The gradual rebranding "is consistent with where we have been moving as an organization in the last two or three years as a single corporation delivering care in four states, and not [as] a confederacy of 19 hospitals," says the CEO of SSM Health Care.
What's in a word?
William P. Thompson
President and CEO of SSM Health Care
I wondered about that after SSM Health Care this month announced that it is changing its name to SSM Health at its 19 hospitals and more than 60 outpatient facilities in four Midwestern states.
At first blush, dropping "care" from a name brand doesn't seem like a big deal. That one little four-letter word, however, has become freighted in the healthcare industry. It has come to suggest, ever so subtly, that the services provided are reactive rather than proactive; that the focus is on delivering sick care instead of emphasizing health and prevention.
The rebranding will be gradual, starting at SSM Health hospitals in mid-Missouri and expanding from there. The process expected to be completed by 2016.
William P. Thompson, president and CEO of SSM Health Care, spoke with me about the name change, what prompted it, and what it signifies. The following is an edited transcript of our conversation.
HLM: What prompted this name change?
WPT: Like every other healthcare system we have been challenging ourselves as to what does the future of healthcare really mean. We've talked about this transition from volume to value.
We recognized about three or four years ago that we were going to have to transform ourselves from being strictly an acute-care, hospital-based, episodic care[-focused], sickness system to a system that was truly an integrated delivery network fully capable of assuming responsibility both clinically and financially for the health of the population.
We recognized that we were going to have to do a better job of connecting with patients and we were going to have to do a better job of assuming risk. We made significant investments in information systems, medical records systems, other infrastructure improvements. We made a significant investment last year to acquire the Dean Health System and Dean Health Plan and to add additional capabilities to our system.
We also had an interesting conversation with some fairly sophisticated healthcare purchasers, large employers and insurers, who told us we were one of the best kept secrets in our communities.
We looked at our various markets and had something like over 100 different names and logos and looks to our identity. When you looked at that, you realized we really are a best-kept secret because the exceptional things we are doing in one of our hospitals or facilities really wasn't transferring to the benefits of the others and we had to change that.
We also recognized that we had to prepare for a more retail- or consumer-oriented business orientation with the growth of high-deductible health plans, defined contributions health plans, and the emergence of public and private exchanges.
Individual people, patients, beneficiaries, customers are going to make more and more of the decisions as to where they were going to receive their care.
HLM: The name change will happen gradually over the next two years. Why not do it all at once?
WPT: It's the old joke: How do you eat an elephant? One bite at a time.
It is a matter of doing it well in one market and rolling it out to the next. We may find that we can speed up the process after we have done it a while, but it is a fairly substantial endeavor to change the signage on our facilities, and change the stationery, [and] all of the existing pieces that are out there.
A lot structural things have to be changed. There are a lot of communications, paid advertising, and other kinds of communications that we are going to have to do.
We also want to make sure we bring our employees along. Part of this transformation we are in is to be much more patient- [and] customer-centric than we have ever been in the past. So we are engaging our employees today in what will probably be a six-month process through a series of meetings and focus groups and conversations.
If you were the patient how would you want to be treated? What would be important to you? We have done a ton of research on branding and identity, but in the future we have to be able to deliver a physician visit virtually. We have to be able to open up some technological portals that allow patients to contact us through their smart phones or iPads, the ability to communicate through our patient portals that we haven't done in the past, recognizing patients want immediate access to a provider. How do we set up same day appointments?
How do we ensure that we have extended hours? How do we facilitate the admission of patients or facilitate a patient's visit in a clinic or office setting? Can we eliminate waiting times in the waiting rooms? Can we eliminated waiting in the exam room?
Those are the questions we are asking to ensure that we can deliver on this promise of "experience exceptional." We want to roll this out having fully engaged our employees and making sure they understand what we are trying to accomplish, but also solicit their help to assure that we can actually accomplish what we are promising.
HLM: What else will the rebranding involve?
WPT: The logo will change slightly. It will be very representative of what we have had traditionally. We are going to use the tagline of "experience exceptional." That will become part of the brand rollout. That is what we want to have a lot of conversations about.
What does that really mean in this new world of retail/consumer orientation where we have to be competitive in an environment where patients are going to act like—it's not the best analogy —people making value decisions about where they buy hamburgers?
They are going to make value decisions about where they buy healthcare and how they want that healthcare. Do they want it in a traditional face-to-face meeting? Do they want a telephone visit or a video visit? We have to be prepared to meet the patients where the patients are, not where we think they should be going, which is the tradition of healthcare.
HLM: Do you see any potential savings in this name change?
