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."
The data affected was non-medical patient identification data related to Community Health Systems' physician practice operations and does not include patient credit card, medical, or clinical information, CHS says.
Community Health Systems Inc. said Monday that its computer network was "the target of an external criminal cyberattack" between April and June that may have compromised the personal data of 4.5 million patients.
"The Company and its forensic expert, Mandiant (a FireEye Company), believe the attacker was an "advanced persistent threat" group originating from China who used highly sophisticated malware and technology to attack the Company's systems," Franklin, TN-based CHS said in a Form 8-K filing Monday with the Securities and Exchange Commission.
"The Company has been informed by federal authorities and Mandiant that this intruder has typically sought valuable intellectual property, such as medical device and equipment development data."
"However, in this instance, the data transferred was non-medical patient identification data related to the Company's physician practice operations and affected approximately 4.5 million individuals who, in the last five years, were referred for or received services from physicians affiliated with the Company."
HIPAA Violated
CHS said the data didn't include patient credit card, medical or clinical information. "The data is, however, considered protected under the Health Insurance Portability and Accountability Act because it includes patient names, addresses, birthdates, telephone numbers and social security numbers. The Company is providing appropriate notification to affected patients and regulatory agencies as required by federal and state law."
CHS said in its SEC filing that it had "completed eradication of the malware from its systems and finalized the implementation of other remediation efforts that are designed to protect against future intrusions of this type."
CHS operates 206 hospitals in 29 states. Since learning of the attack, CHS said it has worked with federal law enforcement authorities to find those responsible for the attack.
"The Company will also be offering identity theft protection services to individuals affected by this attack. The Company carries cyber/privacy liability insurance to protect it against certain losses related to matters of this nature. While this matter may result in remediation expenses, regulatory inquiries, litigation and other liabilities, at this time, the Company does not believe this incident will have a material adverse effect on its business or financial results." CHS acquired Health Management Associates and its 70 hospitals in January.
Healthcare organizations "are coming to the realization as they transform from the fee-for-service to fee-for-value environment that they don't have the skills and capabilities and resources and experiences necessary to successfully do that transition," says an industry analyst.
Hospital and health system mergers and acquisitions dropped slightly in the first six months of 2014 but not enough to suggest any stalling of the industry-wide trend toward consolidation, KaufmanHall consultants say.
In the first of 2014, 43 hospital/health system M&As were announced, compared with 46 in the first half of 2013, says Kit Kamholz, managing director with Kaufman Hall.
"We really don't see it slowing down. We see continued consolidation at these levels," Kamholz says. "If we go back to 2009 or 2010, there were probably between 50 to 60 transactions done and now we are closer to 90 or 100. So the activity has almost doubled over that five-year period on an annual basis."
Of the 43 fully integrated transactions involving change of ownership so far in 2014, forty were acquisitions of not-for-profit organizations—33 by other not-for-profit organizations and seven by for-profit organizations. The total operating revenue of the acquired providers was $10 billion. The transactions occurred across a range of acute-care segments, including not-for-profit, for-profit, rural, urban, and academic health centers, KaufmanHall reports.
Kamholz says M&As are part of a healthcare industry-wide trend toward consolidation and the general belief that bigger is better when it comes to economies of scale, patient populations, market share, and leverage with payers.
"Organizations are coming to the realization as they transform from the fee-for-service to fee-for-value environment that they don't have the skills and capabilities and resources and experiences necessary to successfully do that transition," Kamholz says.
"[They] are coming to that realization at varying speeds. Those at the forefront that are now considering partnership opportunities, whether it be fully integrated or less-than-fully integrated, see that their organizations have gaps as they move towards that transition."
Kamholz says that over the past three or four years there has been an increase in joint ventures or loose partnerships that do not involve a transfer of ownership or assets.
"What is really unclear at this point with those types of relationships is whether there is any real value and benefit to them," he says. "None of them have been around long enough to stand the test of time and prove out a business concept. A few of them have subsequently terminated after forming."
Even though consolidation has been raging for more than five years, Kamholz believes the hospital and health system M&As will continue at a frenetic pace for the foreseeable future.
"There is a point where you reach a size and scale and capabilities that allow you to be successful in the marketplace. The hospital industry is so fragmented right now that we aren't anywhere near that level," he says.
"If you look at the airline industry, there are four or five major airlines now. Look at the drug store industry. You basically have CVS and Walgreens. I don't see the hospital and health system base ever getting that consolidated. We are still very much a mom-and-pop industry. There is a long runway to go from 5,000 providers today, of which half are affiliated with systems, to a point where you have a real level of size and scale that can drive success in the hospital industry."
