A Faulkner County jury returned a unanimous verdict last night that the Greenbrier Nursing and Rehabilitation Center had been negligent in treatment of Martha Bull, 76, who died at the nursing home April 7, 2008 after staff failed to act on a doctor's orders to get her transferred to a hospital emergency room for treatment of severe abdominal pain.

It set damages for pain, suffering and mental anguish at $5.2 million, according to Bull's attorney, Thomas Buchanan of Little Rock. He said representatives of the nursing home had told him a Faulkner jury would never award more than $500,000 in the case. Circuit Judge Mike Maggio presided.

Buchanan expects an appeal. And even an unsuccessful appeal will likely be only the beginning of a long road toward collection, if any. The nursing home is controlled by Central Arkansas Nursing Centers, a private company headed by Michael Morton of Fort Smith. Buchanan said the individual nursing homes are organized as freestanding limited liability corporations, with licenses separate from physical property and small liability insurance policies through a self-insurance-style program based in Bermuda. It is not unusual in Arkansas for nursing homes to be set up this way and to contend they've spent all their liability coverage in legal defense — $100,000 in this case. Buchanan, who said he faced six defense lawyers, said he'd attempt to "pierce the corporate veil" to show a relationship between the nursing home and other parts of the company with assets to collect the judgment.

Lyn Pruitt, who led the defense team, said she couldn't comment on the outcome because of a judge's directive on a pending post-trial issue.

Buchanan said the jury found the nursing home guilty of negligence, medical malpractice and violation of resident's rights, but it did not specifically find that the nursing home caused Bull's death. New legislation from the 2013 legislation, sponsored by Sen. Jonathan Dismang, will make it impossible to sue a nursing home except for medical reasons, not for multiple causes of action. In this case, Buchanan said, the jury awarded damages only under one area for pain, suffering and mental anguish, it wasn't multiplied by the multiple types of culpability.

The case was brought by Bull's two daughters, Rose Perkins and Rhonda Coppak, on behalf of her estate and the beneficiaries.

Buchanan's account of the facts: Bull was admitted to the nursing home March 28, 2008 for 30 days of rehabilitation after a stroke. During the night of April 6, 2008 she said she was in severe pain, sweating and unable to have a bowel movement. Nothing was done. The next shift, she continued to complain. A physician was called at 2:20 p.m. April 7. He sent an order to have her transferred to an emergency room for evaulation in light of a history of stroke and abdominal abscess. The director of nursing received the fax at 3:34 p.m., but was leaving for the day. The nursing director sent it by fax to a new fax in a closet of the nursing home wing in which Bull lived. No one saw it. Bull wasn't sent to the emergency room. She screamed throughout the afternoon, so loudly that residents on other halls complained. She was found dead at 10:20 p.m. April 7. The faxed physician's order was found the next day.

No autopsy was performed. Buchanan said that the nursing home, after fighting the case without relent since it was filed four years ago, admitted in the early stage of the trial, which began May 7, that a mistake was made. But it presented testimony that it wasn't clear what caused Bull's death.

Buchanan said that the nursing home admission of a mistake came only after the trial began. If sincere, it should have done so long ago, expressed regret and demonstrated sincerity by trying to make things right, he said.

Meanwhile, in the legislature and perhaps at the ballot in 2014, the business community will continues to endeavor to make it harder than it already is to collect for pain and suffering of elderly people who are victims of nursing home negligence.

Sarah Kliff at the Washington Post's Wonkblog disputes those who think serial votes by the U.S. House against Obamacare are meaningless political theater. The votes confuse many in the public about something so basic as whether the law actually took effect. The persistence of the resistance contributes to a movement that has produced other meaningful alterations in the law. It discourages adoption of Medicaid expansion in the states.

Speaking of Medicaid expansion: Isn't that map that ran with Kliff's article something? Arkansas is an oasis of sanity in the Confederate States of Republicanism. And it couldn't have happened without significant Republican influence.

As a half-empty-glass kind of guy I'll still believe in full implementation of Obamacare when I see it. I'd still place a small bet on ultimate fiscal failure from congressional strangulation and, in turn, the resulting end of the "private option" in Arkansas. We'd then have a tiny shadow of a remnant Medicaid program to show for this year's sturm and drang. I hope I'm wrong.

