The operator of Georgia's second largest hospital and more than 30 affiliate facilities has opted for a name change that de-emphasizes regional locales and reflects its broader mission as a healthcare destination, says its CEO.
One of Georgia's largest health systems has changed its name to reflect its patient-centric emphasis.
Ninfa Saunders
President and CEO of Navicent Health
Macon-based Central Georgia Health System this week rebranded itself as Navicent Health, and CEO and President Ninfa Saunders says the new name was prompted "by a couple of things."
"Number one, we wanted to have one umbrella name for the health system that was not limited by its regional title," Saunders said.
"The current brand, Central Georgia Health System, immediately makes it local. We thought that as we look at healthcare beyond the walls of the hospital and the region and as we look at patients coming to us because we want to be a healthcare destination, that it should not be so local in its name."
"I've always believed that healthcare is local, physicians are local. However, as a healthcare destination that should not stop us from being able to invoke a name that is inclusive as opposed to exclusive to a particular region."
The name change also better reflects the health system's mission, she says.
"In planning for this we had multiple focus groups… and we were trying to discern from the groups what they saw our health system to be," Saunders explained. "The repeated message over and over again is that everything we do is towards putting the patient at the center of what it is we do every day."
"The confluence is this, the fact that we wanted to have one umbrella name. More importantly we wanted to make sure our brand signified exactly what we intend to do and focused on what were the two drivers for why we felt the rebranding was necessary."
The rebranding is system-wide across more than 30 affiliate facilities, including flagship The Medical Center of Central Georgia, now named Medical Center, Navicent Health. It is the second largest hospital in Georgia.
The name change, the first in more than 40 years at the health system, includes a new logo and motto that reads: "Everything about us, is all about you."
Navicent is derived from a combination of "navigation" and "center," which Saunders says were words frequently used by focus groups to identify what they believed should be areas of concentration.
"The two words that we heard over and over from the patients is that 'there is so much going on in healthcare. What we need is more navigation and coordination of the processes and care that we go through,'" Saunders says.
"And as you do that, please remember that the patient is in the center as opposed to all of the clinicians in the middle and we are on the outside looking in." Navicent Health employs nearly 6,000 people, including 800 physicians and more than 100 residents and fellows in training.
The rebranding comes two years into Saunders' tenure and one year after the launch of the multi-hospital Stratus Healthcare alliance.
Navicent has no relationship with Chicago-based Navicent Inc., which describes itself as a "global advisory firm."
Other renamed facilities include Rehabilitation Hospital, Navicent Health; Children's Hospital, Navicent Health; and Medcen, Navicent Health, a $96 million development foundation; Medical Center of Peach County, Navicent Health; Carlyle Place, Navicent Health, a continuing care retirement community; Pine Point Hospice, Navicent Health; and Wellness Services, Navicent Health.
About $250 million will be needed in 2015 to ensure that the nation's nursing schools can continue to produce enough registered nurses to meet the nation's estimated demand for the next seven years, says the head of the American Nurses Association.
The American Nurses Association is calling on Congress to increase federal funding by 12% to bolster programs to educate, recruit, and retain registered nurses.
Pamela F. Cipriano, RN
President of the ANA
A graying demographic is expected to need more healthcare services. Americans, including nurses, are getting older. ANA estimates that more than 40% of nurses are over age 50, the average age for a clinically practicing nurse is about 45, and 72% of nurse faculty are age 50 or older.
ANA President Pamela F. Cipriano, RN, says additional funding for the Nurse Training Act (Title VIII of the Public Health Service Act), which would total about $250 million in 2015, is needed to ensure that the nation's nursing schools can continue to produce the estimated 1.1 million new registered nurses the Bureau of Labor Statistics says is needed by 2022 to replace a retiring generation of Baby Boomers.
"This has been a pretty confusing time for anyone trying to estimate labor force needs," Cipriano says. "What we have seen since the recession in 2008 is that people held on to their jobs. At the same time, nurses were experiencing a downturn in retirement funding, so many continued to work, both in the clinical and academic settings."
Also in the mix, the Patient Protection and Affordable Care Act and other reforms have put healthcare in a state of flux. About 60% of RNs work in hospitals, and nursing staff layoffs are a common occurrence as hospitals struggle with tighter margins and declining admissions. It's not clear if those jobs are coming back.
"Whether there are overt layoffs or positions are just not getting reposted and refilled is sometimes hard to track. We really haven't seen the aggregate workforce decline in the last year," Cipriano said.
