Farzad Mostashari, MD, the former National Coordinator for Health IT at the Department of Health and Human Services, and Martin S. Gaynor, a professor of economics and health policy, discuss how policy helps and/or harms competition in the healthcare marketplace.
Despite the near-universal agreement that the U.S. healthcare delivery system should remain market-based, there has been surprisingly little talk amongst government policy makers and private payers about the potential for stifling competition with over-regulation.
An essay this month in JAMAcalls for a re-examination of how healthcare rules, regulations, and policies help or harm competition in the healthcare marketplace.
Farzad Mostashari, MD, the former National Coordinator for Health IT at the Department of Health and Human Services, and Martin S. Gaynor, a professor of economics and health policy at Carnegie Mellon University, two authors of the essay, spoke with HealthLeaders last week. The following is a lightly edited transcript.
HLM: When is consolidation in healthcare good?
Mostashari: Healthcare consolidation can be good when the integration leads to the larger organization taking on the work of truly integrated patient care experience.
In particular, as we are entering into this realm of moving from volume to value, when that larger organization uses those efficiencies that are often promised but rarely delivered to actually provide more value, whether it's for the taxpayer, the government, the employer or the individual.
Unfortunately, the evidence to date does not support a whole lot of that kind of good consolidation. On average those entities that have consolidated have increased prices, but not increased quality.
Gaynor: It's important to remember that consolidation is not integration. Consolidation is change of ownership. Integration is really working together and becoming a single organization working to one purpose in a coordinated way.
Simply buying another firm doesn't mean that that post-acquisition that the two entities actually become integrated and coordinated.
HLM: Is there an overarching reason that is pushing healthcare consolidation/integration?
Mostashari: There are payment policies in particular that are literally distorting the economics of healthcare such that they push small and independent practices into employment or other owned arrangements with consolidating health systems.
The shining example of this is when a private practice cardiologist is bought by a hospital so they can re-categorize it as a hospital outpatient department. All of a sudden, for the same service delivered by the same person in the same facility, Medicare and other payers following suit will pay two or three times for that echocardiogram as would have been done in a private practice office.
That is a distorting factor.
HLM: Is government policy the biggest driver of consolidation?
Mostashari: As a former regulator, I absolutely do not believe that there is a federal policy to encourage consolidation. The consolidation is an unintended consequence of some policies. And this is our whole point here.
Every policy needs to consider its implications on competition. To this point, we don't think that many well-intentioned, intelligent people who are addressing policy in their domain are not doing it with an eye toward its impact on competition, and they need to do so.
Gaynor: There is not a federal policy that is designed to promote consolidation. It's just that sometimes there are policies that are designed for a completely separate purpose that unintentionally have that result.
You don't need to consolidate to take risk-based payments. You don't need to consolidate to coordinate care. As a matter of fact, sometimes it can be done more efficiently by independent entities.
There is the possibility of virtual groups, where policy can facilitate independent practices to come together in a virtual way so that they don't have to consolidate under one ownership to take risks or comply with a certain requirement that is coming down from CMS or other payers.
HLM: Why do these administrative fiats become so burdensome?
Mostashari: One of the things I learned as national coordinator is that there are well-intentioned and dedicated policy makers for whom, through an accumulation of either wanting to be responsive to all constituents or trying to accomplish too much, every measure independently and individually is totally reasonable, but collectively when you put it all together it's insane.
When every regulator is thinking of their domain, they are not thinking about this in a more provider-centric way. Every different group that touches them has their own 'we're only asking for one or two little things. What's the big deal?' And it's not just the federal government, it's the private payers too.
In fact, a lot of the burden is on prior authorizations from private payers, it's from all the one thousand paper cuts that the practices are sustaining.
Gaynor: These burdens grow and grow and practices that would be perfectly efficient are no longer efficient because of these growing burdens, and that leads to consolidation, which then leads to less competition.
Nobody designed or planned or wanted that. But it happens. We're saying step back, take a look at that. You need to listen to people who are actually experiencing these things directly. We need better lines of communication and consideration of the holistic impact of these things, not one-by-one.
HLM: You call for the elimination of the Certificate of Need. Does that create problems, such as cherry picking?
Gaynor: There are no valid arguments. CON was established a long time ago, and we have a number of states that have repealed them. There is a lot of research evidence and it does not support the claims that CON constrains costs or reduce investments. It does not lead to more facilities located in "underserved areas."
CON is well-intended. Nobody designs these regulations thinking they are going to do something bad, but it just hasn't worked out. There is a long track record that shows CONs protect existing firms from competitions and it reifies so you don't get innovation and dynamism. If anything, it serves communities poorly.
HLM: What should state and federal regulators be asking when they examine consolidations among providers?
Gaynor: Will it harm competition? If the answer to that is 'no' then from an antitrust perspective, you don't have a problem. If it looks like there is the potential for harm then you look at the other side: Is there a potential for benefits and are the benefits substantial enough and would they be passed on to consumers so that they would overcome any harm that would flow from the merger?
HLM: Do we need another level of bureaucracy to ensure that these regulations are coordinated and not overly burdensome and counterproductive?
Mostashari: Definitely not! Every agency that cares about and relies upon the health of markets should increasingly consider the impact on competition with consolidation.