• St. Bernards: A bargain

How is it possible that a major and small bowel procedure at National Park Medical Center in Hot Springs costs on average $333,470, according to the Centers for Medicare and Medicaid Services, but only $19,740 at St. Bernards Medical Center in Jonesboro?

Or that infectious and parasitic diseases with OR procedures are billed at $257,369 at National Park and $44,446 at St. Bernards?

Why is one of the most common procedures in Arkansas, a cardiac procedure to insert a drug-eluting stent, cost $108,524 at Northwest Hospitals Inc. in Springdale but only $35,803 at St. Bernards? Or that major joint replacement or reattachment of a leg, another common procedure, is $75,655 at St. Mary’s Regional Medical Center in Jonesboro Russellville, but $10,597 at the Physician’s Specialty Hospital in Fayetteville?

Sometimes, hospitals in the same cities charge different rates for the same procedure: Treatment of a stroke, either ischemic or hemorrraghic, without major complications is $17,707 at the Arkansas Heart Hospital, $16,732 at Baptist Health Medical Center in Little Rock, $16,432 at St. Vincent Infirmary Medical Center and $10,733 at the University of Arkansas for Medical Sciences.

The federal CMS data was released for this first time Wednesday, thanks to an Obama administration directive for a more accountable health care system. The huge database shows how 3,337 American hospitals in 306 cities charge for the 100 most common inpatient procedures billed to Medicare. It includes 163,065 charges.

The Huffington Post, writing about the database yesterday, noted that people without insurance pay the most for their healthcare.

People without health insurance pay vastly higher costs for care when less expensive options are often available nearby. Virtually everyone who seeks health care winds up paying inflated prices in one form or another as these stark disparities in price sow inefficiencies throughout the market.

The database includes charges on the 100 procedures in 39 Arkansas hospitals, if I counted right. The disparity between National Park Hospital in Hot Springs and St. Bernards in Jonesboro is striking. Both are non-profit institutions; National Park is run by Capella Health care and St Bernards by the Benedictine Sisters. Financial vice president Harry Hutchison at St. Bernards, who has seen the database, said it was a "very interesting question" why his hospital charges so much less than National Park and other hospitals, but attributed it to lean management and the hospital's goal of being a "good value" to its patients. We've got a call in to National Park as well.

UPDATE: Mandy Golleher of National Park responded this morning to a question on disparity with this email:

UPDATE 2: Golleher sent a second e-mail, which is posted after the first.

Melony Goodhand, who left as chief financial officer and vice chancellor after nine years at UAMS, is apparently no longer chief operating officer at Bristol (Tenn.) Regional Medical Center, a job she took in early March.

Multiple local sources reported to me she'd left the job. The hospital press spokesman hasn't responded to my questions yet, but the hospital website now lists an interim, Brian Hobson, in the COO position. A hospital operator also said she's no longer at the hospital..

When Goodhand left UAMS late last year, the school agreed to pay her $312,000 this year, to be on call for any questions. That agreement remains in effect, a UAMS spokesman said.

For the record: 1) Goodhand is being paid $312,000; 2) new CFO Bill Bowes, will begin work July 1 at $270,000, and interim CFO David Wilcox, is being paid $158,127. Come July 1, rather than retiring as he'd once planned, he'll go back to his associate vice chancellor job at the same pay.

The unearthing of background discussions between UAMS and St. Vincent Health on combination of their clinical operations in Little Rock continues through Freedom of Information Act requests.

For those interested in the nitty gritty, here are some of the latest productions to Joann Coleman, the civic activist who's been pressing the issue.

* WHO KNOWS FIRST?: This batch of correspondence is particularly interesting around pages 18-21 because of St. Vincent CEO Peter Banko's concern that a draft proposal on the combination might be presented to the University of Arkansas Board of Trustees — and thus the public — before it was presented to the St. Vincent Board. Releasing proposed terms to the public and media at even the same time as a release to St. Vincent would be a "nuclear kind of bad" he wrote.

