The Federal Trade Commission says consolidation of Cabell Huntington Hospital and St. Mary's Medical Center is anticompetitive, but shielded by state law from federal antitrust enforcement.
The Federal Trade Commission has decided to drop its challenge of the proposed merger between two Huntington, WVA hospitals, but not without a parting shot at a recently passed state law that made the "potentially anticompetitive" deal possible.
The commission last week dismissed its administrative complaint challenging the proposed merger between Cabell Huntington Hospital and St. Mary's Medical Center, two hospitals located three miles apart.
While maintaining that the merger would hurt competition in the region and result in higher healthcare costs, the commission dismissed the complaint on a 3-0 vote after West Virginia lawmakers passed a "cooperative agreement" with the hospitals, which was approved by the West Virginia Health Care Authority and the state's attorney general.
"This case presents another example of healthcare providers attempting to use state legislation to shield potentially anticompetitive combinations from antitrust enforcement," the Commission wrote in a statement.
"The Commission believes that state cooperative agreement laws such as SB 597 are likely to harm communities through higher healthcare prices and lower healthcare quality."
"If you harken back to some of the previous Supreme Court cases that dealt with state action doctrine, West Virginia passed legislation that empowered a government entity to oversee hospital consolidations and provided a mechanism to actively supervise it," says Levine, a disinterested observer.
"We can surmise the FTC thinks the state did a decent job to qualify for state action doctrine immunity to the antitrust laws, so the merger can't be challenged by federal antitrust authorities."
"They don't like when states try to do it. They don't think it's good for consumers or the healthcare industry and they made that displeasure well known, but nevertheless they have to face the reality that it would be an uphill battle to effectively challenge the merger," Levine says.
2 Steps Toward Immunity
To gain immunity, Levine says states have to do two things:
"Clearly articulate a state policy to displace competition. They usually do that through legislation."
"Provide a mechanism that the conduct is actively supervised by the state, the policy reason behind it being that to ensure that in fact what is being done is in compliance with the state desire to displace competition and nothing else."
The commission warned that its decision to drop the administrative complaint should not be interpreted as a retreat on antitrust enforcement in the healthcare sector.
"We will continue to vigorously investigate and, where appropriate, challenge anticompetitive mergers in the courts and, if necessary, through state cooperative agreement processes," the commission said. "Our decision to dismiss this complaint without prejudice does not necessarily mean that we will do the same in other cases in which a cooperative agreement is sought or approved."
Levine says it's hard to say if West Virginia is on the leading edge of a trend to sidestep federal antitrust regulations. "It really is a state-by-state issue," he says. "What is their political and economic philosophy? Do they want antitrust enforcement or do they want consolidations and cooperation?"
As a side note, the commission bristled at suggestions from West Virginia officials that the consolidation was needed because antitrust laws hinder care collaboration and coordination mandates under the Patient Protection and Affordable Care Act.
"This is fundamentally incorrect," the commission wrote. "The ACA did not repeal the antitrust laws, and it certainly does not condone mergers that substantially lessen competition."
"You can almost hear the frustration in these statements," Levine says. "Time and again the parties defend their actions arguing that the ACA, if it is not compelling their activity, at least promoting it, and that they can't be faulted for trying to comply with the goals of the ACA."
"The FTC continues to come back with the argument that the ACA does not mandate, compel, or recommend anticompetitive activity and that there are all sorts of collaborative associations that can be implemented that do not run afoul of the antitrust laws," he says.
"There is this ongoing battle. The mantra on either side is not going to change."
The Philadelphia-based academic medical center is building a 'hub-and-hub' health system that provides care in lower-cost community hospitals and pushes value over volume.
Traditional hospital mergers and acquisitions create a hub-and-spoke model. The hub hospital, usually a large urban acute care or academic medical center, picks up surrounding community hospitals, often financially stressed, to build a regional referral network and—often left unsaid— to create a larger footprint to improve leverage with payers.
Stephen Klasko, MD, president and CEO of Jefferson Health, says the Philadelphia-based health system is turning that model upside down and creating a delivery system that aims to treat patients in the communities where they live.
By acquiring financially sound community hospitals and providing care in those less-expensive settings, Klasko says the Jefferson Health model can avoid the increases in the cost of care that usually occurs when hospitals consolidate.
"It is asinine to believe that, if you are an academic medical center that's trying to bring in troubled community hospitals so they can send more patients to your expensive hospital downtown, prices will go down," he says. "Our model is 180 degrees from that."
Last week, Jefferson Health finalized its acquisition of the three-hospital Aria Health system, coming a little more than one year after the acquisition of Abington Health.