There is a formal review process for all regulations that involve the Office of Information and Regulatory Affairs that does fine work reviewing regulations and the burden on data collection, for example, or the regulatory impact.
I don't believe competition is specifically one of the regulatory impacts considered.
Gaynor: In a sense, we are just saying 'Hey, when you're formulating rules, regulations, and policies think about their impact on competition.' Just doing that can go an awful long way.
But also, there are plenty of opportunities for communication and consultation across federal agencies, between states and the federal government. And these things happen to a large extent already. What's required is for people to be thinking about these things. But I am not suggesting more bureaucracy.
HLM: Anything else you'd like to add?
Mostashari: The United States has determined that the way we are going to deliver healthcare is through markets. This is one of those issues that is truly embraced across the political spectrum, but we have had surprisingly few actionable policy recommendations around competition in healthcare.
Competition is not just the responsibility of the Federal Trade Commission. There are many actionable policy recommendations across federal, state and private sectors that can help improve the functioning of our healthcare system for everyone.
Armed with improved demographics data, the nation's safety net providers are poised to take population health initiatives beyond the hospital walls to help patients overcome economic and social barriers to health.
There were a couple of new developments in the past week on the population health front that are worth noting.
For starters, the Essential Hospitals Institute, the research arm of America's Essential Hospitals, has been awarded an 18-month grant from the Robert Wood Johnson Foundation to begin the second phase of a coordinated effort to promote community-integrated healthcare.
Bruce Siegel, MD, president and CEO of America's Essential Hospitals, says safety net hospital administrators and clinicians have long understood the linkage between patient outcomes and social-economic challenges such as poverty and the ills that come with it, but have often lacked the resources to move beyond hospital walls and into the communities they serve.
"Essential hospitals often are anchor institutions in their communities and serve patients for whom social determinants profoundly influence health," Siegel said in remarks accompanying this week's announcement.
"While this gives them a deep understanding of these nonclinical factors, applying that experience to improve community health often faces severe resource challenges."
During Phase One of the project, which was also funded by RWJF, the Essential Hospitals Institute late last year completed an assessment its members' capacity to improve population health and to find the support to deploy population health programs.
Using in-person summits, distance learning opportunities, and online resources, Phase 2 builds on those findings by
Supporting population health partnerships among safety-net providers on the state and national level
Compiling and sharing population health tools and resources designed for safety-net hospitals
Convening "learning communities" to build safety-net hospitals' internal capacity to address population health
To mitigate funding restraints, the program looks to leverage safety-net hospitals' unique and leading role in the health of their communities to broker partnerships between essential hospitals, public health departments, and community organizations.
"Our work reflects the simple reality that to succeed as partners of the population health movement, hospitals need support to apply key tools and to develop core partnerships in population health," says Kalpana Ramiah, DrPH, Essential Hospitals Institute's research director.
"Support provided now will have a lasting impact on moving our nearly 300 member hospitals toward community-integrated care."
500 Cities Project
In a similar vein, public health data broken down to the neighborhood level for the largest 500 Cities in the nation will be available on an interactive website starting this week, thanks to a collaboration between RWJF, the Centers for Disease Control and Prevention, and the CDC Foundation.
This granular data source gives anyone living in these regions—from public health stakeholders to local residents—the ability to retrieve, visualize, and explore uniformly defined city and census tract-level data on 27 chronic disease measures, health outcomes, and clinical preventive service use.
RWJF says the data will empower anyone to better see how health varies by location and plan tailored interventions.
Until now, public health officials and other policy wonks were limited by health data available at only the state or county level. This new data source brings that down to the neighborhood level, where local policy makers will be able to identify risk behaviors associated with illness and early death, and health conditions and diseases that are the most common, costly, and in many cases preventable.
The 500 Cities webpage is the latest and most detailed of a number of data sources on public health that includes the annual County Health Rankings and America's Health Rankings, a nationwide public health and state-by-state ranking system that using 34 measures of behaviors, community and environment, policies, and clinical care data; and the VCU Life Expectancy Maps, which illustrate dramatic variances in life expectancy from neighborhood to neighborhood.
Local public health advocates need all the tools they can get to understand the public health threats that pose the greatest challenges to their service areas, especially at a time when the Affordable Care Act, Medicare and Medicaid are under consideration for fundamental redesign.
Data sources such as 500 Cities won't necessarily provide the answers, but they will help policy makers assess the challenges, and where best to steer scant resources.
The proposed rules are seen as an interim measure to stabilize the Obamacare market in the short term, while Congress and the Trump administration work to repeal and replace the Affordable Care Act.
New rules proposed this month by the Department of Health & Human Services would stabilize health insurance exchanges created by the Affordable Care Act and would be credit positive for hospitals and insurers, Moody's Investors Service says.
"Hospitals benefit from functioning health insurance exchanges because they are the primary vehicle for individuals to purchase health insurance and a smaller uninsured population reduces the bad-debt expense that hospitals need to absorb," Moody's said in a Credit Outlook published this week.
"The proposal aims to improve the profitability of health plans offered on the exchanges so that insurance companies are incentivized to continue offering them," Moody's said.