Froedtert, Ministry Health Care Pursue Co-Ownership of Network Health Plan
Froedtert Health and Ministry Health Care will pursue co-ownership of Network Health, a Menasha, WI-based health insurance plan, the two health systems announced Friday.
Network Health provides commercial and Medicare Advantage health insurance plans to employers and individuals in northeastern Wisconsin. The company has been solely owned by Ministry Health Care since 2012.
"The anticipated transaction will position Froedtert Health and Ministry to jointly expand the Network Health service area into southeastern Wisconsin with Network Health offering Integrated Health Network as its provider network in SE Wisconsin," Ministry Health Care CEO/President Nick Desien said in a statement released with the announcement.
"This is a natural partnership that flows from the existing Integrated Health Network of Wisconsin relationship between Ministry and Froedtert Health," said Catherine Jacobson, president and CEO of Froedtert Health and chair of Integrated Health Network.
Integrated Health Network is a clinically integrated alliance of independent health systems, hospitals, and physicians that includes: Froedtert Health, the Medical College of Wisconsin, Columbia St. Mary's, Wheaton Franciscan Healthcare, Agnesian HealthCare and Ministry Health Care. It is one of the first multiple–system accountable care networks in the country.
"With clinical integration, a proven care coordination model, and IT connectivity solidly in place, IHN has the infrastructure to contract directly with all payers and insurers on behalf of its members," said Jacobson.
Desien said the "partnership and expansion of Network Health will accelerate the growth of population health management programs in the communities we serve and we welcome the prospect of expanding our relationship and look forward to our continued discussions."
Ministry Health Care joined Integrated Health Network in September 2013. Since January, Integrated Health Network has been managing care for approximately 90,000 lives, including 55,000 lives through a partnership with UnitedHealthcare that created one of the nation's largest accountable care organizations.
Aurora Health Care, BAMC Sign Form Joint Venture
Aurora Health Care and Bay Area Medical Center agreed to form a joint venture, the two Wisconsin non-profit health systems said in a joint media release.
BAMC began the search for a partner in 2012 and identified Aurora in late 2013. The BAMC Board unanimously approved the agreement this month.
Aurora will serve as a minority partner in the 99-bed BAMC, adding capital and advanced services, while keeping health care local. The joint venture will allow for shared resources, such as technology and supply costs. In addition, the partnership will continue to improve the quality and efficiency of care for the community.
Aurora already has physicians and clinics in the Marinette area, but not a hospital, with the closest being a tertiary hospital, Aurora BayCare Medical Center, in Green Bay. The joint venture will provide BAMC with access to Aurora providers, depth of expertise in care management, supply chain and other areas.
In the coming months, the joint venture will establish its new board of directors, which will then develop a recommendation for facility, clinic and physician planning. BAMC will also work towards the same electronic medical record as Aurora, the two systems said.
Bay Area Medical Center is a 99-bed general acute care hospital located in Northeast Wisconsin. It includes a community primary/secondary care hospital, an outpatient surgery center, and a cancer center. BAMC offers select, advanced medical services, with an emphasis on heart & vascular care, women's services, diagnostic radiology, ambulatory surgery, obstetrics, cancer treatment, and emergency care.
Prime Healthcare Services Acquires St. Mary's Hospital in NJ
Ontario, CA-based Prime Healthcare has completed its acquisition of St. Mary's Hospital in Passaic, NJ. As part of the deal, Prime Healthcare will invest more than $30 million into St Mary's, which serves Passaic, Clifton, Wallington, Carlstadt, Rutherford/East Rutherford, and surrounding towns, Prime Healthcare said in a media release.
"Prime Healthcare is excited about its first partnership with a hospital in New Jersey and looks forward to helping St. Mary's Hospital provide the exceptional patient care residents of Passaic and the surrounding communities want and deserve," said Prem Reddy, M.D., FACC, FCCP, Chairman, President and CEO of Prime Healthcare Services.
"Prime Healthcare's motto is 'Saving Hospitals, Saving Jobs and Saving Lives,' and we plan to continue that at St. Mary's and help it become one of the best hospitals in the state and in the country."
Under the deal:
St. Mary's will continue as an acute care hospital with all current services.
Charity care levels for patients in need of financial assistance will be maintained.
All existing employees will be hired; the physician base will be maintained.
Catholic ethical and religious directives will be honored.
St. Mary's President/CEO Edward J. Condit said in a media release that selling the hospital to Prime will "strengthen St. Mary's financially so that it can dedicate more of its resources to providing even better community care."
The cost of having fewer choices doesn't spare healthcare. Most rural residents can expect to pay more for coverage purchased on health insurance exchanges.
Competition among health plans is a critical component that tempers prices for individual health insurance coverage under the exchanges set up by the Patient Protection and Affordable Care Act.
It makes sense. Give healthcare consumers more informed, apples-to-apples choices among several health plans competing for business on an open exchange and the consumers will gravitate to the best value.
That works in urban and more densely populated areas that have a number of health plans competing for customers using a plethora of providers. What about sparsely populated rural areas?
The answer is not surprising. People in rural areas mostly have fewer coverage options, and because of that most of them—though certainly not all of them—will pay higher premiums.
That's according to a study from the University of Pennsylvania and the Robert Wood Johnson Foundation. It's hard to provide a blanket conclusion to the report because it is fairly nuanced and provides several scenarios involving a 50-year-old non-smoker shopping for silver plan coverage in 2014.
"Rural residents do not have as many choices as urban residents in terms of premiums, issuers, plans, and plan types. They also have less availability of Health Maintenance Organizations, Exclusive Provider Organizations, and Preferred Provider Organizations, and greater availability of Point of Service plans," the study says.
"Most notable is the fact that EPOs are available to half the number of rural residents as urban residents. These differences in plan types may reflect the notion that it is easier to develop and more strictly enforce a restrictive provider network in urban areas than in the more sparsely populated rural areas where there are fewer convenient choices of providers."
The bottom line is that most rural residents can expect to pay more. The study found that "monthly premiums are slightly higher in in rural areas than urban areas ($387 vs. $369)," and that "monthly premiums are meaningfully lower in states that are the most urban when compared to the least urban ($402 vs. $452)."
In 32 states, rural residents paid more in silver premiums than urban residents. In seven states and the District of Columbia there was no difference, or the data wasn't available, and in 11 states rural residents paid less.
"It seems to be simple supply and demand. It's the cost of having fewer choices," saysTimothy Putnam, president/CEO of Margaret Mary Health in Batesville, IN. "In our region there is just one product. There is one choice that people have and this is what comes with it. You take it or leave it. There is demand out there, but limited supply, so we know what happens to prices when that occurs."
On one extreme, the 9% of people in Nevada who live in rural areas would have had to pay about $554 a month for silver coverage this year, $201 more a month than urban residents. On the other extreme, the 55% of Mississippi residents who live in rural areas would have paid $470 a month for silver premiums, $72 less than Mississippians in urban areas.
The differences don't break down neatly along Red State/Blue State lines. Minnesota's rural residents could expect to pay $55 more per month for a silver plan than would urban residents. In Texas, rural residents would pay $20 less per month for similar coverage.
In Indiana, where Margaret Mary Health is located, rural residents pay $452 per month in silver premiums, only $1 more per month than urban residents. However, that is a statewide average that can fluctuate wildly among counties and healthcare service areas, again depending mostly upon competition.
To underscore the importance of competition, another study this month by the Urban Institute looks at premium costs in 10 states with varying numbers of plans in their exchanges, and made no distinctions between rural and urban settings. Not surprisingly, the states with more competitive health insurance exchanges saw significantly lower premiums than did states with less-robust exchanges.
It's unfortunate that rural Americans will likely have to pay a penalty in the form of higher premiums, but I have to confess that I was expecting the disparities to be much greater.
If we factor out the extremes on both ends, Mississippi, Nevada, and other states that skew the findings, the difference between many states is negligible. In 26 states, the premium costs fluctuate no more than $20 per month in either direction. Given the complexity of PPACA, the frenzied start-up for the exchanges, and the heels-dug-in resistance from many states, it could have been a lot worse.
It's hard to draw conclusions from all of this. One year does not constitute a trend. The focus now will be on premium costs in 2015, and whether the variable between urban and rural coverage widens or narrows.
Jeff Thompson, MD, CEO of Gundersen Health System and chair of the as yet unnamed partnership—not a merger or an acquisition—discusses the coalition's intention to improve quality of care, reduce costs, and collectively "get better faster."
Jeff Thompson, MD
CEO of Gundersen Health System
Six Wisconsin healthcare systems that provide healthcare access to 90% of the people in that state have formed a strategic partnership to improve clinical quality and lower costs.
Jeff Thompson, MD, CEO of La Crosse-based Gundersen Health System and chair of the partnership's board of directors, stresses that the affiliation "is a true partnership among our six organizations, not a merger or consolidation. It will allow us to more rapidly learn from each other, share best practices, and serve the needs of patients and families more efficiently."
The partnership's founding members are:
Aspirus – Wausau
Aurora Health Care – Milwaukee
Bellin Health – Green Bay
Gundersen Health System – La Crosse
ThedaCare – Appleton
UW Health – Madison
A commercial insurance plan for the six organizations is being offered through Anthem Blue Cross Blue Shield's Blue Priority network, and will be available through brokers, the federal Health Insurance Marketplace, and private health insurance exchanges.
