The plaintiffs claim the Trump administration aims to 'explode' the ACA's Medicaid expansion and 'cull people whom it deems unworthy.'
Some of the same people who have successfully challenged Medicaid work requirements in Kentucky, Arkansas, and New Hampshire are helping beneficiaries in Indiana challenge that state's new requirements as well.
Four beneficiaries filed suit Monday, with help from the National Health Law Program (NHeLP) and Indiana Legal Services (ILS), in the U.S. District Court for the District of Columbia. They're challenging the federal government's 2018 approval of waivers for the Healthy Indiana Plan, which include work requirements that have been described as less-severe than those imposed by other states.
In a statement, NHeLP Legal Director Jane Perkins said the law narrowly defines the Health and Human Services secretary's discretion to waive provisions of the Medicaid Act.
"We have filed this case because the federal government ignored these limits in its efforts to fundamentally transform Medicaid and explode the Affordable Care Act's expansion of health insurance to cover medically necessary services that low-income adults need," Perkins said. "This approval will not promote coverage, but it will result in significant coverage losses, and that is the administration's goal—to weaken the Medicaid program and cull people whom it deems unworthy from it."
During his time at the helm, the health system's revenues grew to $8.5 billion annually, as it opened sites in Florida, Nevada, Canada, and the United Arab Emirates.
BOSTON – Toby Cosgrove, MD, the former Cleveland Clinic president and CEO who signed on last year as an executive advisor to Google's Cloud Healthcare and Life Sciences team, spoke candidly Monday with conference attendees about his views on healthcare leadership.
The industry's executives need to commit themselves to fostering collaboration and developing the future leaders who will replace them, Cosgrove said, during his talk at the Kyruus ATLAS symposium on access. He also shed some light on what he views as foundational to Cleveland Clinic's success.
Here's what he said about those three key topics:
1. Fostering Collaboration by Touting 'Caregivers'
Cosgrove, a cardiac surgeon, told the story of a time he operated on one of his wife's relatives. Everything went well medically, but when he relayed the positive outcome to the patient's family, they seemed angry, he said.
"'What's the matter?'" Cosgrove recalled asking the family. "And they say, 'Look under the bed.' So I get down on my hands and knees to look under the bed. And there are two things: dust bunnies and an empty IV bag."
"About 120 people touch a cardiac surgical patient on the way through the hospital, and the whole experience was ruined for that family by somebody who threw this IV bag under the bed and didn't clean up," he said.
That's the point at which he realized just how dependent the entire healthcare system is upon not just doctors and nurses but all the people who comprise the industry, including cleaners, clerical staff, suppliers, and bus drivers, Cosgrove said.
That's why the Cleveland Clinic began referring to everyone on its team as a "caregiver." That helps to affirm a collaborative environment, and it has boosted patient satisfaction and engagement, he said.
"Healthcare really is a team sport," he said.
2. Picking Leaders for Their Leadership Skills
Even when he stepped into his role as Cleveland Clinic's CEO in 2004, he didn't fully understand how important leadership is to the success of an organization, Cosgrove said.
"I totally changed my brain about this," he added. "If you have a hospital that's not doing well and you put a capable guy or gal as the head of it, the team changes in about six months. The same can be said for a nursing floor. The same can be said for a department or institute."
But hospitals and health systems frequently fail to select future leaders based on their leadership skills, he said. Too often, leaders are chosen because they succeeded in their technical work, such as being a doctor or nurse, he said.
"We simply take someone who is technically capable, and because they do a good job, we promote them," he said.
That's why the Cleveland Clinic took some cues from the U.S. military and established a leadership institute. The model calls for people to be given leadership responsibilities at a very small level. If they succeed, then they move on to the next step, then they receive additional training, and so on, Cosgrove said.
Leadership is 90% about having experience and learning if you enjoy it and have a knack for it, he said. The other 10% is the technical component of understanding it.
"We have to focus on our leaders and pick them because they're leaders, not because they're great colonoscopists," he added.