"Specifically, the proposed rules aim to improve the risk pool by limiting people's ability to only sign up for insurance when they need medical treatment. The rules would shorten the annual enrollment period, enhance oversight of consumers who enroll during special enrollment periods, and would require consumers who owe premium payments from prior years to settle those debts before being permitted to renew their annual enrollment."
Good for Non-Profits
Non-profit hospitals with large insurance operations could also benefit from the rules changes. Specifically, Moody's cited these organizations: Intermountain Healthcare in Salt Lake City, UT; University of Pittsburgh Medical Center; Geisinger Health System, based in Danville, PA; and Presbyterian Healthcare Services, in Albuquerque, NM.
Moody's estimates that the health insurance industry lost $3 billion on the exchanges in 2014 and more in 2015. The losses likely continued in 2016, but they were offset somewhat because of higher premiums, redesigned plans and more selective participation.
While the proposed rules are seen mostly as a credit positive for hospitals, there is the potential for some credit negatives because they will prevent some people from obtaining health insurance, particularly people in need of medical care.
"As an isolated factor, this is credit-negative for hospitals because it will lead to an increase in bad debt and uncompensated care," Moody's said. "However, despite this negative aspect of the proposed rule changes, hospitals stand to lose more from the exchanges collapsing."
Payers Support the Rules
The proposed rules changes have the support of America's Health Insurance Plans, the insurance industry group headed by former administrator of the Centers for Medicare & Medicaid Services, Marilyn Tavenner.
"We commend the Administration for proposing these regulatory actions as Congress considers other critical actions necessary to help stabilize and improve the individual market for 2018," said Tavenner, AHIP's president and CEO.
"Our commitment is to ensure short-term stability and long-term improvements," Tavenner said. "While we are reviewing the details, we support solutions that address key challenges in the individual market, promote affordability for consumers, and give states and the private sector additional flexibility to meet the needs of consumers."
The healthcare quality rating service claims that patients treated in their Top 100 hospitals have a 27% lower risk of dying than patients treated in hospitals that did not receive the award.
Healthgrades, the online healthcare provider rating service, this week released its widely read list of America's 50 and 100 Best Hospitals for 2017, with few changes seen from the 2016 list.
As in 2016, the Top 50 hospitals, representing the top 1% of all hospitals, were located in 22 states. No hospitals cracked the Top 50 in 28 states, nor the Top 100 in 23 states. California had the most Top 50 hospitals, with 10, and 12 other California hospitals were in the Top 100. Illinois followed with all seven of its selections in the Top 50.
Massachusetts placed only one hospital on the Top 50 list: Baystate Medical Center, a 716-bed independent academic medical center in Springfield. Only three other Massachusetts hospitals made the Top 100 list, down from eight in 2016.
Healthgrades designates Top 100 hospitals as those have been in the top 2% of hospitals in the nation for exhibiting clinical excellence for at least three consecutive years. The Top 50 hospitals are those have been in the top 1% for at least six consecutive years.
Healthgrades evaluates hospital quality for conditions and procedures based solely on clinical outcomes for the most common in-hospital procedures and conditions and adjust for risk factors, such as age, gender and medical condition.
The analysis is based on more than 45 million Medicare medical claims records for the most recent three-year time period available from nearly 4,500 hospitals nationwide.
Healthgrades says the top performing hospitals also outperform their peers in treating a core group of conditions that account for more than 80% of mortalities in areas evaluated by Healthgrades, including heart attack, heart failure, pneumonia, respiratory failure, sepsis, and stroke.
Patients treated in Healthgrades' Top 100 hospitals have, on average, a 27.1% lower risk of dying than if they were treated in hospitals that did not receive this award. If all hospitals, as a group, performed similarly to the Healthgrades Top 100, on average, 179,438 lives could have been saved.
In a whitepaper released with the rankings, Healthgrades said that many Top 100 hospitals engage patients as participants in their care. For example:
Virginia Mason Medical Center in Seattle, WA implemented the Orthopedic Patient-Peer Partner program, an idea put forth by the medical center's orthopedic patients who have undergone joint replacement surgery and return as volunteers to support others who are preparing to undergo hip, knee or shoulder replacement.
HealthPartners hospitals in Minnesota works with first responders to extend care to patients in their homes. Through the Community Paramedic Program, the two largest hospitals in the HealthPartners system work with local first responders to help patients participate in their own care.
Penrose St. Francis Health Services in Colorado Springs, CO, which has been named one of America's 50 Best Hospitals for 10 consecutive years, uses multiple strategies to engage consumers, including an inter-visit communication program that provides digital health coaching.
"Hospitals that have achieved America's Best Hospitals distinction have sustained high quality outcomes for their patients over many years and often, offer programs that engage consumers and their overall communities in their care," Healthgrades CMO Brad Bowman, MD, said in remarks accompanying the study.
"Healthcare consumerism is requiring hospitals and health systems to innovate in a variety of areas, including quality, to meet growing expectations about the level of care, personalization and convenience," he said.
Fresh out of medical school and residency, Van Breeding, MD, could have gone anywhere to practice his profession. The son of a coal miner returned to his home in Eastern Kentucky.