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"While there are some new jobs that have been created in the post-hospital environment, such as home care and outpatient clinics, they're never at the magnitude of what we have seen with hospital-based employment."
"And," Cipriano continued, "we continue to see real variations in terms of what is happening in the local labor markets which is really where it affects nurses, even though we think of it as a national workforce."
Even though consensus has formed around the anticipated demand for more nurses, questions remain about what will become of the nurse workforce as hospitals shift toward outpatient care models.
"How deep will the workforce be in the non-hospital setting?" Cipriano ask. "As we transition more care out of the hospital, we've not really been able to do the forecasting to tell us if the overall size of the work force will shrink a little or a lot as we try to keep people healthy. We don't have a good answer to that question right now. That is a question for the next decade."
Cipriano's comments come as the ANA marks the 50th anniversary on Sept. 4 of the Nurse Training Act. The group is urging Congress to:
Increase federal funding for Title VIII by 12%, to about $250 million for 2015. The program has seen an average 2% funding decrease in the last four years.
Strengthen nursing education by hiring more nursing professors and ensuring an adequate number of clinical training sites for nursing students. That would require nursing schools to significantly boost the salaries offered to highly credentialed nurses who can often earn twice as much or more in a clinical setting.
More than 140,000 RNs passed their entrance exams last year, but ANA says that more than 80,000 qualified applicants are rejected by nursing schools each year because there aren't enough faculty or clinical training sites.
"Nursing is one of the most intensive educational programs you will find," Cipriano says.
"Because there has to be a lot of hands-on [learning] it requires that hospitals have space and staff that will help with the placement of those individuals so they can complete their clinical education. As we have been trying to bring more students in those clinical placements are overcrowded."
After two and a half years of work to coordinate care for more than 28,000 Medicare beneficiaries, Sharp says it cannot make the financial model work.
Sharp HealthCare ACO is leaving the Pioneer Accountable Care Organization pilot program.
The decision, announced quietly in the company's third-quarter finance report, leaves San Diego with no Pioneer ACOs.
"Because the Pioneer model is based on national financial trend factors that are not adjusted for specific conditions that an ACO is facing in a particular region (e.g., San Diego), the model was financially detrimental to Sharp ACO despite favorable underlying utilization and quality performance," Sharp said its financial report, adding that the Center for Medicare & Medicaid Innovation was notified in June.
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Sharp ACO issued a statement this week explaining that it had worked with the Innovation Center for two and a half years to coordinate care for more than 28,000 Medicare beneficiaries but couldn't make the financial model work.
"Despite meaningful reductions in readmission rates and hospital and skilled nursing utilization, as well as improvements in the required quality indicators in 2012 and 2013 for these beneficiaries, CMMI reported break even financial performance for Sharp ACO in both of these years," Sharp ACO said in a media statement.
"The Pioneer financial model is based on national financial trend factors that are not adjusted for specific, often unrelated, rate implications that an ACO is facing in a particular region (e.g., San Diego), Alison Fleury, CEO at Sharp ACO, said in prepared remarks. "As a result, the financial impact can be detrimental to the ACO despite favorable underlying utilization and quality performance."
Fleury said CMMI agreed to address several problems with the financial model beginning in 2015. "Although we support the changes proposed by CMMI in the Pioneer financial model, it would not be prudent for us to place our ACO at financial risk in 2014 as we wait for these changes to be implemented," she said.
Sharp is the tenth Medicare Pioneer ACO to leave the program. Medicare beneficiaries served by Sharp ACO will transfer to traditional fee-for-service programs.
It's difficult to overstate the effect of losing tens of billions of dollars in healthcare funding, and not just on state budgets. Now those leaders who opted out of Medicaid expansion are falling back on an old ploy: When in trouble, form a committee.
A task force in North Carolina this month issued recommendations for improving health outcomes in its 2.2 million residents living in rural areas.
"Priorities" identified in the report include: improving job prospects and investment in rural areas; improving access to school readiness programs and quality daycare for children; improving nutrition education; using primary care to screen for mental health and substance abuse; and incentivizing healthcare providers to settle in rural areas.
Left all but unmentioned in the report, however, was the wooly mammoth in the room. North Carolina is one of 24 states that rejected the Medicaid expansion and the tens of billions of dollars in federal funding that come with it.