3. Flavor of Cleveland Clinic's 'Secret Sauce'
When he joined the organization in 1975, the Cleveland Clinic had just 200 doctors and one hospital, Cosgrove said. Now it has 63,000 employees, 11 hospitals, and a global reach.
During his 13-year tenure at the helm, the health system's revenues grew from $3.7 billion in 2004 to $8.5 billion in 2016, as it opened sites in Florida, Nevada, Canada, and the United Arab Emirates, with plans to open another site in the United Kingdom next year.
"If there's a secret sauce at the Cleveland Clinic, that's how its organized," Cosgrove said.
"We are physician-owned. We are not-for-profit. We're all employees," he added. "We're straight salary, with no bonuses."
"And we take the annual professional review very seriously. You're reviewed by your peers," he said.
"I've had 44 one-year contracts, and that keeps you on your toes," he added.
"I don't know another hospital organized that way."
A letter from Rhode Island Gov. Gina Raimondo suggests leaders of the Providence-based health system may be to blame for talks unraveling over the summer.
After less than six weeks at the negotiating table, the leaders of Care New England (CNE), based in Providence, Rhode Island, walked away last July from a potential three-way deal with Lifespan and Brown University.
Although they said the discussions were collaborative and respectful, CNE President and CEO James E. Fanale, MD, and board chair Charles R. Repucci cited concerns over the potential deal's capital requirements, the expected financial stability of the combined system, antitrust considerations, the community's needs, and other factors.
A letter that Rhode Island Gov. Gina Raimondo sent to Repucci in August, however, suggests that a tussle over who would take the top leadership role may have been a contributing factor as well. Raimondo's office confirmed the authenticity of the letter, which was obtained by The Providence Journal's editorial board and revealed Thursday in a report by G. Wayne Miller.
"It is unfortunate for Rhode Island that the CNE Board held as a condition of your continued engagement in the process that Dr. Fanale be installed as the CEO of the merged entity, and that he lead the transition," Raimondo wrote to Repucci, as the Journal reported.
A spokesperson for CNE told the Journal that the health system takes its non-disclosure agreement seriously, so it will not "engage in any specific discussion covered by that agreement."
When asked for comment, Lifespan President and CEO Timothy J. Babineau, MD, and board chairman Lawrence Aubin Sr., told the Journal, "Regrettably, the letter speaks for itself."
A spokesperson for Brown University didn't respond immediately to the Journal's request for comment.
Boston-based Partners HealthCare had been in late-stage talks to acquire CNE, but it dropped its acquisition plans in June, when CNE entered into the short-lived three-party negotiations, at Raimondo's urging.
Repucci asked Raimondo to nudge Partners to revive their merger bid, but Raimondo declined to do so, as the Journal reported.
The top executive's departure came after months of conflict with the nonprofit's physicians.
The board of trustees for Erlanger Health System, based in Chattanooga, Tennessee, finalized the recent departure of President and CEO Kevin Spiegel, FACHE, and named a new top executive for the nonprofit health system during a special meeting Wednesday.
Under the terms of his separation agreement, Spiegel will receive 12 months' salary—that's $964,000, after a raise last year, as the Times Free Press reported—plus cash to cover the cost of continuing his health insurance benefits, according to a statement from Erlanger board chairman Mike Griffin.
"On behalf of the Board, I want to express our appreciation for Kevin's vision and efforts surrounding our impressive growth and presence throughout the region," Griffin said in the statement. "He has made many valuable contributions over the past six years and, on behalf of the Board, we wish him, his wife and their family all the best going forward."
Spiegel's exit came after months of conflict with the system's physicians.
Erlanger was in the midst of "a challenging time" when Spiegel rose to lead the organization in 2013, then he oversaw a number of accomplishments, including the addition of a new patient tower and services at Erlanger East Hospital, The Erlanger Kennedy Children's Outpatient Center, Heart & Lung Institute, The Orthopedic Institute, The Erlanger Behavioral Health Hospital, and the acquisition of Western Carolina Hospital, according to the statement.
The hospital improved its financial position and made big investments in information technology systems, according to the statement.