Eastern Kentucky has acquired some dubious distinctions over the years. The rugged corner of Appalachia has some of the nation's highest rates of obesity, tobacco use, diabetes, high blood pressure, cardiovascular disease, various cancers, and respiratory illnesses such as black lung and emphysema.
Not coincidentally, the region is also one of the nation's poorest, and prospects have gotten bleaker with the demise of the coal industry. Unemployment in Letcher County, nestled on the Virginia state line, stands at 9%, nearly twice the national average, the poverty rate is above 28%, and local healthcare workers say that many of the 500 or so annual births at Whitesburg Appalachian Regional Healthcare Hospital are delivered by women addicted to opiates and other drugs.
As a newly minted physician fresh out of medical school and residency at the University of Kentucky in 1991, Van Breeding, MD, could have gone anywhere. He chose to return to his hometown of Whitesburg and a career that beckoned with an irresistible call for 16-hour work days, few vacations, scant resources, and low pay.
"Going somewhere else was never ever a thought," says Breeding, 55. "I grew up in this town. I went to high school in this town. All of my family is in this town. My patients are either family or friends of mine."
As a child, Breeding witnessed the societal costs that the coal industry exacted upon the people who worked in the mines and lived in the surrounding area. His father was a miner who was disabled and blind by age 50. At age 7, Breeding watched as his grandmother nearly died from lack of access to care after suffering a heart attack. His good friend, a former high school quarterback, has black lung.
With the coal industry in decline, Breeding, a self-described "Hillbilly Doctor," is dealing with a new set of population health problems that center around poverty and a lack of access to care, including obesity, cardiovascular disease, diabetes and malnutrition. In 2009, one of Breeding's colleagues was murdered by an addict desperate for pain medication.
Breeding practices with Mountain Comprehensive Health Corp. in Whitesburg, one of more than 1,600 government-subsidized community health centers nationwide. His patients are mostly poor and uninsured.
On an average day Breeding works 16 hours, starting with 5 AM rounds at the hospital. He sees about 40 patients a day at the clinic, and then rounds at the nursing home at night. He also makes house calls.
There were only five practitioners at MCHC when Breeding arrived more than 25 years ago. Now there are more than 40 clinicians, and the clinic has expanded from two to seven sites.
Thanks to the Affordable Care Act, Breeding says MCHC has the funding to provide dental and optometry services, and even venture into population health.
Obamacare's Impact
Proactive community outreach efforts by MCHC have created pioneering programs to address diabetes through a "Farmacy Program" that improves access to fresh fruits and vegetables. A colon cancer initiative that improved screening rates from 18% to 60% was lauded by the Centers for Disease Control and Prevention.
Breeding bristles when he hears Kentucky's political leaders vow to repeal the ACA "root and branch."
"It drives me crazy, because I feel in my heart that at Mountain Health Corporation we have the blueprint of what healthcare should be," he says. "If you can practice healthcare like this anywhere in the United States, you are going to have great outcomes."
"There are a lot of drawbacks on stopping Obamacare because these people need preventative care," he says. "If this goes away, we will have to discontinue dental and optometry and we won't be able to have extended hours because we won't have the funding."
"It is going to make a huge difference for healthcare here in an area where we have the highest rates of diabetes, heart disease and high blood pressure and local forms of cancer in the coal fields here in East Kentucky. We rank poorly but we definitely made progress on improving those numbers in the areas where we have a clinic and we have the proof."
Breeding's work has not gone unnoticed. Earlier this year he was named Country Doctor of the Year by Staff Care. Breeding says he will decline the two-weeks of time off that comes with the award, and will ask Staff Care to donate $10,000–the value of the temporary physician services that would have covered his absence–to 20 local charities.
"I don't trust my patients with anyone else," he says.
More than one-in-five healthcare professionals in the United States is foreign-born. The trickle-down effect of a federal travel ban may discourage some providers from practicing their badly needed skills here.
In the 1930s, sociologist Robert K. Merton popularized an idea that's become known as the Law of Unintended Consequences, which has come to mean outcomes that are not intended or foreseen by a purposeful action.
A recent example of the law is the 90-day travel ban imposed on Jan. 27 by President Donald Trump. The ban extends to people in seven majority-Muslim countries: Iran, Iraq, Libya, Somalia, Sudan, Syria and Yemen.
The controversial order has been blocked by a federal judge in Seattle, but the Trump administration is appealing that ruling and requesting an expedited hearing before the U.S. 9th Circuit Court of Appeals.
President Trump has said the temporary ban is needed to ensure that vetting processes for people from those countries are adequate before visa are issued for entry into the United States. Critics say that adequate vetting is already in place and that the ban specifically discriminates against Muslims.
Observers in the healthcare sector fear that one unintended consequences of this ban will harm healthcare delivery in the United States, particularly in underserved areas, both rural and urban.
"More than 22% of all healthcare workers are immigrants, and 28% of those workers are physicians and surgeons," says Jeanne Batalova, senior analyst at the Washington, DC-based Migration Policy Institute.
Batalova says that doctors from the seven countries under the travel ban account for 7% of all immigrant doctors in the United States. "That is a substantial number," she says. "There is a significant over-representation of doctors from these seven countries among immigrant doctors and surgeons."
Batalova says the ripple effects could extend further than the seven countries specified in the ban.