The Urban Institute issued a study this month which showed that the decision by state lawmakers and the governor of North Carolina to reject Medicaid expansion would mean the loss of $40 billion in federal funding from 2013-2022. In addition, 414,000 mostly working poor North Carolinians who would otherwise have qualified for Medicaid, will have to find coverage elsewhere if they can afford it.
Nationally, the Urban Institute says that the 24 states that have not expanded Medicaid are foregoing $423.6 billion in federal matching funds through 2022. Hospitals in those states will lose $167.8 billion in state and federal matching funds, which was to represent a 31% increase in Medicaid to offset reimbursement cuts in Medicaid and Medicare. In addition, 6.7 million residents in those states who would have become Medicaid eligible will remain uninsured in 2016.
As the months pass, other disparities are becoming apparent. Non-expansion states saw the number of uninsured residents fall by 9% since last September, thanks largely to health insurance marketplaces and the coverage mandate. States that accepted the Medicaid expansion have seen the number of uninsured residents fall by 38%.
Politicians in non-expansion states have argued that they cannot afford their share of the expansion, or that they don't trust the federal government to maintain funding levels. Both arguments are suspect.
For example, each state dollar spent on Medicaid expansion on average brings back $13.41 in federal matching funds. North Carolina was required to spend $3 billion in state funds over 10 years to bring down about $40 billion in federal Medicaid expansion money.
"Every comprehensive state-level budget analysis of which we know found that expansion helps state budgets, because it generates state savings and additional revenues that exceed increased Medicaid costs," the Urban Institute says.
"The current structure and past history of federal Medicaid spending show that, when federal leaders turn to deficit reduction, they will almost certainly seek and find other ways to cut Medicaid without lowering the federal share of Medicaid spending below the ACA's statutory level."
It is also difficult to overstate the effect of losing tens of billions of dollars in healthcare funding, and not just on state budgets. Hospitals are often the biggest economic driver in rural communities and the money they generate is spent in the community. Access to quality healthcare is critical for any community hoping to attract business investment.
Politicians bellowing against federal mandates neglect to mention that the Medicaid expansion is not a take-it-or-leave-it proposition. Governors and state legislatures in Arkansas, Maryland, and Kentucky are crafting compromise plans to create private insurance options with money that would otherwise go toward Medicaid expansion.
Of course, rejecting Medicaid expansion was never about state budgets. This was always about political gamesmanship and appeasing the radical base of one political party. Now, healthcare infrastructures in non-expansion states are starting to crack under the strain of that appeasement. Politicians who made those dumb calculations now fall back on an old ploy: When in trouble form a committee!
Georgia is Exhibit A. After leading the charge to reject Medicaid expansion and about $45 billion in federal funding that comes with it, Gov. Nathan Deal this spring established a Rural Hospital Stabilization Committee to find ways to keep rural hospitals in the Peach State from shuttering. One obvious resource, accepting Medicaid expansion money, was not on the agenda.
Don't blame the people serving on these committees in North Carolina and Georgia and other states who are being asked to identify problems and find solutions without access to an obvious, immediate and massive federal resource.
Speak privately with people on these committees and their frustration is palpable. They see firsthand the life-and-death consequences of rejecting Medicaid expansion. It's tragic that their elected leaders choose to ignore that reality.
The recent reaffirmation of mandatory disclosures of all medical malpractice payments has left physicians in Oregon and Massachusetts concerned that it will quash laws crafted in those states for mediated settlements.
"Nobody is trying to carve out a loophole that would compromise the need to report substandard care to the National Practitioner Data Bank," says Alan Woodward, MD, past president of the Massachusetts Medical Society and current chair of MMS's Committee on Professional Liability.
"We asked HHS and the National Practitioner Data Bank to provide a clarification. What they did was to restate the status quo. That is what this whole interpretation is, just to say we've done things this way, this is what the law says, and this is how we interpret it," Woodward told HealthLeaders Media.
A challenge to the mediation laws surfaced last fall when Public Citizen asked then-Secretary of Health and Human Services Kathleen Sebelius to address what the patient advocacy group said were "loopholes" created in Massachusetts and Oregon that allowed physicians in those states to avoid reporting malpractice settlements with the National Practitioner Data Bank.
Public Citizen said the laws "threatened the viability of the NPDB as a comprehensive and reliable source of data regarding malpractice payouts," especially if the Oregon and Massachusetts laws were used as models in other states.