After approving Spiegel's separation agreement, the board appointed William L. Jackson Jr., MD, MBA, as the system's new president and CEO. Jackson had been Erlanger's chief medical officer for nearly four years.
"We have every confidence that he will continue Erlanger's movement in a positive direction and strengthen relationships inside the health system and in the many communities we serve," Griffin said.
Jackson served previously as CMO for Alexandria Hospital at Inova Health System in Virginia.
The board opted to give Jackson a one-year contract, rather than naming him CEO on an interim basis.
"To go with the uncertainty of an interim title would put Erlanger in a position of not being able to move forward," trustee Gerald Webb said, as Elizabeth Fite reported for the Times Free Press.
My questions focus on the critical choices CEOs must make for their organizations, both internally and in relation to the broader market.
I have the privilege of moderating roundtable discussions next week with dozens of senior healthcare strategy executives as part of our ongoing HealthLeaders CEO Exchange program.
There are a few questions I'm especially looking forward to asking. They focus on the critical choices CEOs must make for their organizations, both in how their hospitals and health systems operate internally and how they position themselves in the broader market:
As you pursue mergers, acquisitions, and partnerships, how are you ensuring the end result of the deal will preserve your local market edge? This is an idea I've discussed with CEO Exchange participants in the past, but it's one I'd like to unpack further, in light of recent trends and opportunities.
With the shift to value-based care, does every provider organization need its own in-house payer to handle risk effectively? I've written about some creative payer-provider collaboration. But I look forward to hearing a room full of smart leaders discuss their differing views on the topic.
How are you determining when, whether, and how to compete or partner with new entrants to the healthcare space? I'm thinking not only of the Amazon-backed venture Haven but also of Walmart's recently opened health center prototype and moves by other retail giants.
I led three roundtable discussions when CEO Exchange participants convened late last year, and I left with a much clearer sense for not only the challenges healthcare CEOs face but also how those situations intersect with an organization's mission and an executive's strategic vision. The key takeaways from our conversations are outlined in the Exchange insight report "3 Must-Have CEO Skills in New Healthcare."
The conversations will take place Thursday and Friday at the Stein Eriksen Lodge Deer Valley, in Park City, Utah. We're all booked up for this gathering, but if you're interested in joining future conversations, please email exchange@healthleadersmedia.com.
With care delivery sites across four states, the system's regions often acted independently. That changed as the system reconfigured itself.
Driving around the St. Louis area, it's increasingly tough to miss SSM Health's physical presence.
The number of facilities prominently featuring the Catholic health system's name and logo has risen in the past few years, as part of a coordinated rebranding effort to make the organization's footprint in the community more consistent and apparent.
The patchwork of brands belonging to SSM Health has grown as a result of merger and acquisition activity, but most of them came from the way the ministry was founded, says John Nguyen, chief marketing officer for the St. Louis–based organization. The Franciscan Sisters of Mary were itinerants who traveled wherever they saw a need, opened a new healthcare facility, and named it after significant historical figures, such as St. Francis or St. Mary, he says.
With care delivery sites scattered across four states, SSM Health's various regions often acted independently of one another. That was the case until about five years ago, anyway, when the system's leaders decided to reconfigure it from a holding company to an operating company and realign each of the regions to report directly to SSM Health's centralized office as part of an effort to increase effectiveness and reduce waste, variation, and unnecessary duplication, Nguyen says.
"That was a very big change for the organization," he says, "and I'd be lying if I didn't say we're still on that path today."
The marketing and communications team consolidated its market research functions, condensed 70 separate websites into two, and brought about 300 distinct brands under the single SSM Health umbrella, Nguyen says. As the system linked its disparate components together in the minds of consumers, the public's unaided awareness of SSM Health's brand rose 34%, he says, citing custom research conducted by a third party.
This metric of unaided or "raw" awareness—in which respondents are presented with an open-ended prompt to name a health system and researchers count the number of times SSM Health is mentioned—is a good starting point for the system to track its progress. The next step, Nguyen says, is tracking how well that brand resonates with the public.