"A lot of groups understood this ban as anti-immigrant more broadly and definitely an anti-Muslim ban," she says.
"The interpretation of what the ban means and how it is going to be implemented will vary a lot, and it will vary over time, because when the ban was initially announced a much broader group was included, including legal permanent residents who were denied access to get on the plane. People who are currently in the pipeline to obtain a green card, they are banned from the admissions."
'Some May Choose Not to Come Here'
"Also, we've seen from some reports that the customs and border patrol officers in different areas interpreted the executive orders somewhat differently," Batalova says.
"In some airports they were saying this group is not affected, but in another airport the same group could be denied access. At the moment it is too early to tell because the executive order did not have very detailed rules that would serve as guidance for consistent policy and application."
Rasheed Ahmed, executive director of the Islamic Medical Association of North America says the travel ban has created uncertainty and angst and sends a message that is less than welcoming.
"Given this situation, some might not be allowed in, and some may choose not to come here. They don't want to have this uncertainty for themselves or their families," Ahmed says. "They may choose to go to some other countries in the Middle East or Europe. They may say this is not worth it."
"Those who are in the United States may worry about leaving," he says. "Those who are outside the United States for some reason may not be able to come in, and the potential healthcare experts we need in this country may have second thoughts about their future in the United States."
Physician Shortage Persists
That fear was shared by Association of American Medical Colleges President and CEO Darrell G. Kirch, MD, who said his member schools are "deeply concerned that the Jan. 27 executive order will disrupt education and research and have a damaging long-term impact on patients and healthcare."
"The United States is facing a serious shortage of physicians. International graduates play an important role in U.S. healthcare, representing roughly 25% of the workforce," he says, adding that existing "pathways that include student, exchange-visitor, and employment visas provide a balanced solution that improves healthcare access across the country through programs like the National Interest Waiver and the Conrad 30 J-1 Visa Waiver."
In the last 10 years the Conrad 30 J-1 Visa Waiver by itself has brought nearly 10,000 physicians into rural and urban underserved communities.
"Impeding these U.S. immigration pathways jeopardizes critical access to high-quality physician care for our nation's most vulnerable populations," Kirch says.
The president of the Ohio Hospital Association says the 'root-and-branch repeal' of the Affordable Care Act would greatly disrupt healthcare delivery in the Buckeye State, especially if it's not immediately replaced with a workable alternative.
Regardless of which party is in power, the Patient Protection and Affordable Care Act is in need of a considerable overhaul, says Ohio Hospital Association President and CEO Michael Abrams.
Failing co-ops, anxious payers, and unaffordable premium hikes are among the many facets of the sweeping legislation that need to be revisited, assuming that the Trump Administration and Congress don't eliminate the law altogether, he said.
Abrams spoke recently with HealthLeaders Media. The following is a lightly edited transcript.
HLM: What needs to remain in place for hospitals if the ACA is repealed?
Abrams: Whatever we replace it with, those one million Ohioans who gained coverage under the ACA need to maintain that access to healthcare.
As we talk about replacing [the law] we need to make absolutely sure that coverage remains a priority. If they want to go back and ask why the co-ops failed, why the insurers are skittish about functioning on the exchanges, and why premiums are going up, those are fair questions that a President Clinton would have had to confront as well.
But repealing root and branch and throwing those one million Ohioans into the ranks of the uninsured is ill-advised for hospitals, the Republican Party, and for the one million people who would lose coverage.
HLM: Given the importance of Ohio as a swing state, is Washington listening?
Abrams: Trump's victory in Ohio was decisive. We have eight statewide office holders in Ohio who are Republicans and both chambers of our state legislature are overwhelmingly Republican.
The largest employer in the state of Ohio is the Cleveland Clinic. Community hospitals in our state employ 250,000 people. We are important because of the work we do, but we are also an important part of Ohio's economy. A quarter million people get a paycheck from a community hospital.
Our members are running multibillion dollar companies in these large health systems. They are reporting to boards that are made up of bankers and other business people. We are not an industry that is characterized as hand-wringing liberals.
But by the nature of the work we do in all 88 counties, we do have a community benefit and community service foremost in our mission.
HLM: Is "access" enough or does it have to be affordable?
Abrams: There is a real possibility that the answer to that question is no. I would be concerned if I were a payer. They have talked about retaining the ban on pre-existing conditions but doing away with the individual mandate.
I don't know how the insurance industry can underwrite for that. People are going to have the ability to gain insurance coverage, but they won't have to. Mathematically that is going to be impossible for the industry underwrite.
Premiums that are already going up exponentially could reach into the heavens at that point. I would be very concerned about whether that is manageable.
HLM: Would Ohio hospitals support a transition to block grants for Medicaid?
Abrams: I would find it unimaginable that Congress would want to do unrestricted block grants. At some point they're going to want to put policy guard rails around that. I can see states that are less-conservative than the Republican Congress might implement those block grants in a way Congress would find distasteful.
Looking at my neighbor in Indiana, it is probably a fair indication of where they might be going philosophically, in that Mike Pence is now vice president and Seema Verma is presumably going to be CMS director.
They talk about skin in the game and potentially charging premiums, copays, and deductibles and things like that that frankly, in many states, like Ohio, would be a step back. In some other states that have done no Medicaid expansion, that would be considered some level of progress.
