Empirical analysis confirms that insured people are more likely to be diagnosed and treated for high blood pressure, diabetes, and high cholesterol, a researcher says.
People with health insurance are more likely than uninsured people to have chronic conditions diagnosed and under a treatment regimen, according to estimates by researchers at Harvard T.H. Chan School of Public Health.
The study, appearing this month in Health Affairs, uses 10-years of Patient Protection and Affordable Care Act insurance enrollment projections from the Congressional Budget Office to estimate the number of people who might benefit from improved diagnoses and treatment of high blood pressure, diabetes, and high cholesterol.
Joshua Salomon
"I was surprised that the effect was consistent and detectable across all three of these conditions," says Joshua Salomon, lead author of the study and a professor of global health at Harvard. "In each case, insurance improved diagnoses; in each case insurance improved control, and if you look at the clinical outcomes, in each case the outcomes were healthier for those who had insurance."
Salomon estimated that if the number of nonelderly Americans without health insurance were reduced by half, as the CBO projects, there would be 1.5 million newly insured individuals diagnosed with one or more of these conditions, and 659,000 newly insured individuals able to achieve control of at least one condition.
Salomon conceded that the findings that insured people are more likely to be diagnosed and treated could have been predicted.
"It's because of the lack of direct evidence in general that we were surprised at the degree to which the different measures we looked at all told a consistent story of the benefit from insurance. That was the hypothesis we were testing, but we were surprised by the consistency of the results," he says.
"As healthcare professionals, this is certainly what we would have hoped to find, but there has been surprisingly little empirical analysis of this question in part because it is hard to answer."
"We tend to look for experimental studies to believe cause and effect and there are a few of those. To my frustration, a lot of the discourse around the ACA and health reform in general focuses on cost almost to the exclusion of the health impact. So, the results are intuitive. Perhaps it is surprising that we are able to see effects on health outcomes, not just diagnoses."
The Harvard researchers analyzed data from 28,157 people ages 20 to 64 participating in the National Center for Health Statistics' National Health and Nutrition Examination Survey (NHANES) from 1999 to 2012. The researchers found that insured people had a significantly higher probability of being diagnosed with a chronic disease than similar people without insurance—by 14 percentage points for diabetes and high cholesterol, and 9 percentage points for high blood pressure.
Among those already diagnosed, having insurance was associated with higher probabilities of achieving standard clinical benchmarks for control of each condition, and with significantly healthier average levels of blood sugar, total cholesterol, and systolic blood pressure.
Salomon says his study is not particularly concerned about measuring the return-on-investment or cost savings that comes with the expansion of health insurance.
"I think it's the wrong benchmark. Not everything has to be cost saving to be good value for the money," he says. "We tend to look for cost savings when in fact we are willing to spend money on health and some of our money can be spent in a way that buys health in a relatively inexpensive way and some money can be spend buying health in a more costly way."
"I would say the benchmark should be whether an intervention policy saves money and improves health. That is a higher bar to reach. There are very few examples of interventions that have shown cost savings and health improving. But we should be looking to see if our policies produce health at a cost that represents good value."
Using new methodology, the National Committee for Quality Assurance compares the quality and services of more than 1,000 health plans that collectively cover nearly half of the nation's population.
Health insurance plans in New England and the Great Lakes region received the highest rankings for performance and customer satisfaction under a new nationwide ratings system released Thursday by the National Committee for Quality Assurance.
Using a new methodology, NCQA's Health Insurance Plan Ratings 2015–2016 compare the quality and services of more than 1,000 health plans that collectively cover 138 million people—more than 43% of the nation's population. NCQA ranked 1,358 health plans and rated 1,016: 491 private, 376 Medicare and 149 Medicaid.
Of the 1,016 rated plans, 116 (11%) received a top rating of 4.5 or 5.0 out of 5. Fifty-four (5%) earned the lowest ratings of 1.0 to 2.0. Most plans are in the middle, approximating a "bell curve" when all plans' performances are plotted on a graph.
States with the highest percentage of plans receiving a 4.5 or 5.0 out of 5 rating include Maine, Massachusetts, New Hampshire, New York, Pennsylvania, Rhode Island, Vermont, Michigan, Minnesota and Wisconsin.
NCQA rated three major performance categories:
Consumer Satisfaction: What patients say about their health plans in satisfaction surveys, including about claims processing and customer service.
Prevention: Checkups, tests and other care that keeps people—especially children—healthy.
Treatment: How consistently a plan provides scientifically recommended care for common, costly conditions such as diabetes, depression and heart disease.