* THE ST. VINCENT PROPOSAL: This batch contains the first idea from St. Vincent on management of the blended institutions, an idea for St. Vincent to be in control that UAMS has said went too far.

* TESTING THE WATERS: This batch includes a proposed public opinion poll on the combination, including a sampling of opinion on who might be opinion leaders if the deal moves forward, primarily public officials and rich people — Tysons, Waltson, Stephenses.

A cut to the legal chase. Coleman is raising with university officials a legal point in addition to the obvious questions about patient and employee treatment in an operation that blends a public institution with one limited by church doctrine on some important questions, including patient medical services and employee insurance coverage and equity issues.

It is Amendment 33 of the Arkansas Constitution. You'll be hearing more about the amendment, which establishes the independent governance of institutions of higher education, such as the University of Arkansas Board of Trustees. It says:

... The board or commission of any institution, governed by this amendment, shall not be abolished nor shall the powers vested in any such board or commission be transferred, unless the institution is abolished or consolidated with some other State institution. ....

Can powers of UAMS be transferred to a third-party clinical operator controlled in part by a private institution, St. Vincent or anyone else? Coleman has vowed to press that issue.

• UAMS: No to joining up on all clinical services

But St. Vincent's counter-proposal to the UAMS' term sheet for an affiliation in oncology and cardiology services and administration was this: All clinical "service lines," not just cardiology and oncology, would be included. St. Vincent would also have majority ownership of the non-profit MSO [the management services organization] that would provide administrative support to the hospitals and physicians for a fee.

Their proposal, then: To consolidate the hospitals, and let St. Vincent manage them. Fortunately, UAMS said no again, and St. Vincent has withdrawn its counter offer.

Asked what in particular UAMS found objectionable in St. Vincent's proposal, UAMS Chancellor Dan Rahn mentioned the specifically the framework for ownership, which states that "Financial consolidation (in accounting terms) is important for St. Vincent, so St. Vincent would have majority ownership of the MSO [Management Services Organization]," for a term of 25 to 30 years, but the chancellor said "the whole thing, the way it was framed" was problematic. The proposal, however, would have provided that UAMS "retain sole responsibility for all education and research," which should be included in any joint agreement.

The counter proposal was received Monday evening, and withdrawn yesterday by St. Vincent. However, the two entities are still negotiating, Rahn said, and he believes that by the time the University of Arkansas Board of Trustees meets May 22-23 in Stuttgart that UAMS and St. Vincent will have reached a consensus "on things we could start with" in an affiliation and will present a joint recommendation to the board.

UAMS is "facing significant financial challenges," Rahn said, because of the federal sequester (which cut $10 million from its budget) and changes in Medicare reimbursement, and some kind of partnership is necessary for UAMS to fulfill its mission of education, research and care. He added that UAMS' non-classified employees — those whose pay isn't mandated by the state pay schedule — are not getting a raise in the next fiscal year.

• MARCY DODERER

Doderer is a daughter of Dr. J. B. Norton, who was chief cardiologist at Children's years ago. He helped build Children's into the major teaching hospital it has become. As this article in a San Antonio newspaper shows, she had a family experience with a child's special medical needs, a breathing disorder.

The article notes that Doderer has a long association with Arkansas Children's.

Doderer volunteered as a candy striper at her father’s hospital as a teen, and her first paid job was in the billing office of the hospital’s physician practice plan. In college, she worked as an administrative intern there and was hooked.

“I said at that time, I’m going to run a children’s hospital when I grow up some day.”

She's all grown up.

Democratic gubernatorial candidate Mike Ross has said he would have opposed the recent legislative effort to strip funding from Planned Parenthood for sex education and other health programs (not abortion).

Where Mike Ross goes, Barack Obama follows. From Talking Points Memo:

President Obama on Friday at a Planned Parenthood gala in Washington criticized efforts — led by Republicans — to defund the women's health organization.

"So when politicians try to turn Planned Parenthood into a punching bag, they're not just talking about you, but they're talking about the millions of women who they serve," Obama said, according to a rush transcript. "And when they talk about cutting off your funding, let's be clear, they're talking about telling many of those women, 'you're on your own.' They're talking about shutting those women out at a time when they may need it most. Shutting off communities that may need more health care options for women, not less."