HLM: Could Ohio hospital survive significant Medicaid funding cuts?
Abrams: Depending upon how the funding cuts were to be layered in, it's possible. I don't want to say no cuts no how. But I do fear that large draconian cuts that are blind to policy impact and the impact on beneficiaries are very ill-advised for the Republican Party and for the states.
But if they were to say to me 'we think that there are some pharmaceutical efficiencies that can be gained, or there are some programmatic things we could do differently to gain some efficiencies in state Medicaid programs,' I would be all ears.'
Much of what makes healthcare expensive is not subject to legislative remedy. For example, we have a major opioid and heroin problem in Ohio. Because of that, we have a major problem with neo-natal abstinence syndrome. You can save their lives, those babies, but they are very expensive to treat.
What makes healthcare expensive very often are things like obesity and smoking and opioid-addicted mothers. I hope Congress is at least intellectually curious about some of those cost drivers as they look to gain efficiencies in how we allocate resources in taking care of poor people.
HLM: What about the push to negotiate lower drug prices in Medicare?
Abrams: It could have a positive effect on that piece of the pie. Macro-economically, when you look at the totality of the Medicare program, I cannot imagine that that will have a gigantic impact.
Again, some of the things that make healthcare expensive extend so far beyond one element, but that doesn't mean you shouldn't address it. It's still smart to talk about it and do what you can. But, some of the other things that are making healthcare expensive are not necessarily going to be captured by those policies.
HLM: Would Ohio hospitals oppose Medicare vouchers?
Abrams: From a hospital standpoint, the devil would be in the details. Our people would have a lot of concerns about it.
The whole reason that the Obama Administration took up healthcare is because it's an important economic force in our country. I am not surprised it is back in the spotlight because the law was flawed.
There are lots of opportunities to make positive reforms, but there are also opportunities to make the situation far worse. I am just hoping that they are slow and measured as they consider all these options.
HLM: How debilitating is this lack of certainty for hospitals?
Abrams: I used to feel guilty about not knowing until I would go to meetings and listen to people far smarter and more plugged in than me. But there is just a big shoulder shrug among well-placed policy wonks who just don't know what to predict.
It's all a parlor game and speculation, which can be entertaining. But, I am talking to hospital members for whom it's not a parlor game. They are putting together organizational budgets and they don't know how to budget for the next couple of years. It's a stressful time to be in this segment of the economy.
HLM: What are hospital leaders telling you?
Abrams: There is a lot of anxiety because of the big question marks. In any industry, no one likes uncertainty. There is so much uncertainty because of the political earthquake that this country delivered last November. It's created a lot of anxiety.
People are hiring. They are putting together service lines. They are addressing service lines such as behavioral health, and they are saying 'well, should we continue to build in this method? Should we continue to invest as our long-term strategic plan directs us, or do we need to revisit those plans based on what might happen to us economically?'
I don't talk to anybody who thinks that the situation is going to get easier.
HLM: How is it affecting hospital operations?
Abrams: I don't think it is affecting day-to-day operations at all. When we go to hospital board retreats, a lot of the conversation is around what's going to happen, and they are bringing in experts from the political world and they're all saying 'we're just not sure."
HLM: How do you keep OHA above the politics?
Abrams: I tell our advocacy squad that we have the ability to influence what adjectives people use when they describe us. I prefer that they use words like 'learned,' 'thoughtful,' 'measured' and 'scholarly,' as opposed to hiring a bunch of lobbyists to scream at lawmakers.
We have hired analysts, an economist, and people with that kind of expertise so we can chew through the policy and say this makes sense, or this is what we would not prefer, it's a step back.
We have to be curious about other options beyond expanding Medicaid. We have to be open-minded to other ideas. If they offer something that works, we have to be open-minded. That allows us to transcend partisan politics.
Non-profit hospitals and health systems that raise more money than peer institutions target major donors and invest more resources in fundraising.
Spending money to raise money and targeting major gifts instead of annual gifts provide good returns investment, according to a new report from the Association for Healthcare Philanthropy.
AHP's annual Report on Giving defined high-performing organizations associated with non-profit hospitals and health systems as raising more net funds than 75% of all responding institutions.
These high-performing organization allocated an average 13.5% of resources to research on potential donors and major gifts, compared with 6.4% of resources for all institutions. In FY 2015, the median amount raised by high performers was more than $11.9 million.
AHP said that a key difference between high performers and lower-performing organizations was the type of fundraising activities pursued. High performers focus less on annual gifts and special events while putting more emphasis on major gifts and corporate giving as their major fundraising sources. Planned giving also accounts for a higher share of fundraising revenue for high performers than the average institution.
"Organizations should utilize all channels for giving, but those that raise money most effectively focus their efforts on the most productive fundraising activities," AHP President and CEO Steven Churchill said in remarks accompanying the report.