The combined system includes eight hospitals, 32 outpatient and urgent care facilities, and dozens of physician practices, and about 23,000 employees, all of which is governed by a board trustees that has an equal number of representatives from the academic medical center and the various community hospitals.
"The control is literally across the entire enterprise," Klasko says. "The vision of the board is to look for what is best for the community rather than what is best for downtown."
Jefferson is also in the process of acquiring Kennedy Health, a three-hospital system serving southern New Jersey.
"One thing that is different about our model is that all of our mergers have been shared governance, hub-and-hub mergers with other systems that didn't need to do anything," Klasko says.
"We don't even respond to someone who says we need $200 million to survive."
Keeping Patients in Their Communities
Former Aria CEO Kathleen Kinslow says the health system went into the merger with a "goal to keep patients in their communities."
"When we were going through the process, two things that we had in the forefront were to be able to maintain our mission and to serve patients where they live. Bringing the expertise of an academic medical center into the community allows that to happen," says Kinslow, now the executive vice president and chief integration officer at Jefferson.
"Through the integration process, one of the things as we bring the service lines together is to look at total cost of care. At Abingdon and Aria, based on where we are geographically, the cost of care is lower. Instead of transferring patients to the city hospital, it's keeping them in the community and developing those protocols and systems that need to surround care pre- and post-operatively, and what you need to do in the community will all be continued to be developed."
"The metric we will continue to look at is total cost of care and quality outcomes," Kinslow says. "You can have low cost of care but poor outcomes that wouldn't be advantageous. All organizations have a strong commitment to quality and safety."
Klasko says Jefferson has demonstrated a history of success in population health and cost containment with its participation in the Delaware Valley Accountable Care Organization, a Medicare shared savings program.
"We were one of the top five or six receivers of dollars for quality/cost ratio in the last go around with (Centers for Medicare & Medicaid Services)," he says. "The fact is we are investing lots of dollars investing all the things you ought to do in going from volume to value while frankly some others are doubling down on the old way, and that is why costs haven't gone down."
As for consolidation restricting competition, Klasko says that doesn't apply to Jefferson.
"The beautiful thing about Philadelphia is we have six academic medical centers within walking distance of each other," he says. "We'd have to get a hell of a lot bigger to worry about that."
Last year Ohio's hospitals began a campaign to reduce sepsis encounters and related deaths by 30% by 2018. Nine months into the initiative, the OHA is reporting an 8% reduction in mortality.
First impressions can be misleading.
A quick look at the numbers suggests that Ohio's hospitals are in the midst of a fast-growing sepsis epidemic:
In 2012, the Buckeye State's 220 hospitals reported 26,299 encounters with severe sepsis and septic shock, resulting in 6,250 deaths. In 2015, those numbers had ballooned to 38,487 reported encounters and 7,478 deaths.
Of course, the reason why sepsis numbers are rapidly rising is because reporting systems such as ICD-10 have improved the ability to accurately report the infections, especially upon admission, which is where 80% of sepsis cases are traced.
But even with the proper context, the numbers are alarming and demand a response.
"Because we are encouraging people to identify it, we are not surprised that we have a more honest assessment of the problem in our state," says Ohio Hospital Association President and CEO Mike Abrams.
"If we could go back and apply today's identification standards to the previous years, those numbers would be higher as well. The fact that we are better at identifying it is not the same as saying the problem is worsening."
Abrams says Ohio's hospitals last year decided to "confront the brutal truths" and begin a campaign to reduce sepsis encounters and related deaths by 30% by 2018. Nine months into the initiative, OHA is reporting an 8% reduction in mortality. That's 353 lives saved.
"At every level of healthcare in our state, from CEOs to EMTs, ambulance workers and everything in between, we are trying to make sure that everyone in the system is more capable of identifying sepsis," Abrams says.
"We want to make sure they are curious about whether a patient is septic or becoming septic, and once that status is ascertained that they know what to do. It is a condition that we know how to treat, but it is time-sensitive."
Staggering Sepsis Statistics
Sepsis kills 258,000 people each year in the United States and costs more than $24 billion. It represents 6.2% of all hospital costs across the nation, which makes it the most expensive condition in the nation's healthcare system, according to the federal government's Healthcare Cost and Utilization Project.
HCUP analysis showed that while total hospital care expenditures have remained fairly stable, spending for sepsis rose 19% from 2011 to 2013, more than double the rate for all hospitalizations.
The study revealed that the mean expense per stay associated with those hospitalizations was over $18,000 in 2013, making hospitalizations from sepsis 70% more expensive than the average stay.
Sepsis resulted in nearly 1.3 million discharges that year from U.S. hospitals, an increase of 19% from 2011. Sepsis was also the most expensive hospital condition billed to Medicare, accounting for 8.2% of all Medicare costs incurred in 2013.
Ohio's Two-pronged Approach
Last year, the OHA board adopted two sets of interventions for sepsis; one for leadership commitment, the other for organizational strategies.
Among the recommendations, hospital leaders are asked to provide the resources and visible, vocal promotion of an accountable culture of safety in support of sepsis reduction.
Organizationally, hospitals are asked to develop early identification and intervention processes for sepsis, and coordinate sepsis prevention across the care continuum.
"A lot of it is just a conscientiousness about the process. It is identifying these patients earlier," Abrams says. "This is not like we don't know what to do. This is a condition that lends itself to certain interventions that work. Get the proper antibiotics to these patients in a timely way."
Abrams says hospital leaders respond more assertively when they're shown how their sepsis numbers compare with competitor and peer hospitals.
"Just that act alone raises awareness and identifies it as something that merits leadership level attention," he says.
"Once they understand that 'this is a problem in our facility' and there are interventions that work, that clinical science tells us the three-hour bundle is an actual intervention that clinicians have identified, the hospitals can learn for themselves where things break down."
Ultimately, Abrams says OHA "wants to do for sepsis what we did for ventilator-associated pneumonia: Make them rare."
"Raise everyone's awareness that this is a condition that you need to be intellectually curious about. Once you have identified it, here is a known intervention that works," he says.
"There are all kinds of reasons why you should be curious about sepsis. One is the number of lives you are saving, but the other is the true economic cost to our system that this condition presents. We all need to be interested in this."
The push to eradicate certificate of need statues in several states is spearheaded by a political advocacy group that claims a repeal of the regulations would "lower healthcare costs and improve medical access for millions of citizens."
The North Carolina Hospital Association is expecting to run out the clock this week on H161, a seemingly innocuous bill that would make the bobcat the official cat of the Tar Heel State.
The bill is not expected to pass before session adjourns and hospital lobbyists usually don't monitor bills honoring our feisty feline friends.
In fact, nobody was paying much attention to H161 until it was commandeered in a North Carolina General Assembly committee this spring and radically transformed into a repeal of the state's certificate of need law, effective in 2021.
Even now, there is no language in H161 to express its new intent, owing to the mechanism of legislative committee politics.
"They adopted the new language in committee but never reported it out," says North Carolina Hospital Association general counsel and lobbyist Cody Hand. "Your readers are going to look at a bobcat bill."
Standard Practice in NC Lawmaking
It sounds sneaky, but Hand says there is nothing nefarious afoot. "It's standard practice in North Carolina," he says. "Once the deadline is passed to file bills, they have to find something else to stick it on."
Besides, NCHA knew this bill was in the works.
Americans for Prosperity, the conservative political advocacy group funded by billionaires Charles and David Koch, has for several years led a public call to eliminate CON laws in several states, including North Carolina.
In a March 14 open letter published in the Ashville Citizen-Times, AFP spokesman Joseph Kyzer urged "North Carolina lawmakers (to) seize an opportunity in 2016 to save taxpayer money, lower healthcare costs, and improve medical access for millions of citizens by removing government barriers to patient care."
CON laws are "a systematic scheme to protect hospitals from competition" that limit access to healthcare and result in higher costs for consumers he wrote.
"Large hospital systems and bureaucrats pull the strings in our state's healthcare system by denying new medical practices permission to provide care and compete with entrenched power players," he wrote.
A Distinct Competitive Disadvantage
"Known as Certificate of Need laws, our state has uniquely stringent regulations that restrict new practices in specialty fields like orthopedics and outpatient surgery."
Hand points out that the AFP argument doesn't tell the entire story of the unique responsibilities, mission, and open-door, money-losing mandates that put hospitals at a distinct competitive disadvantage when compared with independent subspecialists.
"We have patients in beds 24/7 and we have emergency rooms that take anyone who walks in anytime of the day," he says. "We don't operate like other businesses and as such we need some protections that CON offers to make sure we have some money-earning procedures to offset the costs of the other services that we lose money on."
Kyzer counters that hospital lobbyists such as Hand "make dire predictions that CON reform will cause financial collapse for their clients, but this is a common tactic of special interests seeking to preserve regulations that benefit their bottom lines."
"Lawmakers," he says, "should put patients first and consider the cost their neediest constituents bear in a system fixed for large providers whose financial interests exercise far more influence in Raleigh."
The bobcat bill isn't going anywhere this session, but Hand expects the CON bill will be back again next year and NCHA is prepping for a fight.
AFP is very well funded, and the Koch brothers are generous donors to state and federal elected officials who support their policies.
Anyone who's ever been through a CON repeal fight is rolling their eyes right now at AFP's predictable line of half-truths.
A show of hands for anyone who thinks that an orthopedic or outpatient surgery center in North Carolina, one of 19 Medicaid non-expansion states, would "put patients first" and warmly embrace 24/7/365 access to care for any and all indigent or even Medicaid patients if only these oppressed free market cherry pickers were liberated from the constraints of draconian CON laws.
Data suggests that minorities continue to seek inpatient care at safety net hospitals, even as access options at other hospitals expand under Massachusetts' universal healthcare reforms.
Assumptions that newly insured minorities under the Patient Protection and Affordable Care Act would expand their traditional inpatient care options beyond the nearest safety-net hospital are being challenged by a report published in the journal Medical Care.
Boston University researchers found that the proportion of discharges among minority patients receiving inpatient care at minority-serving safety net hospitals in Massachusetts increased, even after the reforms expanded access to non-safety net hospitals.
They used 2004 –2009 data reflecting Massachusetts' expanded health insurance coverage under its sweeping healthcare reforms.
Study lead author Karen Lasser, MD, a primary care internist at Boston Medical Center, a 496-bed academic medical center and the largest safety net hospital in New England, says the findings bolster the claim that minority-serving hospitals remain a vital component of healthcare delivery that could be helped by raising or restoring Medicaid reimbursements.
"We made a hypothesis that some minorities would move," Lasser says.
"Was I surprised? Not so much. I've been working in the safety nets in Massachusetts for many years and the feeling is that things haven't changed that much. There hasn't been that migration."
According to the study, funded by the National Institutes of Health, researchers compared inpatient discharge data from Massachusetts, New York, and New Jersey between 2004 and 2009 and identified minority-serving hospitals and safety-net hospitals in each state.
Researchers examined the change in concentrations of minority discharges at minority-serving hospitals and tracked the movement of safety-net hospital users, or patients with at least four hospitalizations within the study period.
The results showed that Massachusetts' minority-serving hospitals saw an increase of 5.8% in minority discharges compared to New Jersey, and a non-significant 2.1% increase compared to New York.
Of those patients identified as "safety-net hospital users" in all three states, 62% continued to receive care at safety-net hospitals in the post-reform period.
Patient movement from safety-net to non-safety-net hospitals was slightly greater in Massachusetts than New York and New Jersey.
"We do need to compensate these hospitals that are doing disproportionate care for poor and minority patients," Lasser says.
"We have another study we are working on right now looking at segregation of hospitals by payer and race and there are certain hospitals that are taking care of less-affluent patients who may have more psycho-social needs and we may need to fund social workers at those hospitals."
Lasser offered several potential explanations for the findings, including the brand loyalty of minority patients to hospitals that are close by and have served them before they had insurance.
Other reasons could include interpretation services for non-English-speaking patients, intensive case management, and a lack of primary care physicians in Massachusetts.
"There are also some providers who aren't accepting new patients or patients with these public forms of insurance that don't reimburse well," she says.
The data is limited to the three-state area, but the Affordable Care Act is modelled on Massachusetts' healthcare reforms, so it would be reasonable to assume that these findings are playing out in other parts of the country since 2014.
"As we expand health insurance, there is this idea that patients can now go anywhere, that they aren't necessarily going to go to safety net hospitals, so those safety net hospitals don't need additional funding for uncompensated care or for all of the special programs the safety nets hospitals take on," Lasser says.
"Safety net hospitals still need those added resources."
If Pioneer Community Hospital of Scott follows through on its closure notice, it will be the sixth rural hospital in the Volunteer State to close in the past sixteen months.
In what is becoming a disturbingly common event, another rural hospital in Tennessee has filed notice with the state that it will close.
If Pioneer Community Hospital of Scott follows through on its 30-day notice with the state, it will be the sixth rural hospital to close in Tennessee in the past 16 months. The list of shuttered hospitals includes Gibson General Hospital in Trenton; Humboldt General Hospital; Haywood Park Community Hospital in Brownsville; Methodist Fayette in Somerville; and McNairy Regional Hospital in Selmer.
(Since 2010, Tennessee has also lost Parkridge West Hospital in Jasper, Starr Regional Medical Center-Etawah, and United Regional Medical Center in Manchester.)
The specific details of the closings vary somewhat for each hospital.
In most cases the hospitals were old and in need of significant capital upgrades. Their patient mixes were largely uninsured or Medicare-/Medicaid-dependent.
When Gibson and Humboldt closed, parent company West Tennessee Healthcare kept outpatient clinics open to assure continued access to care. In most cases, the communities were left to fend for themselves.
The closure of Pioneer Community Hospital of Scott, which is owned by Magee, MS-based Pioneer Health Services, provides a dire example of all the bad things that happen when a hospital shuts down in rural America.
Pioneer is a critical access hospital serving a poor and isolated region. When it closes, residents of Scott County, which borders Kentucky, will have to travel 40 miles on twisting roads to access care at the nearest hospital: Jamestown Regional Medical Center.
'You Can't Get There from Here'
On the economic side, Scott County is one of the poorest counties in Tennessee. The mean annual household income is $30,206, and 26% of families live below the federal poverty line.
The loss of about 100 relatively well-paying hospital-related jobs is sure to have a negative effect on the local economy, and the lack of a hospital will make it that much harder to recruit new businesses to an already struggling area.
"Scott County is one of those places where you can't get there from here," says Tennessee Hospital Association President Craig Becker.
"It is up in the mountains and it's a long haul down to Knoxville for sick patients. That was one of those hospitals that is very much isolated and one where it's going to be a devastating economic impact on that community as well."
The common thread for this spate of closings is that Tennessee remains one of 19 states that continue to reject Medicaid expansion under the Affordable Care Act.
That means that hospitals across Tennessee have to provide charity care for about 350,000 people who otherwise would have been eligible for Medicaid. Becker says 24 rural hospitals in the state have been identified as "vulnerable" to closing and he says the refusal to expand Medicaid is taking its toll.
"All you have to do is look at what is going on in other states (that have expanded Medicaid) to realize that it does make a positive difference for rural hospitals," he says. "We have seen what it can do in other states and we think the same thing would happen here."
Feeling the growing public pressure, the Republican-controlled Tennessee General Assembly has called for a task force to consider a gradual approach to Medicaid expansion.
"We're hopeful on that, but right now there are not a whole lot of details," says Becker.
"Because hospitals are going to be expected to pay for it, until we see the details we are holding back."
Hospital and physician associations warn that the governor's Medicaid privatization scheme has failed to deliver and threatens the program's existence.
Kansas Gov. Sam Brownback's $56 million cut to the privatized KanCare Medicaid program is facing blowback from healthcare providers.
In a media release detailing the cuts, Brownback said KanCare's 4% reductions to providers, which take effect on July 1, would exempt home- and community-based services and almost 100 hospitals defined as rural, densely settled rural, frontier and critical access hospitals.
After identifying KanCare as one of "the three main drivers of budget growth," Brownback said "we are working to slow the growth of government spending and our projected FY 2017 expenditures are less than FY 2015 actuals. Kansans cannot afford the explosive growth of state government spending that occurred in the past."
In a sharply worded open letter last week, however, Kansas Hospital Association President and CEO Tom Bell threw the baloney flag and accused the governor of attempting to obfuscate the scope of the cuts, which were part of more than $80 million in reductions to the overall state budget.
"There has been a flurry of inaccurate or incomplete information, and we need to set the record straight. Despite comments to the contrary, there simply is no 'rural' exemption from the proposed cuts," Bell said.
"Every part of the state will feel the effect of the cuts through reductions in payments to physicians, nursing facilities, home health agencies, hospitals or other caregivers."
More than 30 of the state's 107 rural hospitals are in danger of closing, and Bell said the ongoing effect of the KanCare cuts has become "obvious."
"Almost every comment made about this new proposed policy warns that KanCare reimbursement cuts will seriously jeopardize access to care," he said. "We've now seen concrete examples of hospitals in different parts of the state struggling under the current system, and these cuts will only exacerbate those struggles for all providers."
Kansas remains one of 19 holdout states that reject Medicaid expansion and the money that comes with it under the Affordable Care Act. As a result, Kansas has lost an estimated $1.2 billion in federal matching funds.
Brownback privatized KanCare in 2013 with assurances that the leaner and more efficient program would improve access to care.
So far, those promises have not materialized. Providers and patient advocates hate it, and commercial payers aren't happy with it either. The Witchita Eagle reported last week that KanCare's health plans, Sunflower, UnitedHealthcare and Amerigroup, reported losing $52 million in Kansas in 2014.
Bell accused the governor of reneging on promises made to providers.
"When KanCare was announced, the Administration repeatedly stated that the program would improve access to healthcare and allow the state to avoid cutting provider rates," Bell said.
"And encouraged by these promises, healthcare providers have been good partners regarding KanCare. This despite the fact that the program pays them less than the cost of providing care; despite the growing financial pressure facing those providers; and despite increasing evidence that KanCare isn't working as promised."
The Kansas Medical Society has also weighed in on the cuts, warning that physicians are already providing KanCare services for about half the payment of commercial plans, and that further reductions "are likely to adversely impact access to care, and will inevitably result in higher overall costs to the program."
"If the cuts cause physicians to drop out of the program, or place strict limits on the number of Medicaid patients they are able to see in their offices, more care will be delivered in hospital emergency departments, which are considerably more expensive settings than a physician clinic," KMS said in a statement.
KMS said that the cuts would exacerbate the very problems that the privatization was supposed to resolve: "They represent a reversal of one of the administration's key principles upon which KanCare was founded a few years ago: improved patient care outcomes and lower costs, all to be achieved without cutting provider payments."
Bell said the KanCare cuts are "simply bad public policy" that do not account for the ripple effect that the funding loss will have in communities across the state.
"In Kansas, the healthcare sector is the fourth-largest employer statewide and generates approximately $1.5 billion in state and local tax revenue annually," he said. "The Kansas Industry and Occupational Outlook created by the Kansas Department of Labor puts healthcare among the top 10 job creators, showing more job growth than any other industry in the state with over 33,000 new jobs added over the next decade."
Brownback was elected in 2010 with nearly 70% of the vote on a promise to slash income and business taxes. (He was reelected in 2014 with 49% of the vote.)
Taking a page from the trickle-down economics playbook, Brownback said the lower taxes would spur investment and job growth. So far, that investment and job growth has not kept pace with the cuts, which has led even one-time supporters to concede that Brownback's "real, live experiment" is a failure.
For obvious reasons, state healthcare provider professional associations tend to be very cautious when wording displeasure with elected officials. Perhaps the KHA and KMS are feeling a bit more emboldened because of growing public discontent at the direction of state government.
At least one poll shows that Brownback's 26% approval rating makes him the least-popular governor in the nation.
Or, perhaps the KHA and KMS are just tired of seeing their provider members and the poor and vulnerable patients they serve used as guinea pigs for a radical experiment that isn't working.
The Salt Lake City, UT-based health system wants to tear down silos that often isolate telemedicine visits from the patient's continuum of care.
Over the past several months, Intermountain Healthcare has quietly rolled out its Connect Care telehealth platform for patients in Utah and Idaho.
Program Medical Director William Daines, MD, says Connect Care clinicians will have access to Intermountain patients' medical files as part of a greater effort to include telehealth in the continuum of care. Daines spoke with HealthLeaders Media. The following is a lightly edited transcript.
HLM: Was Connect Care a soft launch?
Daines: We started a launch with Intermountain employees only. That was February 8. It was a great chance for us to solve a few technology problems, to gauge was general interest would be, and also to make sure that our medical protocols and safety mechanisms were working the way we wanted them to.
Sometime in the middle of March we went live with SelectHealth members, our allied insurance partner. In April we started with our public marketing campaign, which included lots of different advertising channels; print, outdoor, television, radio, digital.
There was also a soft digital campaign that launched at the end of March that was on a few patient-facing websites. We've been slowly over the course of February into April increasing our publicity.
HLM: How did you determine the need for Connect Care?
Daines: We've seen direct-to-consumer telehealth has become a growing part of medicine across the country. Utah and Idaho have been a little bit late to the game. When we gauged public awareness of telehealth with surveys in 2015, we only saw that about 10% of people were even aware of telehealth as a concept.
I would venture that if you went to California or New York or bigger cities you would see that telehealth is already a much more publicly known way of getting medical care.
HLM: Were there specific challenges for telehealth in Utah or Idaho?
Daines: There were a few legislative changes that needed to happen in Idaho to give us the legal groundwork to do telehealth. New developments tend to happen on the East or the West Coast and they make their way to Utah a little bit later. It's not that there was any major obstacle. It's just that none of the major healthcare organizations in Utah and Idaho had taken this step into telehealth yet.
HLM: Does Connect Care have a dedicated staff?
Daines: Currently we have two providers and we have two more in the credentialing process. They are going to be on board quickly. We don't know exactly how big our staff will be when we are 100% operational. A lot of it will depend upon patient demand. Our goal is to have 24/7/365 access with wait times of under five minutes.
Currently, our internal staff sees patients from 8AM to 8PM Monday through Sunday. We have a backup group of physicians called the Online Care Group. From 8PM to 8AM or if our daytime call volumes exceed what one provider can handle, they're there for backup.