"We recognize that a single malpractice payment is not necessarily a good indicator of the quality of care provided by a physician or other practitioner," Wolfe said in his letter. "Yet research has shown that a pattern of malpractice payments is an excellent indicator of whether a physician has quality-of-care problems and may need retraining, proctoring, or other serious action to ensure the safety of their future patients."
"If state efforts succeed in creating a legal basis to avoid reporting malpractice payments to the NPDB, it would become more difficult, if not impossible, for NPDB users, such as hospitals and medical boards, to identify such patterns of malpractice by a practitioner when they conduct background checks through the NPDB."
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The Oregon Medical Association issued a statement this month saying it was "recently made aware of the memo and we are reviewing HHS's analysis and rationale to determine how the conclusions will affect the Oregon program. We continue to believe Oregon's Early Discussion and Resolution (EDR) program is good for patients and physicians and will work to continue the goals of the program within the NPDB requirements as they are determined to be."
Woodward was part of a group of physicians who worked with trial lawyers to write Massachusetts' statute for mediated malpractice settlements. He says the HHS ruling puts all that work in jeopardy.
"The whole focus of our program is to do what is morally and ethically right when a patient has an unexpected negative outcome," Woodward says. "It is to increase transparency and encourage full disclosure in an ongoing dialog with the patient. It is to meet the patient's medical, psycho-social, and financial needs without them having to resort to litigation."
"The other major focus is to improve patient safety, because the current system in many ways impedes patient safety improvement," he says. "The concern is that when you tell physicians that any payment, regardless of whether it was a systems error or a human error as opposed to negligent or substandard care, that it is going to be reported to the National Practitioner Data Bank, they are less inclined to participate in this type of open dialog with patients."
"We are absolutely supportive of the statement from Public Citizen that the goal is to protect patients from doctors with a record of substandard or negligent care. We are all in favor of reporting and think that should be reported to the NPDB," he says.
"What we don't want to do is inhibit the adoption of this type of program because of fear of reporting when it isn't negligence or substandard care, but in many cases it is found to be a system deficiency—not having the checks and balances to protect the patient, and there is a series of events that leads to a bad decision."
In our March Intelligence Report, more than half of leaders expect their cardiovascular service line investments to include population health efforts. HealthLeaders Media Council members discuss how a population health strategy aligns with their cardiovascular service line, and where they are making CV investments.
This article first appeared in the September 2014 issue of HealthLeaders magazine.
Jeff Samz Chief Operating Officer
Huntsville (AL) Hospital Health System
Our biggest focus has been around heart failure. It is nurse practitioner–driven, with physician leadership that manages any heart failure patient in our community who we can get to come to the center. We have nurses and nurse practitioners there who have developed a relationship with the patients to not only manage them clinically but also from a social standpoint to keep them from being readmitted and to keep them compliant. We have had that for years, and we have enhanced the aggressiveness of trying to get people into that program to get ready for population health.
We have done a lot of things with trying to improve our discharge teachings as patients leave here, educating them about their medications and what they need to do with follow-up care. We are starting a program to make sure that patients leave here with their appointment to see their physicians. We started a program to deliver medicine at patients' bedsides before they get discharged to improve medication compliance. We started a program this year to call patients postdischarge. We have a nurse navigator grant that we won this year to case manage the highest-risk cardiac patients in-house and get them into these resources to make sure they get good follow-up care.
Robin E. Flint Former Director of the Cardiovascular Service Line
Ellis Medicine
Schenectady, NY
I saw the light some time ago and said we really need to start driving these efforts at the outset with behavioral modification as it relates to nutrition, health, and exercise. The real opportunity here is to begin to drive those efforts back out into the community from an education standpoint, but the issue that we are dealing with is we don't get paid for those things. Fortunately in CV services we still have a positive bottom line, but if you look over the past three years we have seen about a 40% reduction in that margin for the CV service line. It is still positive, but it continues to go down.
We have partnered with two private payers in this community to develop a bundled payment initiative for patients undergoing CABG surgery. We get an up-front bundled payment and we are responsible for those patients 90 days postdischarge. We've talked about doing it with the same payers as it relates to heart failure and atrial fibrillation. This facility is actually going to be working to develop an ACO with other local providers for an insurance product as well. We are seeing some of the efforts begin to pay off. But we've got a long road ahead of us.