In each category, patient outcomes count extra in the scoring; for example, whether blood pressure and diabetics' blood sugar are controlled to safe, recommended levels. The emphasis on results means that, together with consumer satisfaction, outcomes are the main driver of ratings results, NQCA said.
NCQA grouped plans into broad categories, which give consumers a practical guide to understanding their health plan choices. Consumers can "drill down" into any part of the ratings to learn how a health plan handles particular health issues or patient populations.
For example, expectant parents may be interested in performance on two measures of prenatal and postpartum care. Families may be interested in quality results on 10 measures of pediatric preventive care and treatment, ranging from well-child care for infants, to monitoring ADHD treatment of 12-year-olds.
NCQA says it will continue its relationship with Consumer Reports.
The belief that every patient deserves excellent care, regardless of setting, drove a small Illinois hospital to develop the same rigorous approach to care "that any hospital would undertake to avoid [CMS] penalties," says its CEO.
Given their isolation, dearth of resources, and the challenging demographic they care for, critical access hospitals could be excused if the services they provide aren't up to the standards of resource-rich larger hospitals in more urban settings.
Peggy A. Sebastian, president and CEO of the 25-bed critical access hospital located in this town of about 9,500 souls, 30 miles east of St. Louis, says she and her staff of nearly 300 believe that every patient deserves excellent care, regardless of the setting. Being small and isolated, she says is "no excuse."
Peggy A. Sebastian
"We're a critical access hospital, but we want to behave as if we were a PPS (Prospective Payment System) hospital. We want to behave like we're a pay-for-performance hospital," Sebastian says. "We developed three years ago the same rigors that any hospital would undertake to avoid penalties or to be in the bonus earn-back [pool] with Medicare."
HSHS St. Joseph's Hospital is part of the Hospital Sisters Health System, which operates 14 hospitals in Wisconsin and Illinois. The Highland market's patient mix is about 65% Medicare; Medicaid and self-pay account for less than 10%. The hospital has had an average daily census of about 20 patients for the past six months, Sebastian says.
The quest to reduce readmissions started even before the hospital opened its $63 million, 125,000-square-foot hospital and medical office complex in August, 2013. "We wanted to be well on our journey to quality and what we call 'perfect patient care' before we moved into the new facilities," Sebastian says. "The new bricks and mortar were nice, but we were focused on the quality outcomes that patients expected."
"In order to get there we knew we needed a culture that looked at patient-centered care and that perfect patient care was a right of all patients," Sebastian says. "That required some new learning."
Focusing on CMS guidelines on compliance with core measures was a key component of the quality initiative. Sebastian says the hospital just recorded its 29th month of perfect core measure compliance.
Perhaps the most important component in the drive to reduce readmissions and improve outcomes was the strengthening of a 14-member multidisciplinary team that held "daily huddles" to assess each patient's status and discharge plan.
"We expanded their depth and breadth to review all patients for the risk of readmissions," Sebastian says. "The group is quite large. They meet every morning at 8:30 using nursing, physical rehab, pharmacy, cardio-pulmonary, quality, and case management. Over the past year we've added home health, infection prevention, pastoral care, wound center, senior renewal, which is outpatient geriatric psych, and cardiac rehab, along with the hospitalist."
In the past few years, Sebastian says St. Joseph's has taken a more comprehensive and thorough look at the discharge settings for patients. "We look at their living situation currently. What is their support system, meaning family and friends, and what is their access to nutrition? What is their access to travel or transportation to appointments and pharmacy? Can they afford their medications? Those kinds of pieces."
The rigorous discharge review also improved coordination and collaboration with area long-term care and assisted living facilities. "We developed a community collaborative and this group meets six times a year and reviews best practices, their own dashboard or scorecard of performance, and we provide them with feedback on their particular readmission rates and their admissions," Sebastian says.
Accolades
The improvements have not gone unnoticed. HSHS St. Joseph's Hospital was just named an Illinois Hospital Association 2015 winner of the Outstanding Quality Excellence Achievement Award. IHA cited the hospital's patient-centered approached to reducing readmissions and noted that "by improving their care coordination and expanding their multi-disciplinary team approach to discharge planning, St. Joseph's Hospital has successfully reduced their readmission rates by 20% in the past two years."
Sebastian's back-of-the-envelope return on investment estimates show that the multidisciplinary team costs about $46,000 a year, when the compensation for each member of the team is clocked. If St. Joseph's were operating under the pay-for-performance model, she estimates that their earn-back and bonuses each year would be just shy of $100,000.