Missional alignment: a two-sided endeavor
Consistency in external brand identity clearly isn't the only type of alignment CEOs need. Internal consistency of process and mission are just as important. These external and internal initiatives can be two sides of the same coin, Nguyen says.
"A brand, more than just a campaign, is how we galvanize ourselves to that [mission] internally as well as externally and make sure that the experience is hardwired into the services we provide and to how our employees are positioned to do the work," he says.
As SSM Health conducted market research with the public, it asked its own employees what sets the system apart from others. Nguyen says researchers tested a variety of positioning statements both externally and internally and found one sentence, in particular, was positively received all around: "We get to know you better as a person, so we can treat you better as a patient."
That research, combined with a reflection on SSM Health's heritage and mission statement, led Nguyen's team to develop "The Healing Power of Presence," a unifying campaign designed to articulate and reinforce SSM Health's identity for employees and the public alike.
At its core, this type of messaging is about talking to people, understanding their lives and what they are trying to achieve, then boiling that down in a way that resonates with individuals, Nguyen says. If it doesn't reflect the reality of the health system, then it's meaningless, he notes.
"I can make a great campaign and put it out there, but unless there's some passion around that as an organization, that really doesn't mean anything," he says.
If you hope to align a large or complex organization with senior leadership's strategic vision, then you must communicate in a way that empowers managers to act as surrogates for the message. That's why SSM Health published a booklet by CEO Laura Kaiser outlining her vision, then followed it up with weekly communications from her reinforcing that strategy, Nguyen says.
SSM Health also rolled out a formal communications training module for all managers in 2017. The training teaches how communications flow through the health system, what the manager's role is in relaying messages to his or her team, and how to facilitate discussion and feedback, Nguyen says. The training includes a practicum component, so all managers know not only what tools are available but also how to use them.
There will always be some level of variation in a health system as big as SSM Health. The goal in communicating and reinforcing strategy throughout an organization is to get the big things right, so all team members can orient themselves around those priorities, Nguyen says.
"When it comes to communications, it's not the same as clinical practice," he says. "If there's a little gray area in the details, that's OK. We have to make sure the core messaging is right: How is this attached to our mission? Why are we doing this? Why is this better for people? Why is this better for the communities we serve? Why is this better for our organization?"
Related: Health System CEOs More Concerned With Growth Than Costs
An appeals court ruled the Catholic-affiliated health system can be sued for allegedly discriminating against a patient on the basis of his gender identity, after a lower court dismissed the case.
A transgender patient whose hysterectomy was delayed after he mentioned his gender identity to medical staff can sue Catholic-affiliated Dignity Health for discrimination under the state's Unruh Civil Rights Act, an appellate court ruled Wednesday.
Evan Minton was preparing to undergo the procedure at Dignity's Mercy San Juan Medical Center in Carmichael, California, when the alleged discrimination occurred in 2016. The procedure was rescheduled and completed at a non-Catholic hospital nearby within three days.
With backing from the American Civil Liberties Union, Minton sued Dignity Health in 2017, but a judge tossed out the lawsuit later that year, ruling that the prompt rescheduling and completion of the hysterectomy means Minton wasn't deprived of full and equal access to the care he sought.
The appellate ruling, however, overturned that lower court's decision, revived the allegations, and allowed the lawsuit to proceed.
"Without determining the right of Dignity Health to provide its services in such cases at alternative facilities, as it claims to have done here, we agree that plaintiff's complaint alleges that Dignity Health initially failed to do so and that its subsequent rectification of its denial, while likely mitigating plaintiff's damages, did not extinguish his cause of action for discrimination," Presiding Justice Stuart R. Pollak wrote for the appellate court in San Francisco.
In a statement, Dignity Health said that the company's medical teams recognize the specific healthcare needs of transgender patients, that many of its care sites offer specialty care for trans people, and that the organization has a legacy of providing care to all people regardless of their sexual orientation or gender identity, as Cathie Anderson reported for The Sacramento Bee.