Dr. Charles and Cindy Fuller, whose daughter Rachel was fatally injured in the 1999 crash of American Airlines flight 1420 at Little Rock National Airport, have made a gift that will allow Arkansas Children's Hospital to create an endowed chair in burn treatment.

Their gift, with a match from the hospital foundation, will provide $1 million for Burn Center equipment, program support and education activities.

It's an appealing notion, managing government-financed health care programs like Medicaid to encourage less expensive types of care and turning it over to the ever-so-efficient private sector to get the job done.

Here's a sliver of how those good intentions can have unintended consequences. It's from the New York Times, about a program to direct disabled elderly into adult daycare programs paid from Medicaid money.

Such centers have mushroomed, from storefronts and basements to a new development in the Bronx that recently figured in a corruption scandal. With little regulation and less oversight, they grew in two years from eight tiny programs for people with dementia to at least 192 businesses across the city.

The Times finds that many of the people being served at the centers are perfectly fit and enjoying games, free meals and socializing, while the companies that run them pile up profits.

Centers collected over $25 million from managed care plans in the first nine months of 2012, at roughly $93 per person per session, according to state figures. The managed care companies are paid by Medicaid; in New York City, the rate is about $3,800 a month per member.

“The whole thing is going to end up costing the state much more money,” said Valerie Bogart, a lawyer with New York Legal Assistance Group who specializes in advocacy for frail elderly and disabled people. “It’s really up to the managed care plans to be the watchdogs now, and it’s like the fox watching the chicken coop, because they have an incentive to make money from these centers, too.”

It was not supposed to play out this way. The bold Medicaid overhaul, part of a grand bargain with the state’s most politically powerful health care players, has been promoted as a national model for curbing costs and reversing the incentives for fraud. It transferred tens of thousands of recipients of long-term care from a system in which providers billed Medicaid for each service to managed care, in which a capped monthly rate must cover all services to a company’s enrollees.

With the largest Medicaid budget in the country, $54 billion, New York is trying not only to rein in runaway spending, but also to “rebalance” it, away from costly institutional care, like nursing homes and medical models known for overbilling, to inexpensive supports that keep people safely in their communities.

The price of efficiency is eternal vigilance. And, might I add a local angle: The first way to root out fraud isn't drug-testing Medicaid-eligible disabled and elderly or implanting digital IDs on them. It's watching the vaunted private optioneers like a hawk.

• Sen. Sanders and Sen. Irvin explain the amendment.

• BACKROOM: Westerman with Bledsoe in the Members only room outside of Public Health

UPDATE:The Senate approves the appropriation 28-7. The "private option" will be headed to the governor's desk.

FLOOR DEBATE:
***Sen. Hendren and Sen. King raise objections to the lack of amendments in the appropriation bill given the amendments to the enabling legislation.

***Sen. Hester says the amendment "fundamentally changes nothing that made me oppose this bill" and gives anti-government boilerplate. Sen. Hendren follows up with more of the same. The senators look very sleepy. Hendren said opposition didn't mean that he didn't care about those in need — "it is about how we express the care we all share for how we take care of those people." He mentions his granddaughter and the national debt. "That's the future I'm leaving to Haley Ray," he says.

***Sen. Hutchinson says "until recently I was not planning to vote for this bill." He says "unfortunately we will not see any debt reduction if we say no to this." Quotes Barry Goldwater. He says that this is an opportunity to reform "entitlement programs." He called the private option "a down payment" on future reform.

***Sen. Clark takes out a little time to slam Mike Ross, the Chamber of Commerce, and hospitals. He complains about free cell phones. Kind of a hodge-podge approach to arguing against the private option. He also says the federal debt will blow "like Mount Vesuvius."

***Sen. Irvin, the key swing vote, says she has "done everything in my power that I know how to do in order to make a thoughtful choice...What changed for me overnight was listening to everyone in the state, listening to town hall meetings, listening to my colleagues, to my constituents."

After the jump, previous updates.

• Brian Chilson
• MELISSA FARRELL: This mother of two will be one of the 170,000 who go without insurance without the 'private option.'

After the jump, some of what's coming for the state and its people if "do nothing" wins the day: