In an article yesterday in the Washington Post, Mayo Clinic was attacked for cutting off access to Medicaid and Medicare patients. In fact, these cutbacks were extremely limited. The story is the second in the Post by Alec MacGillis that reflects the position of an organization known as the AAMC. Mayo’s response:

Mayo Clinic feels that this story is a distraction from the true issue at hand—that of getting Congress to pay for value. As we have stated on this blog numerous times before, the only way to raise the bar for care while at the same time bending the cost curve, is to reward the best outcomes—Pay for Value, not volume.

Mayo continues to see Medicare patients from its region (MN, IL, WI, IA, SD and ND or 99% of Mayo’s Medicare patients). The change affected only a small number of patients coming from Montana and Nebraska. The change in Arizona involved a single primary care clinic, at which Mayo continues to see Medicare patients for specialty services. This has been conflated in the conservative blogosphere into the meme that ‘Mayo is no longer accepting any Medicare or Medicaid patients.’ This is an outrage.

Like an earlier article in the Washington Post by the same reporter, Alec MacGillis, titled “Is the Mayo Clinic a Model Or a Mirage? Jury Is Still Out”, it is an unabashed attempt to discredit Mayo as an appropriate ideal for reforming US health care. Behind the stories appears to be the AAMC, the Association of Academic Medical Centers, which represents the country’s teaching hospitals and lobbies for the continuation of special extra payments to these hospitals. The official of the AAMC quoted in the article is in fact “AAMC’s ‘voice’ on advocacy issues,” Dr. Atul Grover, head of its Advisory Panel on Health Care. Dr. Grover, recently of The Lewin Group (a subsidiary of for-profit United Health Care) took on the advocacy position in March. His assignment: to be, according to AAMC President Daryll Kirsch, MD, “the main architect and strategist of the AAMC’s advocacy agenda, effectively mobilizing the association’s government relations and communications teams and resources to accomplish the legislative goals of the academic medicine community.” The AAMC is best known in the industry as lobbying for the continuation special extra payments to these hospitals.
Mayo’s position has been that US health care would benefit from a health care system that is more like “Mayo-care for all.” For this it has endured a series of attacks by the AAMC and several specialty societies, including the ACC, the American College of Cardiology. It is no accident that the AAMC-influenced article appeared in the Washington Post appeared on the day of the vote in the Finance Committee on the Baucus bill.

The gist of the attacks has been to question Mayo’s quality, its low costs, how sick its patients are, and whether its practice is “transferrable.” I hope to settle these questions by providing the facts as they have been well established and that are surely well known by the AAMC and other organizations.

The data in the tables below shows that the attacks on Mayo’s patient mix, quality, costs and outcomes are unsubstantiated. For this data, I accessed the publicly available American Hospital Directory (ahd.com) which compiles data from HHS’s Center for Medicare and Medicaid Services, the Agency for Healthcare Quality and Research, and other public sources.

oThe Dartmouth Atlas (showing regional differences in surgery and costs
o The Commonwealth Fund State Scorecard (new)
o The Kaiser Family Foundation StateHealthFacts (newly updated)

Mayo’s Credentials as High Quality, Low Cost Provider

For the analysis below, there are two sets of medical centers provided for comparison. The first is the complete list of hospitals in the Top Ten of the annual US News and World Report rankings (in which Mayo has scored second place every year just after Johns Hopkins since the ranking was introduced in the early 1990s. All data is for Medicare.

# US News Top 11 Sev CMI adj Cost COL Adjusted
1 Johns Hopkins 1.82 $12,484 0.96 $11,985
2 Mayo/Saint Marys 1.97 $8,926 1.00 $8,926
3 Reagan UCLA 2.16 $11,625 1.03 $11,974
4 Cleveland Clinic 2.33 $6,987 0.97 $6,777
5 Mass General 1.85 $9,774 1.25 $12,218
6 Columbia Presb 1.89 $10,525 1.24 $13,051
7 UCSF 2.07 $14,803 1.13 $16,727
8 U Penn 2.27 $9,032 0.97 $8,761
9 Barnes-Jewish 1.86 $7,800 0.93 $7,254
10 Brigham & Women’s 2.02 $9,937 1.25 $12,421
10 Duke 2.00 $7,920 1.02 $8,078
US AVERAGE 0.89 ahd.com CNNMoney

The second list includes nearby health systems or similarly organized practices (in addition to Cleveland Clinic in the first list these include Intermountain Health and Geisinger Clinic). Gunderson/Lutheran is a somewhat smaller integrated group practice. HealthPartners (Regions Hospital) is a successful co-op.

Other Major Centers Sev CMI adj Cost COL Adjusted
Geisinger 1.87 $7,157 0.84 $6,012
Gunderson-Lutheran 1.70 $7,941 0.95 $7,544
Intermountain 2.03 $8,287 0.95 $7,873
Mayo/Saint Marys 1.97 $8,926 1.00 $8,926
Olmsted Medical Group 1.23 $8,620 1.00 $8,620
Regions Mpls/StP 1.63 $8,128 1.00 $8,128
U of Minnesota 1.85 $11,432 1.00 $11,432
U Wisconsin Madison 0.98 $10,529 0.93 $10,968
US AVERAGE ahd.com CNNMoney

In brief, Mayo sees a mix (severity) of patients commensurate with that of its peer hospitals. It does this while achieving lower costs and high quality (see ahd.com).
The Commonwealth data [pdf]shows that Minnesota in which the Mayo system is the primary provider has low instances of unnecessary deaths; Mayo’s region is typical of Minnesota as a whole (Dartmouth).

The Dartmouth studies have shown that in addition, Mayo does very well in terms of avoiding unnecessary procedures, manages end-of-life care well, and saves money as well. A specific study of patients with chronic conditions by the Dartmouth Institute for Health Policy and Clinical Practice and the Robert Wood Johnson Foundation, which accompanied its 2008 Atlas, reported:

Consider this comparison between the Mayo Clinic’s flagship St. Mary’s Hospital and
UCLA Medical Center.
• Spending: UCLA spent more than $93,000 per patient over the last two years of
life. The Mayo Clinic, by contrast, spent $53,432—a little more than half the
amount of UCLA on similar patients over the same period of time.
• Utilization: Chronically ill patients in their last six months of life had more than
twice as many physician visits at UCLA compared with Mayo, and they spent
almost 50 percent more days in the hospital.
• Resource Use: Compared to the Mayo Clinic, UCLA uses one-and-a-half times
the number of beds, almost twice as many physician FTEs in managing similar
patients.

This study concludes “If the U.S. health care system mirrored the practice patterns of gold-standard health care systems such as the Mayo Clinic in Minnesota, Medicare could save tens of billions of dollars annually. Those savings would come just when Medicare needs that money most, as baby boomers prepare to retire in droves, putting unprecedented pressure on the health-care system.”

IN THESE STATISTICS it should be noted that in addition to Mayo, the other centers which also achieve these goals are also centers which practice in the tradition of the “integrated group practice.” These include the Cleveland Clinic (which is the most similar to Mayo but sees a high percentage of Medicaid patients), Geisinger Clinic (Pennsylvania), and Intermountain Health (Utah).

This analysis should settle the question as to whether Mayo provides excellent care to a challenging set of patients, does this at lower cost, and achieves excellent results in terms of measures of quality and patient satisfaction, avoiding both unnecessary surgeries and unnecessary deaths, by well established criteria.

If others have data that contradicts this, it would be better for us all if they would produce it rather than mislead the country at this critical time with blatantly false and intentionally misleading information and insinuations.

The case that I recall best was in 1984 in a federal district court in New York, in which Judge Mary Lowe ordered the Board of Elections of the City of New York to begin registering all potential voters regardless of whether they have homes or not. It actually referred to a park bench in that case too.

Here is a letter to the editor which I found in the database of the New York Times that confirms the 1984 case and explains a bit more about it.

New York Times letter to the editor Dec. 4, 1990:

“To the Editor:

I would like to correct two minor errors in your Nov. 17 article about the constitutional rights of a formerly homeless Connecticut convict. You state that last year “a Federal judge in New York ruled that for the purposes of voter registration, a park bench was a home.”

Judge Mary Lowe ordered the New York City Board of Elections to enroll homeless voters in October 1984. Homeless New Yorkers thus have been registering and voting, in increasing numbers, for six full election cycles. (A resident of the Fort Washington men’s shelter, Tyler Trice, even qualified as an independent candidate for State Assembly on the primary election ballot this fall.)

Further, rather than calling a park bench a home, Judge Lowe ruled that a home, as traditionally conceived, could not be made a prerequisite of the right to vote, which she called a “fundamental right, which is preservative of all other rights in a democracy.” To paraphrase, she said, “You don’t need a home to vote,” which became our motto. WILL DANIEL Director, Homeless Voter ‘90 New York, Nov. 17, 1990.”

I like that part about the right to vote being a fundamental right, which is preservative of all other rights in a democracy.

And there have been many other cases. I clipped this from another site:

This one: http://www.mydd.com/story/2008/10/29/23272/260

Quotes:

A requirement that people live in a traditional dwelling in order to vote placed an unconstitutional constraint on the voting rights of homeless persons. Coalition for the Homeless v. Jensen, 187 A.D.2d 582 (N.Y. App. Div. 1992).

States should use a broad interpretation of the term “residence” to include any place, including a non-traditional dwelling, that an individual inhabits with the intent to remain for an indefinite period. Pitts v. Black, 608 F.Supp. 696 (S.D.N.Y. 1984); In re-Application for Voter Registration of Willie R. Jenkins, D.C. Bd. of Elections and Ethics (June 7, 1984).

When registering to vote, homeless people may designate a shelter, park, or street corner as their residence. Fischer v. Stout, 741 P.2d 217 (Alaska 1987).

Remember, each case is unique. This information is intended to describe principles from key cases in specific jurisdictions, not to act as legal advice. If you or your clients need help with a specific problem, contact a local lawyer. NLCHP has expertise in these issues and may be able to help you or your lawyer with additional information.

Bd. of Election Comm’rs v. Chicago/Gray Area Union of the Homeless, Circ. Ct. of Cook County, Illinois, County Dept., County Div., Miscl. No. 86-24 (1986).
Addressing a challenge to Chicago’s residency requirements for voter registration, the Circuit Court of Cook County held that a person lacking a permanent abode may register by stating under oath that she lacks a permanent abode and by presenting two pieces of identification. The person who is experiencing homelessness must also provide a description of the location where he or she resides that is specific enough that election officials can assign him or her to a voter precinct. Prior to an election, mail will be sent to the mailing address listed on the registration card and will include a postage prepaid return postcard which must be mailed back to the Board of Elections.

Coalition for the Homeless v. Jensen, 187 A.D.2d 582 (N.Y. App. Div. 1992).
Several homeless plaintiffs challenged New York election officials’ application of a provision of the New York Election Law. The provision at issue allows election officials to subject “groups likely to include transients” (such as students or people living at a “welfare institution”) to a more searching inquiry than usual order to determine whether they are eligible to register to vote. Based on the provision, the election officials rejected the applications of 240 Camp La Guardia residents and required that they give testimony in court to prove their residence. One hundred and seven of the applicants appeared in court and were accepted as voters, but the trial court rejected the applications of those who did not appear in court.

The Supreme Court, Appellate Division, overturning the trial court’s decision, held that due to time constraints placed on people who were experiencing homelessness, election officials violated the individuals’ constitutional right to vote by failing to take reasonable, good-faith steps to determine the true residency of the individuals who were homeless. All 240 votes were subsequently counted.

Collier v. Menzel, 221 CalRptr. 110 (Ct. App. 1985).
Three plaintiffs experiencing homelessness challenged the Santa Barbara county clerk’s rejection of their registration applications, in which they had listed a public park as their residence. The court found that the residence was sufficient for registration purposes because the applicants had a fixed habitation in the park and intended to remain there. The court held that denying voter registration because applicants listed a city park as their residence violated the Equal Protection Clause of the Fourteenth Amendment. The opinion further stated that people who were experiencing homelessness should be encouraged to register and vote in order to provide them with some greatly needed political influence and electoral power. Election officials must now use the specific spot within the park where the persons regularly sleep in order to determine their election district.

Committee for Dignity and Fairness for the Homeless v. Tartaglione, No. 84-3447 (E.D.Pa. Sept. 14, 1984).
Ruling on a challenge to Philadelphia’s residency requirements, the District Court for the Eastern District of Pennsylvania held that a homeless voter may satisfy the residency requirements set forth in the Pennsylvania Election Code by “declaring on the Voter Registration Application the address of a shelter with which the applicant has an established relationship, and which will accept first-class non-forwardable mail for the applicant.” The person must then vote in the district where the shelter is located, even if the person resides in a different precinct. This ruling provided the basis for Philadelphia’s current policy regarding registration and voting by homeless peoples.

Fischer v. Stout, 741 P.2d 217 (Alaska 1987).
A candidate who lost an election appealed for a recount, alleging that election officials had illegally rejected ballots of voters who claimed to reside at a military base. The Supreme Court of Alaska held that persons could list a military base generally as their residence, stating that a residence is a fixed place of habitation to which the individual intends to return, and it need not be a house or an apartment, or have mail service. It need only be a specific locale within the district. The court acknowledged that a homeless shelter or even a park bench would be sufficient.

Hartman v. Kenyon, 277 Cal.Rptr. 765 (Ct. App. 6 Dist. 1991).
Based on the Walters v. Weed court decision (see below), a citizen contended that individuals who had moved from a precinct could legally vote at their former precinct. The California Supreme Court distinguished Walters, holding that a voter is only entitled to vote at the precinct of his or her former residence if he or she has not moved to a new residence with intent to stay. In other words, if a voter has moved but has not acquired a new place of residence, he or she is considered to be residing at his former residence until acquiring a new place of residence. Otherwise, he or she must vote in the precinct of his or her new domicile.

In re-Application for Voter Registration of Willie R. Jenkins, D.C. Bd. of Elections and Ethics (June 7, 1984).
In an administrative hearing, the D.C. Board of Elections ruled that an intent to reside in a place can constitute a place of residence for voting purposes. This ruling established the homeless voting policy for Washington, D.C., which allows a voter to name the location where he/she sleeps as a residence even if the place is a nontraditional home. The voter must also provide a mailing address of a place to which the person has sufficient ties. The person will vote in the district of his/her place of residence.

Pitts v. Black, 608 F.Supp. 696 (S.D.N.Y. 1984).
Plaintiffs challenged a New York State Election Law provision forbidding people living on the streets from registering to vote. The District Court held that the New York City Board of Election’s application of the residency requirement disenfranchised an entire group of people, which is forbidden by the Equal Protection Clause. The court found that a person’s “residence” is the place at the center of the individual’s life and the place where he/she presently intends to remain. The court reasoned that people need only have a specific location that they consider their “home base” — the place where one returns regularly, manifests an intent to remain, and can receive messages and be contacted.

Walters v. Weed, 752 P.2d 443 (Cal. 1988).
Individuals whose votes were uncounted in a city council election challenged the rejection of their ballots. These individuals had abandoned their domiciles within the precinct and were thus not considered residents of the precinct, rendering their votes invalid. However, many of the plaintiffs had not yet met the requirements to establish new domiciles, as they did not live at new locations where they intended to stay. The California Supreme Court ruled in favor of those voters who had not yet established new domiciles, holding that when a person leaves his or her domicile with no intention of returning to live there, and when that person currently resides in a place in which he or she does not intend to remain, that person may vote in the precinct of his or her former domicile until a new domicile has been acquired.

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