Of course, there is no bonus because St. Joseph's is a critical access hospital. So, why bother with the expense if you're not going to collect the bonus?
Powered by Culture
"Because we believe that every patient deserves perfect patient care. That is our commitment," Sebastian says. "When you surround yourself with inspired people excellence is achievable. I surrounded myself with management and colleagues who aspire to perfect patient care, who believe in the Catholic mission of the Hospital Sisters, and we pursue excellence. Because we are all aligned under that same culture it is not three or four people moving the needle, it is 300 people moving the needle."
The Protecting Access to Rural Therapy Services Act clarifies that general supervision of most outpatient therapeutic services by a physician or non-physician practitioner is sufficient for payment of therapeutic hospital outpatient services, the bill's co-sponsors say.
The U.S. Senate has passed legislation that delays through Dec. 31 the enforcement of a direct supervision policy for outpatient therapeutic services that critics complained would jeopardize services in rural areas, particularly for critical access hospitals.
"Many hospitals find the federal government's supervision requirements for outpatient therapy impossible to meet, which jeopardizes access to this important care," Sen. Jerry Moran, (R-KS), a sponsor of the bipartisan bill said in prepared remarks.
"Rural hospitals need reasonable flexibility to staff their facilities so they can provide a full range of services to their communities. I continue to advocate for passage of the Protecting Access to Rural Therapy Services Act, the PARTS Act, bipartisan legislation I introduced to permanently address this outpatient therapy supervision issue. In the meantime, I am pleased we were able to pass S. 1461 in the Senate to continue providing much needed regulatory relief to many hospitals in Kansas and across the country."
The bill, which passed the Senate by unanimous consent last week, prohibits the Centers for Medicare & Medicaid Services from implementing the policy. Although the legislation is seen as bipartisan, it is not clear if the companion legislation sent to the House will become a casualty of the smoldering debate over funding for Planned Parenthood that threatens a shutdown of the federal government.
Moran, and co-sponsors Sens. John Thune, (R-SD), and Jon Tester, (D-MT), said in a joint statement that the extension provides additional time to advance the Protecting Access to Rural Therapy Services (PARTS) Act (S. 257), which clarifies that general supervision of most outpatient therapeutic services by a physician or non-physician practitioner is sufficient for payment of therapeutic hospital outpatient services.
The PARTS Act will:
Require CMS to allow a default setting of general supervision, rather than direct supervision, for outpatient therapeutic services;
Create an advisory panel to establish an exceptions process for risky and complex outpatient services;
Create a special rule for CAHs that recognizes their unique size and Medicare conditions of participation; and
Hold hospitals and CAHs harmless from civil or criminal action for failing to meet CMS's current direct supervision policy for the period 2001 through 2016.
Congress has prohibited CMS from enforcing the rule that requires direct physician oversight of outpatient therapy services at critical access and small rural hospitals after critics complained that it was particularly burdensome in areas where physicians are in short supply.
The practical effect was that relatively routine outpatient services such as drawing blood were restricted or even eliminated because physicians weren't readily available to provide immediate supervision.
A third attempt at a merger between Beth Israel Deaconess and Lahey Health makes sense, says an industry observer, but neither health system will confirm whether talks are underway.
Maybe the third time's a charm.
Lahey Health and Beth Israel Deaconess Medical Center reportedly are making a third attempt to merge. The Boston Globe, citing four unnamed sources, reports that the merger talks are in the early stages. The two health systems tried to negotiate a merger in 2011 and again in 2014, but each time those talks collapsed.
Media sources at both health systems would neither confirm nor deny that the talks were underway.
"Lahey Health continually seeks collaborative partnerships with health care organizations that share our mission to deliver coordinated, high-quality care for our patients at an affordable cost. We cannot comment on any specific discussions," spokesman Andrew Mastrangelo told HealthLeaders Media.
Jennifer Kritz, Mastrangelo's counterpart at Beth Israel, said: "We are always open to opportunities to affiliate with providers that share our commitment to high quality, affordable care, but we don't comment on any specific discussions."
Adam Powell, a healthcare economist, and president of Boston-based Payer+Provider Syndicate, says the merger makes sense as both health systems attempt to achieve more leverage during payer negotiations, experience less ACO network leakage, and increase the feasibility of offering a proprietary health plan.
"Partners has been attempting to add hospitals to its system, and it is no surprise that Beth Israel and Lahey are attempting to do so as well. Beth Israel and Lahey have unsuccessfully attempted to merge twice before, but this time may be different. Lahey Health laid off 130 people and cut the pay of its top executives in May 2015 after having lost $21 million over the course of the fourth quarter of 2014 and the first quarter of 2015."
Were the merger to take place, the unified health system would compete in the Eastern Massachusetts market against rivals Partners HealthCare and for-profit Steward Health Care System.
"It would leave three major health systems in Greater Boston: Partners, Beth Israel/Lahey, and Steward," Powell says. "The merger has the potential to make Partners and Beth Israel even stronger competitors. Harvard Medical School's campus, the Longwood Medical Area, contains hospitals from both Beth Israel (Beth Israel Deaconess Medical Center) and Partners (Brigham and Women's Hospital). Both systems are affiliated with Harvard, and have long had an element of "coopetition." However, it is often said that Beth Israel has somewhat lower prices than Partners, and as such, it has room to increase its strength through a merger."
Powell says it's not clear how Massachusetts Attorney General Maura Healey would respond to a potential major health system merger.
"As Healey assumed office in January 2015, she did not oversee the previous merger attempts," Powell says. "It has been reported that shortly after assuming office, Healey unraveled a deal that her predecessor, Martha Coakley, had worked out to enable Partners to expand. Healey has previously expressed deep concern over the rising healthcare costs in Massachusetts, and may take action against efforts that may further increase costs."
BCBSNJ Launches Statewide OMNIA Health Alliance
Horizon Blue Cross Blue Shield of New Jersey has launched OMNIA Health Alliance, a statewide collaboration with seven health systems and a multispecialty physician group to "radically alter" the transition from fee-for-service to value-based care delivery.
Robert A. Marino, chairman and CEO of Horizon BCBSNJ, said in a media release announcing the creation of OMNIA that "significant intellectual and financial resources" would be dedicated "to change this paradigm by developing new approaches to keep individuals healthy through increased population health management and more integrated, coordinated care that rewards better health outcomes, an enhanced patient experience, and lower cost care."
"The OMNIA Health Alliance is an unprecedented collaboration that will significantly transform how health care is financed and delivered in New Jersey for the better," Marino said.
"Through the OMNIA Health Alliance, we are all making a long-term commitment with a new level of trust, cooperation, and energy that will benefit health care consumers in New Jersey."
The OMNIA health systems are: Atlantic Health System, Barnabas Health, Hackensack University Health Network, Hunterdon Healthcare, Inspira Health Network, Robert Wood Johnson Health System, and Summit Medical Group.
Premier Health, IUH Open Urgent Care Centers
Baton Rouge, LA-based Premier Health has announced the opening of the first of 12 urgent care centers in Indianapolis in partnership with Indiana University Health.
By year's end, Premier Health will operate 38 centers in three states and a workforce of more than 650 people. Premier Health CEO, Steve Sellars says the company will double in size over the next three to five years.
"There has been a nationwide shift to less-expensive, cost-effective healthcare models, and large health systems want to partner with an urgent care company that has a successful track-record of partnering with hospitals," Sellars said in a media release. "These types of joint-ventures are Premier Health's core business. We've done more of them than almost any other company of our kind in the country."
Ron Stiver, president of clinical services at IU Health, said "teaming up with Premier made sense because of the company's demonstrated expertise in partnering with health systems to launch and operate urgent care centers."
The clinics in Indianapolis will operate as IU Health Urgent Care.
Before a panel of lawmakers, lobbyists for hospitals, doctors, and insurance companies justified consolidation in their markets while blaming others for stifling competition.
A U.S. House subcommittee heard payers and providers offer their views on competition and consolidation of the healthcare marketplace under the Patient Protection and Affordable Care Act Thursday.
For the most part, lobbyists for hospitals, doctors, and insurance companies spent their morning before the Subcommittee on Regulatory Reform, Commercial and Antitrust Law defending their turf, trumpeting cost-savings innovations by their members, and justifying consolidations in their markets while blaming others for stifling competition.
Barbara L. McAneny, MD
American Medical Association board member Barbara L. McAneny, MD, told the subcommittee that the federal government should more closely examine consolidations in the health insurance and hospital sectors.
"Given the present structure of the health insurance market, health insurers have the ability unilaterally or through coordinated interaction to exercise market power by raising premiums, reducing service, or stifling innovation," McAneny said. "Accordingly, health insurer markets require more, not less, competition and mergers must be carefully scrutinized."
McAneny said that many hospital markets already are highly concentrated and non-competitive and that further acquisition could "undermine the ability of physicians on behalf of patients to shop for hospitals based upon quality factors."
"Too much consolidation reduces the incentive of hospitals to compete on these factors, allowing the merged hospital in a concentrated market to provide potentially sub-optimal care for patients," she told the committee.
"A hospital acquiring market power through merger may also substantially lessen the practice options open to physicians such that the hospital obtains market power as an acquirer of physician services."
Rick Pollack, president and CEO of the American Hospital Association, told the subcommittee that hospitals are adapting to a rapidly changing landscape that is moving toward value-based care and reimbursement models.
"To better serve their communities, hospitals and health systems are integrating with other providers in a variety of ways to ensure more coordinated and patient-centered care and improve efficiency and reduce costs," Pollack said.
"Hospitals are making progress in all of these areas despite operating in an environment that has enormous capital and regulatory demands and payments linked increasingly to achieving high performance. Meeting these demands often requires significant restructuring for hospitals, all of which has taken place during a period of historically low levels of hospital price growth."
"On the other hand," Pollack said, "the recently announced commercial insurance deals will not benefit consumers. Instead, they will lead to further consolidation of an already highly concentrated health insurance market, fewer choices for consumers for commercial insurance and MA plans, and higher premiums and/or out-of-pocket costs."
Rick Pollack
AHIP's Stance
Not surprisingly, Dan Durham, executive vice president, strategic initiatives, at America's Health Insurance Plans, did not agree with Pollack's assessment.
"Provider-related costs are a significant portion of total medical costs, and the growth in such costs has had a critical, and detrimental, effect on consumers," Durham said. "Consumers benefit when healthcare providers compete to offer them lower costs, higher quality services, and innovative approaches to delivering care."
"There are situations in which provider consolidation does not impede these benefits or may even enhance them. In other situations, however, consolidation diminishes competition among providers and leaves consumers with higher costs, diminished quality, and a reduced prospect of innovation or improvement."
Thursday's testimony was heard before a subcommittee thick with partisan acrimony.
Subcommittee Chairman Tom Marino, (R-PA), who has voted repeatedly to repeal Obamacare, said that Thursday's hearing was the first in a series that would examine PPACA's effect on competition and cost in the healthcare marketplace. He made his position clear before testimony was heard.
"There is no doubt that there has been significant movement in each of the hospital, insurer, and physician markets since the enactment of Obamacare," Marino said in opening remarks. "I have infinitely more confidence in the judgment of a competitive marketplace over the judgment of government. Obamacare is another government experiment of attempting to replace the will of the market with its own, an experiment that in my view has gone horribly wrong."
Subcommittee ranking member Hank Johnson, (D-GA), said in his opening statements that the PPACA has expanded coverage to 16.4 million uninsured people, dropping the uninsured rate by 35% while lowering the cost of care. He stated that consolidation in the healthcare sector had been well underway before PPACA went into effect.
"It's clear that now we have put it to work, the Affordable Care Act is saving lives and money," Johnson said. "Rather than demonizing an administration that has done so much for so many, we should be ensuring that the progress we've made in such a short time is not jeopardized by anti-competitive behavior or consolidation."
As diabetes rates ratchet steadily up, researchers find that the use of community health workers and peer support groups for chronic disease prevention and management can work in all settings, particularly low-resource areas.
A grim new report out this week estimates that half of Asian Americans and Hispanic Americans with diabetes don't know they have the disease.
The estimates from the National Institutes of Health and the Centers for Disease Control and Prevention are detailed in the Sept. 8 issue of the Journal of the American Medical Association and the findings should alarm anyone who cares about population health.
The estimates for the first time quantify the prevalence of diabetes in Asian Americans and the news is not good. Researchers estimate that Asian Americans have the highest proportion (51%) of undiagnosed diabetes among all ethnic and racial groups. Hispanic Americans have the highest prevalence (23%) of diabetes, 49% of which is undiagnosed.
But wait. It gets worse.
The NIH/CDC researchers estimate that the prevalence of diabetes for all US adults went up by as much as 12% from 1988 to 2012. Those levels rose regardless of sex, age, level of education, income, or racial group or ethnic subgroup.
Thomas Gaziano, MD
About 14% of the overall population has diabetes, of which just over 5% is undiagnosed. About 20% of non-Hispanic black adults have diabetes, with about 37% undiagnosed. Prevalence of diabetes for non-Hispanic whites is 11%, and 32% are undiagnosed. Diabetes cost the nation about $245 billion in 2012 in the form of medical care and lost productivity.