"Catholic hospitals do not perform sterilizing procedures such as hysterectomies for any patient regardless of their gender identity, unless there is a serious threat to the life or health of the patient," Dignity told the Bee. "Courts have repeatedly recognized the right of faith-based hospitals not to provide services based on their religious principles."
Dignity Health merged with Catholic Health Initiatives earlier this year to form CommonSpirit Health, a $29 billion system with 142 hospitals across 21 states.
While this lawsuit pertains to the specific context of California law, it reflects a national conversation about the obligations healthcare providers have to lesbian, gay, bisexual, transgender, and queer patients.
On the federal level, Section 1557 of the Affordable Care Act prohibits sex-based discrimination in healthcare, which the Obama administration interpreted as banning discrimination on the basis of gender identity and expression. Some healthcare providers said that interpretation would force them to provide certain services that contradict their own medical judgment.
A federal judge in Texas—the same one who would later declare the entire ACA invalid—blocked the Health and Human Services (HHS) Office for Civil Rights (OCR) from enforcing the Obama administration's interpretation. Then the Trump administration moved this year to reinterpret that provision more narrowly, scrubbing gender identity altogether. The government received nearly 156,000 comments on the proposed rule.
HHS OCR Director Roger Severino has acknowledged that the dispute over whether sex-based discrimination includes gender identity discrimination is up for argument in a case pending before the U.S. Supreme Court. How the justices decide that case could affect the way HHS OCR must interpret Section 1557.
The debate over the ACA's nondiscrimination provisions comes as Trump's HHS OCR has pushed also for more vigorous enforcement of other federal laws that protect healthcare workers' right to refrain from assisting in the performance of services that contradict their religious views or conscience. That, too, has drawn praise from faith-based organizations and prompted concerns from LGBTQ rights advocates.
A federal judge vacated the CMS policy, saying the agency overstepped its legal authority in making the payment cut to off-campus provider-based departments.
A site-neutral payment policy touted by the Trump administration as among its healthcare policy successes was vacated Tuesday by a federal judge.
The policy had reduced reimbursement rates for clinic visits at hospital-owned outpatient provider departments by 40%, to match the rates paid for clinic visits in physician offices—so the ruling hands a big win to hospitals that had worried the policy might spoil their investments in outpatient facilities.
"This ruling is a positive step towards understanding that providing services to patients as a hospital department is not synonymous with physician clinic services," said Monica Hon, vice president and director of client solutions at the healthcare consulting firm Advis. "Hospital outpatient services are operating under the main hospital's policies, quality standards and regulatory requirements. This level of quality and efficient care should be recognized in the reimbursement."
The Centers for Medicare & Medicaid Services exceeded its authority when it finalized the policy last year, over hospitals' objections, as part of the Outpatient Prospective Payment System (OPPS) final rule for 2019, U.S. District Judge Rosemary M. Collyer wrote in her opinion.
Although CMS believes it is overpaying for care provided in hospital-owned facilities that could instead be provided more cost-effectively in a doctor's office—and that may, in fact, be the case—the agency cannot ignore the law's clear process for setting OPPS rates, Collyer wrote.
The agency argued that its non-budget-neutral approach was authorized by a provision of the law that lets CMS propose a "method" for controlling unnecessary volume increases.
While the law doesn't define "method," it does make clear that a "method" isn't a price-setting tool, Collyer wrote, "and the government's effort to wield it in such a manner is manifestly inconsistent with the statutory scheme."
Collyer granted summary judgment to the hospitals and vacated the relevant portions of the OPPS final rule.
In a joint statement, the American Hospital Association and Association of American Medical Colleges said they are pleased with the decision.
"The ruling, which will allow hospitals to maintain access to important services for patients and communities, affirmed that the cuts directly undercut the clear intent of Congress to protect hospital outpatient departments because of the many real and crucial differences between them and other sites of care," they said. "Now that the court has ruled, it is up to the agency to put forth remedies for impacted hospitals and the patients they serve."
America's Essential Hospitals President and CEO Bruce Siegel, MD, MPH, called the ruling "a victory for vulnerable patients and an important step toward protecting access to care in underserved communities." The vacated policy had exacerbated gaps in care, he said, by erecting financial barriers to establishing clinic networks.