Foundation
Location
1
Dignity Health
San Francisco, CA
2
Children's Hospital Los Angeles
Los Angeles, CA
3
Seattle Children's Hospital Foundation
Seattle, WA
4
Sutter Health
Sacramento, CA
5
Miami Children's Health
Foundation
Miami, FL
6
Wake Forest Baptist Medical Center
Winston-Salem, NC
7
Boston Medical Center
Boston, MA
8
Hoag Hospital Foundation
Newport Beach, CA
9
UMass Medical School / UMass Mem
Shrewsbury, MA
10
Medstar Health
Columbia, MD
AHP's Report on Giving surveyed 199 institutions on their FY 2015 philanthropic activities, for response rates of 15.6%. AHP said it was not authorized to reveal the amount raised by each healthcare institution.
AHP's 5,000 members in the United States and Canada represent more than 2,200 healthcare organizations in North America and abroad that raise more than $10 billion each year.
Medical doctors don't need to undergo a near-death experience to better engage with patients. What they need is empathy, says a pulmonary disease specialist who learned first-hand.
It took her own near-death experience in 2008 for Rana L.A. Awdish, MD, to comprehend the gulf in empathy that exist between hospital staff and the patients in their charge.
Awdish, who specializes in pulmonary disease, critical care medicine, and internal medicine at Henry Ford Health System in Detroit, MI, details her experience in a recent essay in the New England Journal of Medicine.
She spoke with HealthLeaders Media about the need for understanding the patient perspective. The following is a lightly edited transcript.
HLM: What is needed to understand the patient perspective?
Awdish: You don't need a near-death experience. What you need is empathy. Physicians have many things that they have to tend to every day. We cut back on those conversations that connect us with our patients. That is a mistake.
All of that is reciprocal and it's why we went into medicine in the first place. But we are at risk of demoting that on the list of things that are important in the day, just because of the many demands placed on us.
In every encounter, center yourself with your patient and try to understand from their perspective what they are going through, because that is the first step of empathy, taking the perspective of another person.
HLM: What happened in your experience as a patient that allowed you to see the lack of empathy that you had not seen as a physician?
Awdish: My position changed from being the physician to being the patient, being in the patient's bed.
The things I thought my patients needed from me, the highly technical expert care we deliver so proficiently, I took that as a given. I knew that would happen.
I didn't know that as a patient I would have needs beyond that. That sounds naïve, that I perceived that all my patients wanted was to get well, but I truly saw suffering as an extension of the disease. I thought my role was to cure the disease, or at least treat it, and the suffering would be alleviated. There was no reason to tend to it in the moment because it would just delay solving the problem.
HLM: How do you walk the line between empathy and being overcome by patients' suffering?
Awdish: There is this idea that we are all taught in medical school about the necessity of partition, maintaining composure regardless of the circumstances so that your emotions are not the ones in the room that matter.
We were taught that both as a means of preservation, but also of protecting our patients from our emotions. I would argue that that [guidance] is antiquated and misguided. To foster resilience in physicians there have to be moments of connection and shared purpose and attention to suffering because that is what fulfills us in the end.
It is not prescribing the right anti-hypertensive. It's connecting with our patients as people, feeling their suffering and feeling that you have alleviated it somewhat.
We don't get depleted by that. There is reciprocity in that. That is the frameshift that has to happen. The fear of connection is misguided.
HLM: Can empathy that be taught?
Awdish: If it's not, I should retire because I am fully convinced that it is where we need to go. Yes, there is good evidence that perspective taking can be taught, that having a sense of your own implicit bias can be taught, and that it can be improved upon. We use situational learning to do that, but there are many avenues by which we can affect change.
HLM: What have you done at Henry Ford to address empathy?
Awdish: The first thing was to start a discussion. We developed programs that are professional development tools.
We spend all of our time in medical school and residency and fellowship learning clinical skills and content and we don't spend a lot of time developing our emotional intelligence, our narrative competence, our ability to get a history from someone that is authentic to who that person is, but not just trying to corral them into 'yes' and 'no' answers.
Everyone goes into medicine because they want to do right by their patients, and they don't want to harm them. We in medicine have a history of unintentionally harming our patients through our behaviors, and so we are all focused on changing that.
HLM: What metrics do you use to know you are succeeding?
Awdish: The measure of success that I care about most is this sense of relationship between physicians and their patients. One of the tools to measure that is physician engagement. When physicians have relationships that are nurturing and fulfilling and their patients are co-creating a care plan with them, those physicians have longevity.
CMS has a measure called CAHPS, which looks at provider communication, which measures how effectively we are communicating as rated by our patients. It's under the umbrella of patient satisfaction, and all of those intangibles that go into someone wanting to recommend your practice or wanting to come back to you.
There are issues with the survey, as there are with every tool, but we have to embrace it and note that physician communication drives those scores.
HLM: How do you avoid making this 'one more thing' that frazzled physicians have to contend with?
Awdish: There are very few interventions that you can make in healthcare that not only engage the patient in their own care, that also improve adherence to medication, but also improves provider engagement and longevity and resilience.
That is the Holy Grail. How do we make patients happy at the same time as we are engaging providers and enhancing their professional fulfillment? This to me is so tangible.
We were medical students who were thrown into family meetings with no skills, no road map, no plan for how to get from A to B, no sign posts to watch for.
Until I found those tools, I would find ways to avoid those situations because I wasn't skilled. Being shown what to do gave me the courage to enter those conversations knowing they would turn out OK and I could help people and not wreck myself in the process.
