Don’t Blame Northam for Virginia Medicine’s Structural Flaws

Governor Northam when announcing stay-at-home order this morning.

by James C. Sherlock

I have to give Governor Ralph Northam a partial pass on a key issue. Much of the criticism directed at him is for actions or inactions that are based on incomplete data and, as a a consequence, incompletely informed staff assessments concerning the business of healthcare in this state. That is a structural problem in state government, not a leadership problem.

The Department of Health is not designed as a crisis action agency and has no authority to oversee Virginia’s healthcare system as an industry. It administers Certificate of Public Need regulations and oversees the practice of medicine, not the business of medicine. No agency regulates that business except in the narrowly focused and demonstrably failed COPN system. There is no such regulation because Virginia’s integrated health systems don’t want their businesses to be regulated, and not any other reason.

Virginia’s Board of Health is not designed or populated to function in a crisis and it hasn’t in this one (See this post from Feb. 22). The public health issues addressed by the Virginia State Board of Health include the prevention and control of chronic disease, not pandemics.

Likewise, the Board of Medicine is not structured to help with pandemics. The Board of Medicine prescribes regulations necessary to ensure continued practitioner competence, not crisis readiness.

The State Commerce Commission regulates health insurance, not the business of healthcare delivery. The commission possesses only information it needs to carry out that function.

So, the COVID-19 crisis started with the state government having little information about such things as inventories of emergency equipment and supplies — inventories for which it had never defined specific requirements. The state may still have no such information.

Thus, in making state emergency orders affecting both health insurance and healthcare delivery, Northam may not have possessed the information he needed to do so with confidence.

When the crisis wanes, Virginia must create a state health commission with active oversight, regulatory and coordination roles in the business of healthcare and the business of health insurance on the model of the Maryland Health Care Commission (MHCC).

The Maryland Health Care Commission was created in 1999 to streamline health care regulation and provide coordinated information to the Governor, the Health Commissioner and the public. The commission is organized around the health systems it evaluates, regulates, or influences. It uses data gathering, public reporting, planning and regulation in a coordinated attempt to improve quality, address costs, and increase access.

The Maryland Health Care Commission is an independent regulatory agency whose mission is to plan for health system needs, promote informed decision-making, increase accountability, and improve access in a rapidly changing health care environment by providing timely and accurate information on availability, cost, and quality of services to policy makers, purchasers, providers and the public.[1]

The qualifications of the Commissioners and the numbers of executive staff of the MHCC far exceed those of any such panel in the government of Virginia.

The Commission in FY 2017 had an appropriation for 57.9 full time staff positions[2]. It has four centers:

  1. Center for Health Care Facilities Planning and Development, similar to the COPN Division of the Virginia Department of Health.
  2. Center for Health Information and Innovative Care Delivery. The Center gathers clinical information as well as business information, serves as a policy center for health information technology, and manages the Commission’s Advanced Primary Care programs.
  3. Center for Analysis and Information Services. This Center’s main function is to rapidly create, securely maintain and analyze large healthcare databases and to interpret population surveys. The Center produces reports to guide health policy, including reports on health expenditures, health insurance, the uninsured and uncompensated care.
  4. The Center for Quality Measurement and Reporting. This Center provides meaningful information to consumers about the quality and outcomes of care provided by Maryland hospitals, long-term care facilities and health benefit plans.

In FY 2017, the Commission was appropriated nearly $35 million, which included $15 million for MHCC operations and $4 million for the state health information exchange. Also included was a special fund appropriation of $12 million for a Trauma fund, which MHCC administers, and $3.2 million for the Maryland Emergency Medical Systems Operations Fund. The Maryland Health Care Commission’s budget is funded by a user fee assessment on hospitals, nursing homes, payers and through the licensing process of the Health Occupational Boards. The assessment is designed to maintain a surplus of 10% of the budget.

Going into a crisis with Virginia’s current system does not match hopes with reasonable expectations. Virginia needs to emulate the Maryland example, both in day-to-day coordinated oversight and regulation of the business of healthcare, especially the state-granted regional monopolies, and in crisis response.  We can’t put the Governor and the citizens of Virginia in this situation again.


[1] https://mhcc.maryland.gov

[2] The Maryland Health Care Commission, Report to the Governor, FY 2017 (through June 30, 2017).  The annual report meets the requirements in state law that the Commission report annually to the Governor, the Secretary of Health and the Maryland General Assembly

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20 responses to “Don’t Blame Northam for Virginia Medicine’s Structural Flaws

  1. Jim, you make an important point here. We cannot blame Northam for the failures and limitations of Virginia’s governance structure.

    We can, however, blame him for telling Virginians a month or so ago not to worry because the state has “a plan.” Virginia does have a department of emergency medical services, which may not do all the stuff that Maryland’s health commission does but was responsible for developing some kind of emergency response.

    • Maybe his plan depended upon the White House… “It will go away. When the spring comes it will be like a miracle. It will just go away.”