The only ray of sunshine to come out of the estimates is that the proportion of people with undiagnosed diabetes dropped 23% over that same nearly three decades.
Coincidentally, these estimates arrived in my email this morning as I was listening to a three-hour briefing sponsored by Health Affairs entitled: Noncommunicable Diseases: The Growing Burden.
I'll focus on a briefing in Health Affairs detailing the success of community-based interventions that was given by Thomas Gaziano, MD. He determined that marginally trained community health workers in resource-poor countries such as South Africa, Mexico, and Guatemala could provide effective screenings for cardiovascular diseases in adults, by asking a few simple questions using either a paper-based or cell phone-based screening tool.
"We found that screening by community health workers was very cost-effective or even cost-saving in all three countries, compared to the usual clinic-based screening," Gaziano wrote. "The mobile application emerged as the most cost-effective strategy because it could save more lives than the paper tool at minimal extra cost."
A briefing by Edwin B. Fisher, PhD, focused on the use of community health workers and peer support groups for chronic disease prevention and management. The good news here is that these programs can work in all settings, particularly low-resource areas.
"Success factors for peer support programs include proactive implementation, attention to participants' emotions, and ongoing supervision," Fisher wrote. "Reaching those whom conventional clinical and preventive services too often fail to reach; reaching whole populations, such as people with diabetes, rather than selected samples; and addressing behavioral health are strengths of peer support that can help achieve healthcare that is efficient and of high quality."
Fisher cited seven community health workers in Chicago who were able to reach 3,787 "hardly reached" low-income Latino adults to help them monitor blood sugar levels.
"A big issue in healthcare around the world, especially with non-communicable diseases, is the hardly reached, those who we too often fail to engage," Fisher said at the briefing. "We found that peer support is remarkable effective."
Given that a frighteningly large percentage of Americans in general and minorities in particular don't know they have diabetes, rallying communities around improving population health seems an obvious tactic. Yet, Fisher says other countries with far fewer resources, such as Thailand and Pakistan, have done a much better job.
"The U.S. is sort of culturally handicapped in approaching these kinds of interventions," Fisher says. "In this area we very much have more to learn from places like Pakistan and Thailand as opposed to their needing to learn from us."
Federal prosecutors allege that between 2003 and 2013, Columbus Regional Healthcare System "provided excessive salary and directorship payments to an oncologist affiliated with the hospital in a financial arrangement that violated the Stark Law."
A Georgia hospital will have to pay upwards of $35 million to resolve allegations of False Claims Act violations involving self-referrals and overcharging for care, federal prosecutors say.
Columbus Regional Healthcare System has agreed to pay $25 million, plus additional contingent payments not to exceed $10 million, for a maximum settlement amount of $35 million. Andrew Pippas, MD, a Columbus-based hematologist/oncologist affiliated with the hospital, has agreed to pay $425,000 for his alleged role in the infractions, according to Michael Moore, U.S. Attorney for the Middle District of Georgia.
Federal prosecutors allege that between 2003 and 2013, Columbus Regional "provided excessive salary and directorship payments to Pippas that violated the Stark Law," which prohibits certain physician referrals for Medicare and Medicaid patients if the physician and the referring entity have a financial relationship.
Prosecutors also allege that from May 2006 through May 2013, Columbus Regional overbilled Medicare and Medicaid for services at higher levels than supported by the documentation, and between 2010 and 2012, they overbilled for radiation therapy at higher levels than the therapy that was provided.
Columbus Regional and Pippas will pay $24.6 million to the federal government for federal healthcare program losses and $759,000 to the state of Georgia for the state share of its Medicaid losses.
"Now that we have these matters behind us, I am looking forward with renewed energy to continuing to advance and improve the cancer care we deliver at the John B. Amos Cancer Center," said Pippas, in a statement issued by Columbus Regional. As of Tuesday evening, Pippas was listed on the leadership page of the Georgia Society of Clinical Oncology.
"The maximum amount of this settlement, some $35 million, is appropriate given the number of alleged violations involving the False Claims Act and the Stark Act," Moore said in prepared remarks.
"Access to healthcare is on everyone's mind, especially with respect to rural communities. The type of conduct alleged in this case puts that access at risk," Moore said. "This settlement reflects on the one hand, the Department of Justice's commitment to make sure that hospitals and physicians who commit violations of federal law are held to account, and on the other hand, especially with the requirement of the monitoring agreement, makes sure that we continue to have appropriately functioning healthcare providers accessible to the wide array of communities they serve."