Ruth Krystopolski
Executive Vice President of Care
Innovation for Sanford Health
President of Sanford Health Plan
Sioux Falls, SD
We've had a fully integrated health plan at Sanford for 17 years, so we've constantly managed the population in that health plan. There are nearly 100,000 people in it. We are rather diverse from a geographic standpoint, and support centralized enterprisewide structures around population health. That applies to our cardiac service line, our cardiovascular services. In the Sioux Falls market in particular, we have a freestanding heart hospital facility that integrates the full spectrum of care that a patient would need from a cardiac standpoint.
We have really been focused on how we help the populations we serve deal with their cardiovascular disease and impact positively their overall health. We have been doing it for a number of years and now are formalizing the structure to support not only cardiovascular services but all of the service lines that Sanford provides.
Sanford uses a single electronic medical record platform across the entire enterprise—inpatient, outpatient, and for every specialty and ancillary service and for our health plan. So we are 100% fully integrated from the data standpoint, and that is going to allow us to more timely engage individuals whose healthcare we might be able to help improve and hopefully improve outcomes and provide value to them.
Joseph Butz
Senior Divisional Vice President for Cardiac
and Transplant Services
Sentara Healthcare
Norfolk, VA
A population health strategy fits for the cardiovascular service line for us. It's demonstrated by where we are making the investments, and that is in the physician and ambulatory footprint. We have five key drivers for us in the cardiac service line.
No. 1 is wellness. That is dealing with cultural and social issues and driving compliance and engaging more of a holistic approach to the care.
The second area is data: patient registries and databases. You see that with the EMRs collecting the data and creating enterprise data warehousing. We are systemizing all of that to be on the same platform and do things in the same way, reducing disparities in the operations, which in turn generates data to deal with the population.
The third area is risk management. We have to have a larger ambulatory footprint, so that means investing in physicians, physician practices, and alliances and networks.
The fourth area is innovative disease management. For example, how do we develop boutique chest pain centers to manage those patients? How do we manage them to keep them out of the hospital and to get them out of the EDs?
The last thing is the heart care team approach, where you bring in a cardiologist, cardiac surgeons, and an anesthesiologist together to manage patients. You are looking at using population management in a whole new way in an acute care setting to manage these patients.
Nearly 70% of organizations searched for a family medicine physician in 2013. The percentage of primary care positions that go unfilled every year "continues to be a problem," says an Association of Staff Physician Recruiters executive.
The demand for primary care physicians and advanced practice nurses continues to grow, and hospitals are beefing up recruiting efforts as the competition intensifies, the Association of Staff Physician Recruiters reports.
ASPR's just-released benchmark survey details more than 5,000 physician and advanced practice nurse searches by 145 healthcare organizations across the country in 2012-2013.
As in previous years, primary care continues to be in high demand. Nearly 70% of organizations searched for a family medicine physician in 2013; the most common physician search, followed by hospital medicine and internal medicine.
Half of all family medicine and internal medicine positions went unfilled. The percentage of unfilled positions for both of these primary care specialties grew over the prior year with rates increasing from 36% to 47% for family medicine and from 41% to 52% for internal medicine positions, ASPR said.
"I don't think there are any surprises with primary care continuing to be the top searches for both physicians and advanced practice providers. The percentage of positions that go unfilled every year continues to be a problem," says ASPR Executive Director Jennifer Metivier.
"We had 38% unfilled in the current report compared with 33% in the prior year. The demand continues to increase. The supply is not keeping up."
More than 19% of all searches were for advanced practice providers. Approximately 71% of nurse practitioner and 50% of physician assistant searches were specifically for primary care, an increase from 38% and 43% respectively in the prior year, ASPR said.
"I was surprised to see the jump for the advanced practice providers," Metivier says. "It goes to show we are relying more and more on advanced practice providers to fill these gaps for primary care. It is not surprising really if you think about the situation we are facing."
More Demand, More Recruiters, More Spending
The survey found that the median number of provider searches conducted per organization increased from 20 to 26, the median number of in-house physician recruitment staff per organization doubled from one to two people, and annual recruitment budgets rose from a median $245,000 to $321,000 from 2012 to 2013.
"These indicators show that some of these healthcare organizations are putting more focus on physician recruitment," Metivier says. "They're realizing the need to put additional staff and money into this so they can be more successful. When an organization has 30, 40, 60 or more physician searches open one person cannot manage that. They need additional funding and staffing."
"Over time it will be interesting to see if we continue to see growth in that area. We don't have historical data on that point, but the fact that they are staffing with greater numbers and it looks like they are putting more money into it shows they realize that they need to do this to be successful to compete against so many people recruiting those same providers," Metivier says.
Multiple Recruiting Strategies
The report also shows that healthcare organizations with successful recruiting programs often rely on a number of strategies.
"I don't think it is all about money but it certainly helps," Metivier says. "We are definitely seeing more hospitals use payback assistance with student loans, sign-on bonuses and relocation assistance and those types of things. The organizations that are better equipped to offer those incentives are definitely in a better situation and more likely more successful in filling these open positions."
Metivier says ASPR findings show physicians and advanced practice nurse recruiting in rural America remains a challenge.
"Location is definitely a top reason why people decide they are going to accept a position and we clearly see that in more rural areas it is more difficult to recruit," she says.
"A lot of physicians spend their training in large cities, so even if they are from a rural area they become accustomed to a more metropolitan lifestyle and sometimes it is hard to make that transition back to a more rural area."
A small survey of seniors at a NC emergency department finds that 16% were malnourished and 60% were either malnourished or at risk. Before sounding the alarm bells, however, it's important to put this limited study into perspective.
More than half of "cognitively intact" seniors who went to the emergency department at University of North Carolina Hospital in Chapel Hill last summer were either malnourished or at risk for it.
That's according to a new study published this month in the online issue of Annals of Emergency Medicine. Specifically, the small sample of 138 patients age 65 and older surveyed across eight weeks in June and July 2013 found that 16% were malnourished and 60% were either malnourished or at risk.
Before sounding the alarm bells, however, it's important to put this limited study into perspective.
"Our study is restricted to a single emergency department in the Southeastern United States," cautions study coauthor Timothy Platts-Mills, MD, an assistant professor of emergency physician at UNC School of Medicine. "That said, I don't think ours is off-the-charts high. It is probably fairly representative and I would be surprised if it's much lower than 6% in any ED, which is what we view as the baseline in any community."
Many of these elderly patients do not fit the stereotype of the destitute recluse with no access to care or the cognitive capacity to know better. For example, 95% of the patients in the survey had a primary care provider, 93% lived in a private residence, 96% had some health insurance, 4% were Medicare/Medicaid dual eligible, 64% had both Medicare and secondary insurance, 69% were white, and 35% had a college education.
And while the findings are high, they actually could be higher because the surveyors, using the Mini Nutritional Assessment Short-Form, filtered out patients who were too ill to respond, or who could not communicate, or who were cognitively impaired or who'd already been discharged.
Citing earlier research that estimates that about 6% of seniors in United States are malnourished, and 30% of hospitalized seniors are malnourished, Platt-Mills says the UNC survey finding "sits pretty nicely in between those two."
There was no prevalence of malnutrition based on the patient gender or education level, or between urban and rural dwellers. More than three-quarters (77%) of the 22 malnourished patients said they'd never before been diagnosed with malnutrition or identified as at risk of malnutrition. The prevalence of malnutrition was higher among people with depression (52%), those residing in assisted living (44%)*, those with difficulty eating (38%), those who had difficulty buying groceries (33%).
"We saw pretty strong associations between people saying they had financial difficulty buying food and being malnourished, and difficulty eating due to dental pain and being malnourished," Platt-Mills says. "Being poor by itself does not mean you are critically ill. Unfortunately poverty is fairly common in the United States and older adults are not excluded from that. Some of the things that leads people to being malnourished are endemic in the population."
Cause and Effect?
Are these elderly patients malnourished because they are ill, or are they ill because they are malnourished? Platt-Mills says that's not clear.
"For some of these patients, their acute illness is unrelated to their malnutrition. For others, the malnutrition is causing their illness. For others, the illness is causing their malnutrition. For at least some patients, the malnutrition appears to be due to financial hardship," he says. "So for these patients the malnutrition is not a result on an illness but rather due to environmental factors -- and may be predisposing them to illness."
"We certainly have older patients who will tell us sometimes I have to choose between medications and getting food. That screams for an intervention. That seems like a choice that older adults should not have to make," he says.
Is there anything that clinicians and administrators at community hospitals around the nation can due to measure the extent of patient malnutrition, and develop a care regimen?
"There are a couple of things," Platt-Mills says. "Sometimes emergency physicians and clinicians are wary of making diagnoses if they don't know how to act on them. Before a hospital institutes a policy for screening all older adults for malnutrition it makes sense to consider the resources that are available in the community."