    • There is no department of emergency medical services. There is a Department of Emergency Management, which historically has had responsibility for coordinating response to hurricanes, floods, earthquakes, and tornadoes. Its emergency operations center has been activated, but is playing less of a role during this crisis than during others.

      The Department of Health does have an Office of Emergency Medical Services, but the mission/function of that office is to regulate and support local rescue squads.

  2. I like the plan to possibly release people convicted of lesser crimes from jails, yet threaten me with jail if I leave my house without an “essential” purpose. Do I then have to serve my “up to one year”?
    It’ll also get really interesting if police start enforcing this in neighborhoods where a disproportionate impact may occur. We’ve been told any disproportionate impact is unacceptable.

  3. Oh no, no, no …

    Ralph Northam was not spontaneously generated as Governor of Virginia. He was a state senator from 2008 – 2014 and Lieutenant Governor from 2014 – 2018. He was also an MD that entire time as well. Northam had 12 years as a senior member of Virginia’s state government to address structural issues with regard to medicine in the state. I’d have to go back and look but I’m guessing as an MD he was on the key sub-committees and committees for medical policy in Virginia.

    Northam is just another member of Virginia’s plantation elite. He was a good boy as a state senator taking money from special interests and making sure those special interests were rewarded – just like the rest of the state legislature. He didn’t rock the boat and ran for Lt Governor when outsider Terry McAuliffe needed an obvious member of the plantation elite as part of the Democratic slate. Northam did as he was told while Lt Governor and when the Democratic Party “powers that be” decided it was his turn … voila …. in an off year election in a state with no campaign contribution limits – he came down from Richmond and became governor.

    We’re #40 among states in COVID-19 testing. That’s on him. He’s too much of a plantation elite lifer to admit we have a testing problem. That’s on him. Last week his adorable friend Dr Peake (sp?) said there was no way to know when the epidemic would peak in Virginia. Today Northam issues a “stay home” order until June 10. I give up – with a failed testing effort and no idea when the peak will occur – how did he come up with June 10?

    Northam is up to his blackface in this mess.

  4. Interesting discussions here. Most folks here, including some conservatives, appear to be now supporting the idea that government should be stepping forward and executing plans to coordinate, direct, and even possibly regulate healthcare corporations that have historically had their way in controlling private for-profit healthcare. While some conservatives here have tip-toed around blaming the federal government for the horrific lack of recognizing the pandemic, fulfilling its role in national coordination of a response, and responding quickly to juice up supplies and testing, they have enjoyed painting Northam as the fall guy for any shortcomings in Virginia’s response. Now, Mr. Sherlock has noted a key point, that “Going into a crisis with Virginia’s current system does not match hopes with reasonable expectations. Virginia needs to emulate the Maryland example, both in day-to-day coordinated oversight and regulation of the business of healthcare, especially the state-granted regional monopolies, and in crisis response.” I support Mr. Sherlock’s premise. But certainly this premise would likely support more government control and execution of an emergency plan requiring the citizens to accept and follow such a plan. Is everyone willing to follow such a plan that you are so clearly saying that we should have? On one hand I hear many blaming Northam for not having quickly come up with a plan and not issuing orders soon enough. On the other hand, I hear some complaining that they may choose not to comply with the Governor’s orders even when they are based on expert medical science. What is it? Do you want more government when there’s a pandemic or a wide-spread emergency? Do you want less government so you can just do what you want to do? Or do some here prefer just to call Gov. Northam various names? And a thank you for James posting the pyramid standard for our communications here on the blog.

    • Testing adequacy varies state by state. Every state had to deal with the hand dealt by the Federal government. Northam has played that hand poorly while 39 other states have played it better. We have the 18th highest COVID-19 deaths per capita and the 40th Coronavirus testing per capita. That is unacceptable to me and should be to you as well. As for Northam’s response – who could know given the inadequate testing? However, Northam may have found a means to make up for Virginia’s poor execution. This morning Republican Governor Larry Hogan or Maryland issues a stay home order. This afternoon Democratic Governor Ralph Northam did the same. Maybe Northam will continue to follow Hogan’s lead effectively outsourcing leadership in the COVID-19 response to Maryland.

      • looks to me that even the states that have more testing, STILL have to issue “stay in home” directives. More/better testing would have to be more on the level of South Korea and Germany to make a difference. Even the states that tested more have little to show for their efforts if they have to have the same lockdown.

        • The grapes were probably sour. Testing is irrelevant. Without adequate testing how in the world did Northam pick June 10 as the date Virginia’s lockdown will end?

  5. I thought I heard the phrase Unified Command used in one or more of the Press Releases but I cannot find any discussion of it.