'Not an Admission of Liability'
Columbus Regional issued a statement announcing the $35 million settlement, but noted that it "is not an admission of liability. The parties agreed to settle in order to avoid continued costly and protracted litigation."
"We are glad to put these issues behind us and focus 100% of our energies on continuing to deliver quality patient care and service at all of our entities," Columbus Regional CEO and President Scott Hill said in a statement released by his office.
Columbus Regional will enter into a five-year corporate integrity agreement with the Department of Health and Human Services, Office of the Inspector General.
The settlements resolve allegations filed in two lawsuits by Richard Barker, a former Columbus Regional executive. The lawsuits were filed under the whistleblowerprovisions of the False Claims Act and the Georgia False Medicaid Claims Act. Barker's share of the settlement has not yet been determined.
Since January 2009, the Justice Department has recovered a total of more than $24.9 billion through False Claims Act cases, with more than $15.9 billion of that amount recovered in cases involving fraud against federal healthcare programs, prosecutors said.
Nearly one in four of the 173,000 new jobs created in the U.S. economy in August was in healthcare, according to preliminary figures from the Bureau of Labor Statics.
Preliminary jobs data from the Bureau of Labor Statics shows that healthcare created 41,000 jobs in August, 314,200 jobs in the first eight months of 2015 and 457,000 new jobs over the past 12 months. The healthcare sector has accounted for 18.5% of the nearly 1.7 million non-farm payroll additions in the overall economy in 2015, BLS preliminary data show.
Within the healthcare sector BLS data show that the ambulatory healthcare services created 21,000 new jobs, and hospitals created 16,000 new jobs. Nursing and residential care created 3,500 jobs.
The healthcare sector accounted for more than 15.1 million of the nation's jobs in August, with more than 4.9 million jobs at hospitals, more than 6.9 million jobs in ambulatory services, and more than 3.3 million people in nursing and residential care, BLS preliminary data show.
BLS data from July and August are preliminary and may be considerably revised in the coming months.
In the larger economy, the 173,000 nonfarm payroll additions in August tapped down the nation's unemployment rate to 5.1%, with 8 million people unemployed.
The number of people unemployed for less than five weeks fell by 393,000 in August. The number of long-term unemployed—people jobless for 27 weeks or longer—was 2.2 million in August, and represented 27.7% of the unemployed, BLS preliminary data show.
Announcements of separate joint ventures between Lifepoint and a regional medical center in Wisconsin and Carondelet and three major health systems in Arizona top the latest round of healthcare business news.
LifePoint Health has entered the Wisconsin hospital market after finalizing a joint venture that gives the Brentwood, TN-based for-profit company a majority stake in Watertown Regional Medical Center, the hospitals announced jointly on Tuesday.
Jeff Seraphine
The deal marks the first conversion of a hospital's tax status from not-for-profit to for-profit in the state of Wisconsin.
Jeff Seraphine, president, Eastern Group at LifePoint Health, says the hospital chain has had Wisconsin on the expansion radar for a long time.
"It's always been an attractive state for us, there just hasn't been a lot of opportunities," Seraphine says. "There haven't been a lot of pieces moving around up there that gave us the opportunity to partner with communities, but when the Watertown opportunity came about, we were right there and excited to be a part of it."
Jeff Baum, chairman of the WRMC board of directors, says it took a little extra effort to convince community leaders and state regulators, that the conversion to for-profit status would benefit all of the stakeholders.
"We had a lot of explaining to do. The staff got it pretty quickly, but it did raise some questions. Let's put it that way," Baum says. "When the community heard we were going to become a for-profit hospital the first thing they said was, 'Oh my God! You're going to have to raise all the prices to pay the shareholders.' But that's not true."
Allan Baumgarten, a Minneapolis-based research consultant who monitors hospital acquisitions across the Midwest, says Wisconsin has been "relatively late to get for-profit hospital companies."
"Michigan didn't have a for-profit hospital presence until about six years ago, but now has Tenet, LifePoint, and Prime and almost got Community Health Systems," Baumgarten says. "I assume that LifePoint is looking for other hospitals to acquire in the state."
"Almost all of the hospitals in the southeast corner of the state (from Madison south and east to the lake and the Illinois border) are already in larger systems," he says. "If LifePoint wants to grow in that region, it may be looking at some of those systems. Or it may be looking in other parts of the state, where there are still a few dozen independent hospitals, many of them small critical access hospitals."
Financial terms of the JV were not immediately disclosed, however it is understood that LifePoint will own 80% of the hospital and WRMC and the community will own 20%. Governance will be shared equally on a board with equal representation from WRMC and LifePoint.