WPT: I don't know how much we could save, but the fact is we can now use a single promotional piece across our entire system with very minor changes. We can use some common advertising, common production of both print and television and other media ads, making it easier to transfer that across the entire system.
There are some significant [potential] savings, but that is consistent with where we have been moving as an organization in the last two or three years as a single corporation delivering care in four states, and not [as] a confederacy of 19 hospitals.
Health policy researchers at the University of North Carolina are building an interactive computer model to attempt to empirically answer questions about patients-per-physician ratios by region and by specialty.
It's real and it's happening right now, as a quick chat with a physician recruiter or most hospital executives in most parts of the country will verify.
The shortage is expected to intensify in the coming years as more physicians retire, the general population grows and grays, and more people get health insurance under the Patient Protection and Affordable Care Act.
Still, there is something clunky about these projections. They may accurately reflect gross patients-per-physician ratios. That's easy to identify and track. These ratios don't, however, account for the more intuitive, subtle way that healthcare providers make their localized adjustments to provide access to care in their service areas.
If there is a shortage of cardiologists, for example, to what degree will primary care physicians alleviate that shortage by taking on the more routine monitoring of cardiac patients? Along those lines, how do we determine how many nurse practitionersor physician assistants will step in to alleviate a shortage of primary care physicians?
I can't prove it, but from what I am hearing anecdotally, providers are already doing this informally on a patient-by-patient level in their service areas. When they see a need they find a way to meet it.
"We do it, but not officially," says Tim Putnam, CEO/President of Margaret Mary Health in Batesville, IN. "We look at what the specialist is doing that could be done by a family physician. Some specialists are seeing a lot of patients on maintenance that they really don't need to see."
Now health policy researchers are the University of North Carolina are building an interactive computer model to attempt to empirically answer those questions. Erin Fraher, team leader at UNC's Program on Health Workforce Research and Policy, says FutureDocs Forecasting Tool tries to factor in "plasticity."
"Past workforce models that have produced estimates of future shortages have said 'we are going to need X many primary care physicians or X many cardiologist or X many general surgeons.' That is not how healthcare is delivered on the front lines," Fraher says.
"We want to create a model that acknowledges that depending upon the community you are in and the models of care you have. For circulatory conditions you might use more internists and family physicians in a rural community and cardiologists in an urban community. Plasticity lets you think about who can deliver a set of services and allow different configurations in different communities for those services."
FutureDocs is granular to the level of Tertiary Service Areas so its usefulness might be limited for smaller hospitals that need greater local detail.
Erin Fraher
"If I were a health system or a hospital I would use this model to look at demand and what the workforce looks like, and using plasticity to see if I can use a less-expensive workforce. You can look at physician assistants and nurse practitioners in this model," she says.
"Look what happens when physicians retire and what if you increased physician (full-time equivalent) by 5%? Those seem like marginal changes, but in workforce models, two of the biggest drivers are FTEs and retirement. As a health system, just educating people about that could be a short-run way to solve a workforce shortage. The model allows you to educate yourself, your HR director, your local physician community, and your medical society or whomever you are collaborating with what the situation looks like under a set of scenarios and how it might change."
When plasticity is factored in, Fraher says, providers and hospital administrators might learn that the physician shortage, while real and immediate, is also manageable.
"Everyone is screaming 'physician shortage,' but most studies are written about national estimates," she says. "People love the big data numbers.'We are going to be short thousands of primary care physicians and thousands of specialists.'"
"FutureDocs has the ability to see that it may or may not be true depending upon the community you are in. In fact, overall, the model says the capacity of physicians to meet the demand for healthcare services is in balance and will continue to be in balance."
A bigger issue for local providers is not the national shortage of physicians, but the disparities in the numbers of physicians between different regions.
"Some places have severe shortages and other places actually look pretty good or even over capacity," Fraher says. "FutureDocs helps people see that your perception of this physician shortage depends upon where you are sitting geographically."
"Your demand for healthcare services for circulatory conditions are going to be much higher in Florida [where] you are going to have lower demand for OB/GYN. No brainer! This is a model that allows you to see those variations in utilization and surplus and shortage across communities."
"My hope," says Fraher, is that the model will provide a more nuanced picture that has been treated a bit more glibly at the national level."
Hospitals in states that have rejected expansion have seen flat or sagging admissions and little if any reduction in the numbers of uninsured and non-paying patients, while states with Medicaid expansion have seen the opposite, a PwC study finds.