Identifying local resources such as Meals on Wheels and asking if they have the capacity to expand is a nice start, Platt-Mills says. "That makes it easier to start screening people."
"The other thing to keep in mind is that some of these problems are a little more complicated than just getting food to people," Platt-Mills says. "Loneliness, depression, and dental problems are common among older adults. So, simply dropping off a bag of groceries at the door for someone who is lonely or depressed might not solve the problem. They might not be eating because they feel isolated. Eating is often a social behavior. Then, the question is what additional resources are available to help address loneliness and try to help older adults feel more part of a community."
Practically speaking, emergency physicians and other ED staff would be challenged to make that sort of in-depth assessment given all of their more immediately priorities.
"That is often seen as beyond the reach of physicians and certainly emergency physicians don't spend a long time taking up those issues," Platt-Mills says. "But if we are going to take up the question of health for older adults seriously we have to think about how we can partner with community groups to solve those problems as well."
The United States spends billions of dollars on healthcare, particularly for the elderly. Are we being pound wise and penny foolish? What if some fraction of that money was redirected toward social services that could ensure that seniors are fed properly, or that their homes are safe and clean, and that they have contact the outside world?
"A doctor isn't necessarily the person who is going to solve this particular problem so we need to think about the resources that older adults need to maintain their health," Platt-Mills says.
"What about the idea that 16% of our patients might be taking three blood pressure medications but they didn't even have a bowl of cereal for breakfast this morning? There is a lot to be said about policy changes that could better address that."
*(Platt-Mills says he was surprised by the high prevalence of malnutrition or at risk from seniors in assisted living. "That seems insanely high. I think a lot of people have had that same reaction," he says. "Why are they vulnerable at all? I would say the level of care that occurs in assisted living is pretty variable, and so is the oversight.")
The agreement reached between the Department of Justice and not-for-profit Carondelet Health Network to resolve whistleblower allegations is Arizona's largest False Claims Act recovery, says the US Attorney handling the case.
James Beckmann
CEO and President, Cardondelet Health
For the second time this month a hospital chain has agreed to pay tens of millions of dollars to the federal government to resolve Medicare fraud allegations.
Arizona's Carondelet Health Network has agreed to pay the federal government $35 million to resolve whistleblower allegations involving fraudulent inpatient billings to Medicare and other federal healthcare programs.
Federal prosecutors said that from April 7, 2004, through Dec. 31, 2011, Carondelet St. Mary's Hospital and Carondelet St. Joseph's Hospital improperly billed Medicare, the Federal Employees Health Benefit Program, and Arizona's Medicaid program for inpatient rehabilitation services that should have been done in a less-costly setting.
"Shortly before becoming aware of the United States' investigation, Carondelet disclosed to the government some inpatient rehabilitation overpayments and tendered a substantial repayment," says a Department of Justice media release.
"However, based on its investigation, the United States had concerns about the nature of Carondelet's disclosure, including concerns that the disclosure and the repayment Carondelet tendered were not timely, complete, or adequate."
Catholic-sponsored, not-for-profit Carondelet offered to return $24 million in 2012. Though the amount was deemed insufficient, federal prosecutors said this week that the attempt at restitution was "one of several factors in reaching the settlement amount and the resolution of the case." The settlement is not an admission of liability by the hospitals, or a concession by prosecutors that the claims are not well founded, the Justice Department said.
Carondelet said in its own media release that the investigation never involved allegations that patients were harmed or received compromised care.
"As a leading healthcare provider in Southern Arizona, Carondelet is dedicated to enhancing the health and well-being of this community and this region," Carondelet CEO and President James K. Beckmann said in the media release.
"As a part of that promise, we hold ourselves accountable to the highest standards of integrity. I commend our leadership team who reviewed, audited and voluntarily disclosed our past billing discrepancies. We are proud of our proactive Corporate Responsibility Program and our ability to identify and resolve these issues that occurred some years ago."
The settlement does not require the health network to submit to a corporate integrity agreement, "due to the strength" of its corporate responsibility program," Carondelet said in the media release.
John S. Leonardo, the US Attorney for the District of Arizona, said in prepared remarks that the settlement "is the largest-ever False Claims Act recovery in Arizona, and it reflects the longstanding and ongoing efforts of our office to guard the vital, but limited funding of federal healthcare programs."