Our goal is as soon as possible to be staffed 100% internally and have all the medical care being provided by Intermountain providers.
We feel strongly about that. We feel Intermountain has strong brand recognition and a long and prestigious dedication to high-quality care.
HLM: Are their special challenges that come with telehealth?
Daines: One of the things we have seen with telehealth is that for the past five or 10 years it's emerged as a new way of accessing care, but it is operating separately from people's normal care providers.
They might have a normal primary care doctor who they see on a regular basis. But when they access a telehealth provider, the primary care provider is not aware of it, the medical records don't get transferred, the telehealth provider can't see what medications the patient is already on. The primary care doctor can't see what medications the telehealth provider prescribes.
I am a big believer in continuity of medical care, but it's impossible to ask one doctor to be available for every patient 24/7/365.
Systems such as Intermountain Health Connect develop channels of communications and shared treatment standards so that if you happen to see one of our providers in urgent care or in one of our emergency rooms or one of our primary care practices there is shared communication between all the providers involved in the patient's care and they are all operating according to shared treatment standards.
HLM: How does the Connect Care platform work?
Daines: All of our visits are video-based. We partner with America Well that has a video based platform. It's like Skype except it is secure, (Health Insurance Portability and Accountability Act-) compliant, and has a high-resolution video feed. We also have the ability to accept photographs or PDF medical records.
HLM: Do you have any expectations for telehealth patient volume?
Daines: That number is in flux. I can't provide solid numbers right now because we are rolling out our marketing campaign. We haven't reached a point that I would consider static or a representative sample. Maybe by later this summer we will have a better sense of what we are seeing.
HLM: Is telemedicine different from an in-patient visit?
Daines: It reinforces and amplifies the things I should be doing during my general patient visits. Unfortunately, it's become a little bit of a cliché that the doctor is off in the corner during the exam looking at the computer and barely paying attention to the patient.
With telehealth you have to fight that urge even more. You have to make sure you are looking into the webcam so the patient gets a sense that you are looking at them and not looking at some screen.
You have to really listen. We know that about 80% of medical diagnoses can be made just from what the patient tells you. The physical exam is important for some medical conditions but there are many things we diagnose just by listening. A video visit really reinforces how important listening is in the doctor/patient relationship.
HLM: How did you settle on $49 as the fee for telemedicine visits?
Daines: If you look at other organizations that are doing this around the country that is a pretty standard rate. It is much less expensive than an urgent care visit, much less expensive than an ER visit.
We are partnered with some insurance plans so that even that $49 can be reduced if you're covered. Insurance companies understand how important it is to do the right thing for the right patient in the right place at the right time.
If someone calls with a medical complaint that is clearly not fit for telehealth, for example chest pains or stroke-like systems, what is best for them is to go to the ER and not to be charged for what is essentially a triage phone call.
We are not looking to extract $49 from a patient when they are already going to have to go to the ER and get a higher level of care.
HLM: What metrics will you use to determine if Connect Care is working?
Daines: There are a couple of things. When somebody's finished a visit we ask them a few questions about their experience, what they thought of the provider and the total platform experience.
With some patients we follow up later on to make sure they actually get better. One of the most important things with any medical treatment is are we helping the patients feel better, stay healthy, be healthy.
We also want to be part of the solution to the healthcare expenditure problem, not part of the problem. We want to help lower the cost of care by helping patients get the care they need in the appropriate setting at the appropriate time.
The Helping Hospitals Improve Patient Care Act has bipartisan support in the House, addresses key reimbursement issues created with the passage of the Bipartisan Budget Act of 2015, and has the support of the AHA and other hospital groups.
Hospital lobbyists are backing a bipartisan bill in Congress that would ease payment restrictions for some outpatient services and adjust 30-day readmissions penalties to account for socioeconomic disparities.
The Helping Hospitals Improve Patient Care Act (H.R. 5273) has bipartisan sponsors in the House Ways and Means Health Subcommittee, is paid for with offsetting budget cuts, and addresses what its backers say are Medicare reimbursement problems created with the passage of the Bipartisan Budget Act of 2015.
In a letter this week to senior committee members on the House Ways & Means Committee, the American Hospital Association urged the lawmakers to pass the bill, after spelling out the problems created by the BBA.
"Under current law, facilities operating before Nov. 2, 2015 are 'grandfathered' and
can continue to be paid at the hospital outpatient department (HOPD) rate, while new facilities
opening after Nov. 2, 2015 are capped at the lower Physician Fee Schedule rate," AHA Executive Vice President Tom Nickels said in the letter.