Medicaid expansion under the Affordable Care Act has been in place less than one year, but it's already creating a gaping financial chasm between hospitals in states that accepted the expansion money and those that have rejected it, a PwC Health Research Institute analysis suggests.
The PWC study examined recent earnings data from the nation's five largest for-profit hospital companies that have a combined 538 hospitals in expansion and non-expansion states and found a stark contrast.
Hospitals in the 24 states that have rejected expansion continued to see flat or sagging admissions and little if any reduction in the numbers of uninsured and non-paying patients.
Hospitals in the 26 states and the District of Columbia that expanded their Medicaid coverage to include an additional 7.2 million people, and accepted the billions in federal dollars that accompanied it, saw a significant rise in Medicaid inpatient admission and a concurrent decline in self-pay and charity care.
"Surprise? That is a fair assessment. As we came up with this we were struck by some of the results," says Robert Valletta, US Health Services Leader for PWC. "At this point in time it appears that this is working the way that I think it was intended to work from a governmental perspective. So far, I think we should enjoy what we've found."
Specifically, PwC found that:
Dallas-based Tenet operates hospitals in five expansion states and saw uninsured and charity care admissions drop 46%, coupled with a 20.5% increase in Medicaid admissions. In the second quarter, Tenet saw a $78 million drop in unpaid care.
Franklin, TN-based Community Health Systems operates hospitals in 29 states, including 12 expansion states that account for just 23%, of CHS's overall revenue. However, those expansion state hospitals provided a major financial lift because self-pay emergency room visits fell 41%.
CHS has seen a corresponding 10.4% increase in Medicaid admissions through the first half of this year compared to the same period in 2013. The surge in new paying customers and reduction in uninsured patients, accounts for about $40 million to $45 million of CHS's earnings. CHS expects another $40 million benefit through the second half of 2014.
HCA Holdings revised its earnings outlook to account for better-than-expected revenue. The company hospitals in five expansion states saw Medicaid admissions grow 32% with a corresponding 48% drop in uninsured admissions through the first half of the year. Uninsured volume also declined 2% in non-expansion states.
LifePoint Hospitals operates in 20 states—seven of which expanded Medicaid. The health system saw second-quarter earnings of about $158.7 million, a 35.8% increase over the same span in 2013. Of that, LifePoint executives attribute about $13 million to the PPACA's coverage expansion. About 80% of LifePoint's newly-covered admissions came from Medicaid in the second quarter.
Pennsylvania-based Universal Health Services reported a 30% increase in second-quarter adjusted net income, to $155.6 million compared to $118.9 million during the same period a year ago.
Chip Kahn, president of the Federation of American Hospitals, says Medicaid expansion is doing what it was designed to do when hospitals agreed to support healthcare reform four years ago.
"If you look at the Congressional Budget Office numbers, this is what it was supposed to do, which is [to] allow these many uninsured Americans, most of them relatively low or very low income, to have access to healthcare. That's what's reflected here," Kahn says.
"It also reflects a level of both un-insurance and the pressures from that that hospitals have historically and particularly in the last few years been dealing with."
Although the PwC analysis examines the effect of the expansion on for-profit hospitals, Kahn says the Medicaid expansion money is benefitting the non-profit hospitals as well.
"This isn't a for-profit/non-profit issue," he said. "This is benefitting all of the patients who now have coverage and it is benefitting all of the hospitals in those states regarding the uninsured who previously couldn't pay for the care we provided, both for-profit and non-profit."
"In some states," he added, "public hospitals are seeing a tremendous shift because the people who are still coming to their hospitals so many of them now have coverage."
Although Medicaid's low reimbursements remain a point of contention with all providers, Kahn says many hospitals understand that half a loaf is better than nothing.
"They were coming into the hospital previously and frankly were unable to pay anything or if they were it was a pittance," he said. "Now, they have coverage like other Americans and yes, the payment amounts are significantly less than private payment for private coverage or for Medicare coverage. At the same time, it is compared to what?"
Valletta says hospitals understand that an "an absolute counter to the increase in Medicaid revenue is a reduction in the free care revenue, which is a direct increase to margins and revenues. So, clearly you'd rather have even a small amount of revenue than no revenue at all."
The PwC report avoids arguments for and against the Medicaid expansion. Valletta says it's fair to expect that these ongoing and pronounced disparities will stoke the pressure to expand Medicaid in non-expansion states.
"We are not passing judgment as to whether the states should or shouldn't. We are just stating the facts of what happened in those particular states where there was expansion and the direct contrast to those where there wasn't," he says.
"You can see that even within the large for-profit systems there was a distinct difference in their hospitals that are in expansion states versus not."
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."
