the state and federal levels to increase funding for educational institutions.
As baby boomers edge toward retirement age, they will increasingly utilize health resources. The number of elderly in California will almost double in the next 25 years, according to the National Economic Council.
To gear up for anticipated increases in the demand for services, Cedars-Sinai is boosting resources in fields heavily utilized by geriatric patients, such as cardiology, neurology, oncology, orthopedics and pulmonary medicine. Priselac said that as options for outpatient treatment increase, patients who do require hospitalization will be sicker and require a more intense level of care.
This month construction is beginning on the North Care Tower, which will add 120 intensive-care beds. Educational programs on health and wellness, and early intervention tools, such as the Cedars-Sinai Heart Watch, have been adopted to attract the health-conscious baby boomer generation. The American Association of Retired Persons ranked Cedars-Sinai as the No. 2 metropolitan hospital in the nation.
Baby boomers are only one segment of the diverse population served by the medical center. To reach vulnerable groups with little access to care, 120 programs target the elderly, ethnic minority populations, pregnant women, children and the poor.
As technology advances, the potential for ethical dilemmas also increases, for example, end-of-life issues. As part of the hospital's bioethics program, physicians and other professionals regularly meet to discuss challenges they face as health-care providers. A committee is also available to doctors and families when they need help sorting through options in a specific case.
Rather than coming up with the answers, Priselac said, "we put in place the resources and a process to let the individual, the family members and their physician come to the right decision as a group."
Last year, the medical center cared for more than 44,000 in-patients and more than 137,000 out-patients. Assuring quality control and patient safety is challenging for a system where close to 10,000 people -- from doctors to orderlies to volunteers -- provide care in some form.
Cedars-Sinai "is universally committed to patient safety and patient care quality," Langberg said. Priselac chairs the medical center's Quality Council, and the hospital maintains numerous committees to address aspects of this issue.
While state law will soon mandate such solutions, the medical center is already in the process of instituting a $20 million computerized patient information system that includes entry of physician orders. By having doctors enter orders electronically, rather than by writing them, the system streamlines the process and allows prescriptions to be immediately and automatically checked for potential problems, such as drug interactions or allergies. Langberg said the system reduces medication errors by about 60 percent.
The patient information system is just one example of how Cedars-Sinai has embraced information technology. The medical center was named one of the 100 "most wired" hospitals and health systems in Hospitals and Health Networks magazine. The new S. Mark Taper Foundation Imaging Center features all-digital instruments, enabling rapid transmission of test results to physicians.
To view a patient's X-ray or lab results, doctors no longer have to wait for film to be delivered to their offices. They don't even need to be on site. A special computer program enables physicians to have instant access to patient and other medical data with a few key strokes on their Palm Pilot or computer.
The doctors who founded Cedars-Sinai would be amazed to see how their 12-bed hospital has grown and astounded by today's world of medicine that utilizes such tools as computers, magnetic resonance imaging and artificial livers. While it's hard to imagine what the next century might bring, Priselac promised, "What will be here ... is Cedars-Sinai's continued commitment to the community."