There are very few things that can do that, that can engage both sides. It's team building, so when nurses are drawn into this, the whole team functions better. I don't think there is a downside to communication training.
HLM: There are thousands of employees at hospitals. How do you get everyone on the same page?
Awdish: No one has the resources to assign one-on-one care coordinators. When you orient people to a mission, when as an institution you let people know what their value is and not just their jobs, and you engage them in patient care in whatever position they are in, that they understand they are part of the care team, it translates across the culture.
These are not things that are specific to physicians and nurses. If you are in healthcare you need these skills because you have points of contact and you cannot imagine the impact you have on patients.
That is part of what we do at the new employee orientation. It is transporters, and billing clerks, and radiology techs, and everyone engaged in the process. To show them what it means to work here and the lives that you can impact, when maybe you don't think that that is what you signed up for when you signed up for the job. It changes the conversation.
HLM: Can what you're recommending be done at hospitals with few resources?
Awdish: You can start with a simple focus on empathy, which is taking the perspective of the other person, identifying what you see that they are feeling, whether it is sadness or anxiety or being overwhelmed, and reflecting it back to them so they know they are being seen. In many ways that is what is missing in healthcare.
Our patients feel they are seen as diseases rather than as people who are bearers of disease. By reinserting empathy in every interaction you can overcome much of that.
Health system leaders, hospital communities, and the AHA are expressing concern about the travel ban issued by President Donald Trump.
Citing the experiences of his immigrant grandparents, Montefiore President and CEO Steven M. Safyer, MD, offered a spirited critique of the travel ban imposed Friday by President Donald Trump.
"We are in the midst of a challenging time," Safyer wrote in a letter this week to colleagues at the Bronx, NY hospital. "The ideals upon which our nation was built are being questioned."
"My grandparents settled in the Bronx from Poland escaping persecution and found a community that embraced them in a country that gave them an opportunity to build a new life," he wrote. "As an institution, Montefiore was founded on our commitment to healthcare as a basic human right, and we continue to live our values of humanity, innovation, teamwork, diversity and equity."
Safyer said the hospital would not cooperate against any attempts to violate access to healthcare or medical training. That includes:
Refusing to provide information about the immigration status of patients, students, or employees without due process legal proceedings.
Refusing any attempt to learn or question anyone about their immigration status, except as legally required.
Treating equally all applications to the Albert Einstein College of Medicine or graduate programs regardless of their immigration status.
Continuing to provide financial aid and other support services for students regardless of their immigration status in the event that the Deferred Action for Childhood Arrival policy is curtailed.
"Montefiore will not waiver on our commitment to our principles," Safyer wrote. "We will continue to stay true to our values in support of our patients, associates, students, trainees and community."
AHA, Other Health System Reactions
Safyer offered one of the more strongly worded criticisms of the travel ban. The American Hospital Association was more circumspect as it raised concerns that the ban would negatively affect healthcare delivery.
"We are concerned that, without modification, President Trump's executive order on immigration could adversely impact patient care, education, and research," AHA President and CEO Rick Pollack said in a media release.
"We are hopeful that the Administration will find solutions to preserve patient access to medical and nursing expertise from across the globe, ensuring care is not disrupted. Hospitals and the patients we serve often rely on international collaboration among clinicians to advance care and an efficient visa program is essential to their success. We rely on a diverse workforce to deliver the care patients and families need. We will work with the Administration to come up with a solution that patients can continue to rely on for their care."
The Mayo Clinic said this week it was "currently assessing the situation," particularly as it relates to the status of 80 staff, physicians and scholars, and 20 patients who have ties to the seven country included in the executive order.
"We are not aware of any Mayo Clinic staff traveling for Mayo Clinic business who are currently affected. We are not aware of any Mayo-sponsored non-immigrant visa holders who have been immediately affected. We are still unsure of how Mayo staff and their families who are traveling for personal reasons may be affected," Mayo said in a media release.
"A number of Mayo Clinic staff and trainees have expressed concern about the potential impact this order may have on their future plans, and we are working to more fully assess and advise on these concerns in a rapidly changing legal environment."
On Sunday, Mayo Clinic CEO John Noseworthy, who last month met with President-elect Trump, expressed concern and added that he was "actively monitoring this situation."
Also this week, Yale New Haven Health System told its more than 20,000 employees that all noncitizens should "strongly consider" not leaving the country because of the travel ban, while Hartford HealthCare CEO Elliot Joseph wrote in a blog post that "people of all political persuasions are feeling a bit inundated by—and confused about—recent changes to entry requirements to the United States, and related court decisions."
An open letter to Toby Cosgrove, MD, CEO of the Cleveland Clinic, urges the organization to reschedule a fundraiser planned to be held at a Trump-owned facility, and to condemn the travel ban.
The letter is signed by medical students, residents, physicians, and other healthcare workers opposed to "the Cleveland Clinic silently continu[ing] to promote ties with the Trump administration."
Cosgrove is a member of the White House's "strategic and policy" forum and did not immediately comment on the letter, which was posted Tuesday.
Asked about the fundraiser, Clinic spokeswoman Eileen Sheil told CNBC there would be "No change for this year," but added that "we are not committed after this year's event."