The joint venture will invest $100 million in WRMC and the community over the next 10 years, targeting "significant advancements" in technology, expanding clinical services and population health and wellness initiatives. No layoffs are anticipated and LifePoint has committed to hiring all employees, subject to pre-employment screenings.
Seraphine says LifePoint was comfortable with an 80/20 joint venture model instead of an outright acquisition because WRMC wanted an ownership stake, and that similar governing structures have worked in other LifePoint ventures.
"Our goals and the way we work in either a full acquisition or a partnership model [is] so we work with the community to find out what works for them," Seraphine says. "We feel comfortable with a shared governance model where we can work in a collaborative way with the community, especially in a state like Wisconsin where there hasn't been a long history for an investor-owned company like LifePoint. It's a great way for the community to be at the table from a governance perspective, and it allows people to be more comfortable with a new arrangement."
Baum says the JV ensures that the community will have a say in how healthcare is delivered.
"We still own a part of the hospital and that made it much easier to talk to the man on the street and explain that we still owned part of the hospital," he says. "When LifePoint offered up 50% of the board, that pretty much sewed it up for us."
Proceeds from the transaction will be used to pay off WRMC's existing financial obligations. The remaining assets will be used to create a charitable foundation focused on community health.
Richard Keddington will become WRMC's new CEO on Sept. 14, replacing John Kosanovich, who retires after 20 years as WRMC's CEO. Keddington has served for the past five years as CEO of Select Specialty Hospital, a two-campus, 63-bed hospital in Milwaukee.
The joint venture between Watertown Regional Medical Center and LifePoint was subject to regulatory reviews by the Attorney General of Wisconsin. Baumgarten says the JV with LifePoint could signal an end to WRMC's strategic alliance with University of Wisconsin Health. "The website no longer mentions anything about being a member of the UW Health Partnership."
Financial terms of the deal were not disclosed, and the health systems declined to comment beyond the media release. However, Tenet is the majority partner and will manage the operations of the network's three hospitals, two physician groups, outpatient and ambulatory services, and affiliated businesses in Tucson and Nogales, AZ. Dignity Health and Ascension have minority interests in the partnership, the health systems said in a joint statement.
Tenet and Dignity Health separately own and operate hospitals and clinics in the Phoenix area and together manage Arizona Care Network, an accountable care organization that includes more than 750 facilities across Tenet's and Dignity Health's Phoenix-based healthcare systems, with more than 3,400 providers and more than 200,000 covered lives.
The Tucson-based joint venture will connect Carondelet to ACN, which will is expected to increase access to care for patients, strengthen and grow Carondelet's relationships with physicians, provide development opportunities for current and future employees, and fund strategic growth initiatives across Southern Arizona.
The facilities in the new partnership include:
St. Joseph's Hospital (486 beds) in Tucson
St. Mary's Hospital (400 beds) in Tucson
Holy Cross Hospital (25 beds) in Nogales
Carondelet Heart & Vascular Institute at St. Mary's Hospital
Carondelet Neurological Institute at St. Joseph's Hospital
Carondelet Medical Group
Carondelet Specialist Group
Carondelet's services also include imaging centers and other ambulatory services and ancillary businesses. The joint venture will maintain Carondelet's Roman Catholic identity through an agreement with the Diocese of Tucson. Carondelet's existing charity care policies will remain in place.
SSM Health Commits $500M to Build New St. Louis Hospital
One day after transferring ownership from Tenet Healthcare Corp., Catholic, not-for-profit SSM Health announced on Tuesday that it has committed $500 million to build a new replacement hospital and outpatient care center within the next five years. The new hospital will be built near the existing 365-bed academic medical center now known as SSM Health St. Louis University Hospital, the health system said in a media release.
SSM Health and Saint Louis University this week mark the start of their expanded partnership, which includes Saint Louis University Hospital joining SSM Health St. Louis. In June, SLU announced it would reacquire the hospital from Tenet and would give the hospital to SSM Health in exchange for a minority financial interest and governance rights in SSM Health St. Louis. The deal became official on Tuesday.
"While the current hospital has served the community well, we have the opportunity to construct state-of-the-art academic facilities that incorporate the best practices in patient-centered design," said SSM Health President/CEO William P. Thompson said in prepared remarks. "This significant investment will enable us to deliver an improved patient experience and even better care for our community."
For-profit Tenet has operated SSM Health St. Louis University Hospital for the past 17 years. The sale was completed on Monday. The relationship between SSM Heath and the university extends back to 1903.