    I think Jim’s post is balanced and fair and there are indeed shortfalls in Virginia that need to be addressed but I’m pretty sure that if Northam had proactively proposed a top-down command and control Govt structure when he took office, pretty sure Conservatives would not have been supportive.

    and geeze – Northam is accused, at the same time of being “too slow to act” and “Draconian”… no win

    People are angry and upset over this and inclined to blame especially the folks who are not fans of “big” govt to start with, in – the irony being that
    they opposed big govt until now and now those same folks – complaining because it’s not doing big govt things as much as they want it to!

  6. My biggest problem with Northam is that he failed to get an adequate testing program running in Virginia at a time when everybody was saying that testing, testing, testing was the key. My next biggest problem with Northam was his silent cover up of the testing inadequacies throughout his Coronavirus press releases. So, he’s both failing to execute a major aspect of the COVID-19 program (which is being better executed by 39 other states) and he’s not transparent / honest about his administration’s shortcomings in that key aspect of response.

    And we should trust him from here on because …… ?

    • I agree testing is key but who does the testing? I got the impression
      it was supposed to be the Feds and Cuomo just took over when the
      Feds did not … but I do not know what resources Northam had at
      his disposal to do that…

      How did the other states get their own testing capabilities?

      Have you seen where Northam is asking Trump to set up testing in NoVa?

      why is he doing that?

    • Exactly, DJR — and I would add a third problem: Northam is lacking not only in transparency but in leadership. Cuomo is all over the TV and every other media outlet and he explains, he cajols, he threatens — and he vents on behalf of his State over the incompetence and opacity in the White House. He is visible to the public and reassures that somebody, your Governor, knows how bad it is out there and is doing his damnedest about it; in other words he sounds like he cares! Where is Northam? Particularly given the absence of transparency and communication skills in the WH, who in Richmond is even acknowledging the numbers NoVa is already dealing with, let alone reassuring that specific supplies and more hospital beds and scarce medical equipment and staff resources are on the way?

  7. http://jlarc.virginia.gov/pdfs/reports/Rpt244.pdf

    That’s the 20 year old JLARC study of the Health Dept. Nothing comparable since. I’ll let others digest the 141 pages tonight, while I ignore for a while…Did notice the first recommendation on the exec summary involved better prep for communicable diseases…..

    As to the political gamesmanship and preening, be ashamed, people. None of us here are really knee deep in this. This is The Peanut Gallery, nothing more.

    • re: ” This is The Peanut Gallery, nothing more.”

      Cheap seats chattering class…. but let me point out that we have
      always had an “in house” group of govt critics here in BR and they
      are just doing their thing as usual!

      • My advice now is let the people with the real jobs do them, offer useful info and maybe some insight. Plenty of fodder for reporting and debate. The carping, second guessing and snark are out of place. Trump, Northam, Cuomo, the others, you wanna be them now? This is deadly serious, not a stupid campaign.

        Plenty of great posts have appeared.

  8. re: ” The carping, second guessing and snark are out of place. ”

    yep

  9. Structural deficiencies are nearly always exposed and sometimes dispositive in a crisis. It’s like trying to teach an elephant to play Beethoven because the situation and the audience demands Beethoven. I have a lot of problems with Dr. Northam’s leadership style, but he has a health care business regulatory structure designed not to regulate, and it is not a revelation that it cannot play chopsticks much less the great masters.
    Changing subjects, again I point to the panic among his political advisors reacting to the Washington Post piece last week that called him weak. In the face of that, I am surprised that he did not order a lockdown until Christmas.

  10. Northam IS weak. Even if he has no structural support in VDH, he has the opportunity to be the Cheerleader in Chief, Mr Transparency, Mr. Not The White House. Instead – [crickets]. What he has done seems merely to announce measures that imitate Hogan of MD, but about a week or two later after he sees the favorable public reaction across the Potomac River. That’s a fail, in my book.

  11. I think it is true that Northam is not Cuomo. Heckfire, Trump is not Cuomo!

    Northam is no cheerleader, correct. It’s not who he is – even when he ran for Gov, he was not exactly a barn-burner type orator…. he just is not that kind of person.

    He’s also not a Hogan, but he may well be closer to the DC Mayor or NC Gov or West Va Gov in terms of public presence.

    Virginian’s performance is in this pandemic is also mediocre but also not that far different than most states. Virginia is not New York – that’s clear also.

    He also said this on Friday:

    ” Gov. Ralph Northam said Friday the state is competing with Virginia’s own healthcare systems, other states and other countries to buy personal protective equipment and coronavirus testing supplies, but that responsibility should fall on the federal government.

    “We are all out there bidding literally against each other,” Northam said at a news conference in Richmond.

    He said he asked President Donald Trump on a call with other governors Thursday to create a regional federal testing site that would service Virginia, Maryland and Washington, D.C., where more than 360,000 federal workers live.

    “Our country needs a national solution,” Northam said.”

    so his biggest fault is that he is not a very good cheerleader – agreed.

    But the rest of this criticism is not warranted in my view. We have enough problems already without people chewing on each other just because we’re angry and not happy. Suck it up and accept that not every Gov is Cuomo and move on. Geeze.

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