A spokesperson for CMS said the agency is aware of Collyer's decision and determining what steps to take next.
Editor's note: This story was updated Wednesday afternoon with additional information.
'We ought to consider that,' said Sen. Chuck Grassley during a hearing with witnesses from FTC and DOJ regulators, who asked for more resources to protect competition.
Republican Sen. Chuck Grassley of Iowa reprised his concerns Tuesday over anticompetitive practices among healthcare providers, and he suggested that Congress should think about empowering more regulators to keep an eye on the industry's numerous nonprofits.
Quoting from a report in The Wall Street Journal on so-called "anti-steering clauses," his letter accused dominant hospital systems of using "secret contract terms to protect their turf" and thwart attempts to lower costs.
"Has the FTC looked into these practices in more detail since my letter last fall? Are they problematic?" Grassley asked during Tuesday's hearing. "What actions, if any, has the FTC taken?"
FTC Chairman Joseph Simons said his team would like to do more to address Grassley's concerns but that they are butting up against statutory limitations.
"We're very interested in looking at unilateral conduct by hospitals, that are problematic under the antitrust laws," Simons said. "But, generally when we do that, we find that they're nonprofits, and we don't have jurisdiction over them."
"That's another reason why we've been asking the Congress to eliminate our exemption for nonprofits," Simons said.
"Gosh, I never gave that any thought," Grassley replied. "We ought to consider that."
Unlike the FTC, the DOJ does have authority over nonprofits, said Makan Delrahim, assistant attorney general for the DOJ's antitrust division. The DOJ has exercised that authority in two enforcement actions to block anti-steering practices in healthcare, including one case involving Charlotte, North Carolina–based Atrium Health, he said.
"We were prepared to litigate. It had been in investigation for over three years," Delrahim said of the Atrium case during Tuesday's hearing. "We entered into a consent decree where the hospital system terminated those practices just this past year."
Furthermore, a working group within the Trump administration is currently assessing whether there is a regulatory means by which to address these anti-steering practices, Delrahim said.
Consolidation advanced noticeably between 2012 and 2016, according to a report by the Health Care Cost Institute.
The top-line finding of the Health Care Cost Institute's latest report won't surprise anyone who's been paying attention to the industry in recent years: markets are increasingly consolidated.
The number of metro areas that were either highly or very highly concentrated increased to 81 in 2016, from 75 in 2012, out of the 112 markets studied, according to the HCCI Healthy Marketplace Index (HMI) report released Tuesday. That means nearly three-quarters of U.S. healthcare markets are highly concentrated.
The report points to Milwaukee, Wisconsin, and Houston, Texas, as examples of the consolidation trend. Those two markets were highly concentrated in 2016 after being moderately concentrated in 2012. But the increases in concentration levels were widespread.
"Our findings add to the growing consensus that most localities have highly concentrated hospital markets, and this is becoming increasingly true over time," said Bill Johnson, PhD, an HCCI senior researcher and an author of the report, in a statement.
"The increased concentration we observed can be driven by many factors such as hospital closures, mergers and acquisitions, changes in hospital capacity, patient preference, or changes in patients' insurance networks," Johnson added.
But the report goes further than that top-line finding and suggests that rising consolidation may be related to higher prices. As healthcare leaders and policymakers alike look for ways to tamp down the cost of care, the report points to a growingbody of literature that documents a relationship between market concentration and heightened prices.
"Increasingly concentrated hospital markets have been linked to the rising cost of hospital care by nearly every expert in the field," HCCI President and CEO Niall Brennan said in a statement.
The report found a "slightly positive correlation" between market concentration changes and inpatient price index changes overall. But some metro areas bucked the pattern, such as Memphis, Tennessee, where prices decreased slightly as concentration increased.
"Although consistent with previous literature, our analysis does not necessarily show that increases in concentration caused increases in prices," the HCCI report states. "Changes in both measures could be due to many factors other than market consolidation which are related to both concentration and prices."