"The BBA did not provide for HOPDs that had already begun construction and spent millions of dollars and countless man hours to build facilities based on the prior reimbursement amounts."
"In addition, the way BBA was developed, with no hearings or Committee consideration, with legislative text released approximately one week before it was signed into law, put those HOPDs in an unfair and untenable situation," the AHA continued.
Calendar Adjustment
The bill moves the grandfather date from Nov. 2, 2015 to Dec. 31, 2016, or 60 days after enactment, whichever is later.
While the adjustment creates "significant relief" for hospital HOPDs caught in that time period, Nickels noted that "some HOPDs that were underway on Nov. 2, 2015 will not be completed by Dec. 31, 2016 in order to qualify for the grandfather. We would like to continue to work with the Committee to find additional ways to address the issue."
Safety Nets React
America's Essential Hospitals praised a provision in the bill that amends and adjusts the Medicare Hospital Readmissions Reduction Program "to level the playing field for hospitals that are disproportionately penalized by the program: those that care for large numbers of low-income and other disadvantaged patients."
The adjustment would act as a "bridge" while data is being compiled under the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT).
Until then, the bill allows the Secretary of Health and Human Services to compare performance of hospitals that service similar proportions of Medicare/Medicaid dual eligible patients when applying readmissions adjustments.
When IMPACT data is obtained, HHS would adjust performance payments based on that research.
Community and Rural Hospitals React
The Federation of American Hospitals also backs the bill, which federation President Chip Kahn said "recognizes the importance of access to hospital care for millions of Americans. That is why I am pleased to offer the support of the FAH for this targeted, thoughtful measure that would, among other provisions, allow community hospitals to finalize essential outpatient arrangements in order to better serve patients in their communities."
"At the same time," he said, "while the reduction might be viewed as minor, the effects of cumulative cuts on hospitals are taking a toll, and further cuts must be avoided."
The bill also extends for five years the Rural Community Hospital Demonstration Project, which Nickels told lawmakers "has become vital to participating hospitals and is providing valuable data on potential new models for these vulnerable hospitals."
Other provisions include:
A "mid-build" exception to the current law on increasing the number of beds for long-term care hospitals;
Modification of the treatment of ambulatory surgery center patient encounters for the meaningful use program;
A delay in CMS authority to terminate contracts for Medicare Advantage plans failing to achieve minimum quality ratings while CMS conducts research and reports on socioeconomic status and quality ratings;
A requirement that CMS report Medicare enrollment data by Congressional district.
A "cross walk" of 10 inpatient surgical codes that will be linked to outpatient surgical codes.
The bill is sponsored by Reps. Pat Tiberi (R-OH), House Ways and Means Health Subcommittee chairman, and Jim McDermott (D-WA), the subcommittee's ranking member.
Pediatrician and senior executive Marc Harrison, MD, will take over in October, with the retirement of Intermountain CEO Charles W. Sorenson, MD.
Marc Harrison, MD, a pediatrician and senior executive at Cleveland Clinic, has been named president and CEO of Intermountain Healthcare, the health system announced.
Harrison will take over at the Salt Lake City, UT-based not-for-profit health system on Oct. 15 with the retirement of Intermountain's current CEO Charles W. Sorenson, MD. Sorenson will stay at Intermountain as founding director of the health system's leadership institute, which opens in 2018.
Harrison, 52, most recently chief of International Business Development for Cleveland Clinic, and CEO of the Cleveland Clinic Abu Dhabi.
He led a 3,500-member multi-national workforce and oversaw clinical and business operations for the new medical campus, which cared for patients from 31 countries in its first 10 months of operations. He has also served as chief medical office for Cleveland Clinic, and chairman of pediatric critical care.
"Dr. Harrison has impressive experience and a proven track record of leading health organizations and is immensely qualified to build on Intermountain's legacy and oversee the organization as we continue the work of transforming healthcare to meet the challenges ahead," Intermountain Board Chair Scott Anderson said in prepared remarks.
Harrison earned an undergraduate degree at Haverford College and a medical degree at Dartmouth Medical School. He completed a residency and an internship in pediatric critical care through the University of Utah School of Medicine, working primarily in the critical care units of Intermountain's Primary Children's Hospital.
His wife, Mary Carole Harrison, MD, served as the chief resident in the same program. Marc Harrison later received a masters of Medical Management from Carnegie Mellon University and studied management at Harvard Business School.
Intermountain Healthcare includes 22 hospitals, 185 clinics, a Medical Group with about 1,300 employed physicians, a health plans division called SelectHealth.