"Inpatient rehabilitation services are very costly to taxpayers, and it is critical that these federal dollars be reserved only for those qualified patients who need the intense rehabilitation therapy services provided in an inpatient setting," Leonardo said.
The settlement resolves a whistleblower lawsuit filed in 2011 by Jacqueline Bloink. These suits allow private citizens to bring civil actions on behalf of the federal government and share in any recovery.
Bloink's relationship with Carondelet and her share in the settlement were not disclosed in the Justice Department media release. Attempts to contact Bloink, who now runs a compliance consulting firm, were unsuccessful. However, the Arizona Daily Star reported that Bloink, a former employee of Carondelet, stands to receive $6 million from the settlement.
This week's settlement marks the second time in three weeks that a hospital chain has paid out tens of millions of dollars to the federal government to resolve Medicare fraud allegations.
On Aug. 4 the Justice Department announced that the federal government would accept a $98 million payment from Community Health Systems Inc. to settle system-wide fraud allegations at the Franklin, TN-based for profit hospital chain.
This week, the Justice Department issued a copy of the corporate integrity agreement binding CHS for the next five years.
Rising numbers of women in higher education and a growing desire among healthcare workers for work/life balance are fueling physician assistant job growth. But the head of a PA industry group says the lack of diversity among PAs is "disturbing."
A first-of-its-kind statistical profile of the nation's certified physician assistants shows that they are in high demand everywhere across the nation, with many recent graduates having three or more job offers.
The more than 76,000 responses to the National Commission on Certification of Physician Assistants survey, the group represent 80% of the more than 95,500 PAs working in the nation, also showed that 66% of PAs are women, and 86% of PAs are white.
Dawn Morton-Rias, president/CEO of the NCCPA, says a lack of diversity for PAs is a problem shared by many professions. For example, the most-recent data from the Association of American Medical Colleges for 2008 showed that 75% of physicians were male and white.
"This is a statistic that is disturbing across the board. Certainly as America becomes more diversified we want to have a much more diverse profession as well," she says. "We certainly are interested in partnering with the educational institutions and others to promote diversity within the profession."
"It's not that we are OK with it. It is what it is and this is what the data are showing. But we are attentive to the social demands that healthcare faces and we are interested in partnering to the best extent possible to recruitment and retention and certification of diverse PAs."
Morton-Rias says the predominance of women in the PA workforce has been gradual. "That hasn't always been the case. It's been in transition over the last several years to see more women in the profession," she says.
As for why, Morton-Rias says: "There are more women in higher education and seeking careers across the board. So that plays a part. And as people choose career paths they want work/life balance and the PA profession does that as well."
The survey also found that:
The median age of certified PAs was 38 in 2013
PAs, in their principal clinical setting, see an average of 70 patients per week
Over 75% of PAs practice in an office-based private practice or hospital setting
Over 52% of recent graduates have three or more job offers
Morton-Rias says the data on job offers support the perception that PAs have seen "phenomenal growth" in the last decade.
"There is high demand for PAs. They are utilized and integrated into the healthcare sector across all disciplines and settings and in all 50 states," she says. "Every state has legislation enabling physician assistants to acquire licensure. Evidence suggests that there is a continued demand for healthcare providers as implementation of the Affordable Care Act continues and growth in PA programs continue and we continue to see good employment across the United States."
The job prospects outlined in the survey are consistent with those of other sources. Physician and advanced practitioner search firm Merritt Hawkins says it received fewer than 10 requests to recruit PAs and NPs four years ago. Over the last two years requests grew by over 300% and the firm conducted close to 200 PA and NP searches last year.
"PAs and NPs are joining the ranks of primary physicians in the sense that they can pretty much point at a spot on a map and work there if they so choose," Merritt Hawkins President Mark Smith said. "It is not a feeding frenzy yet, but it is getting there."
For the time being, Morton-Rias says the nation's PA educational programs are trying to keep up with demand. "We currently have 187 programs, each of which graduates about 35–40 per year. Those numbers are not striking, but there is steady growth between 40–75 new PA programs in the pipeline," she says.
"We expect that the numbers of PAs will continue to climb. As is the case in healthcare across the board, the distribution challenge [is] to see where PA s go and where they choose to work."
"The programs are doing the best they can and the certification components that we are responsible for are meeting the needs of the current population and we are prepared to expand that as the number of certifications and recertifications continues to climb."