The partnership intends to expand coverage options, and is evaluating other insurance carriers and administrative products. The partners are also open to extending membership to other healthcare organizations that can demonstrate delivering quality, value-based care.
Thompson says the partnership was developed to build on and advance clinical quality, efficiency, and customer experience attributes that are documented and shared among the six organizations.
In addition to providing healthcare access to most of Wisconsin, the six partners serve people in Illinois, Iowa, Michigan, and Minnesota. Each partner system uses the same electronic medical records system, making it easier for patients to access their records and share with doctors in the network.
Thompson spoke with HealthLeaders Media about the partnership soon after the announcement. The following is an edited transcript.
HealthLeaders: Why did Gundersen join this partnership?
Thompson: When we first started, the talk was about putting together an insurance network. We felt like if it was going to be an insurance network we weren't interested. We were already in a variety of networks.
But if you are interested in developing a group of organizations that do not want to spend all of their time with the merger, governance, and asset allocation and all that kind of thing, but want to spend their time improving care and lowering costs, then there are some real possibilities.
We talked around that for a while and felt that being an organization that could have an insurance product and eventually take risk across a broader population had some real advantages.
But probably the biggest advantage for our patients and our organization was to put together a group that all had the ability and track record of quality improvement and working on cost reductions and saying, 'If we all commit to making each of us better, how we can get better faster?'
That is what we believe we can accomplish and that is why we came together.
HealthLeaders: Is there a specific agenda as this partnership progresses?
Thompson: That all has not been completely designed out. We do have a number of subgroups under the new organization. A business group has already formed and chosen a leader for supply chain. We are all in buying groups, but we do believe there are some things in the supply chain and contracting that as a group we can do better at and find where each of us are saving.
Our quality committee has already met and will work on making sure our data connects and that we have the same definitions. They've already started their conversations about where we might be able to get the most improvement. We believe there is an opportunity for the groups to focus in certain areas. We just haven't designated those. We expect in the next couple of months to have that started.
HealthLeaders: What does this partnership mean for healthcare consumers in Wisconsin?
Thompson: I don't think most of that will change hardly at all, at least not right away. The earliest thing that will occur is the network will have a relationship with the [Anthem] Blue Cross and Blue Shield Blue Priority insurance product. But at no point did we say we are going to limit it to a single insurance product. It's not about insurance products. It's about trying to become better more quickly. So we believe that that will come first, but there will be more opportunities afterwards.
There will be an advantage for those employers who have employees spread across the parts of five states that these organizations cover. And the state of Wisconsin could be served by this group as well.
HealthLeaders: Will this partnership facilitate other collaborations?
Thompson: That is a potential. We all recognize that. But we believe that right now, as things are changing rapidly, as the opportunities are there, our focus is best left on making care more reliable and bending the cost curve down. If we as a group can work together on that, then those other things will either happen or not.
Whether we are part of a big organization or not is less important to our communities. What is important to our communities is that the care be even more reliable and the cost of the care becomes less.
HealthLeaders: Where do you see this partnership in five years?
Thompson: We have the potential to prove that you don't need a merger and governance and asset changes to cooperatively accomplish things that are part of all of our own missions.
We all have a mission to take care of patients in our communities and we believe that will drive us to great performance. It will be likely that other people will ask to be a part of this when they see our success, so it is likely we will grow. But again, our target is not to become big. Our target is to become better, faster.
HealthLeaders: Are you saying that being under one ownership arrangement is irrelevant?
Thompson: Certainly trying to get to that adds a ton of complications and we don't believe it necessarily helps us.
We believe right now with the strong commitment to boards of the organizations, the CEOs, the senior leadership of the organizations, that we can improve more quickly, we can take out costs, and that all of the complexities of governance and asset changes and all of that are not going to slow us down because we aren't doing that.
HealthLeaders: Does this partnership require government approval?
Thompson: We've checked with a number of lawyers and they don't believe it does, because we are not merging and we are not sharing price data and things like that. But we are working on quality improvement.
We are working on sharing best ways to reduce costs. We will all have multiple outside partners, so we believe right now that it does not come even near the gray areas of antitrust issues. Besides, there are other giant competitors in the region.
Looks like when lawmakers return next month, Congress will retroactively approve another stopgap measure related to oversight of outpatient therapy services at critical access and small rural hospitals.
Things have gotten so dysfunctional in the U.S. Capitol that Congress can't even act on a bill to delay something.
Since 2012 Congress has suspended a Centers for Medicare & Medicaid Services rule that requires direct physician oversight of outpatient therapy services at critical access and small rural hospitals.
The oversight rule was suspended because it proved particularly burdensome in areas where physicians tend to be in short supply. The practical effect was that relatively routine outpatient services such as drawing blood were restricted or even eliminated because physicians weren't readily available to provide immediate supervision.
That delay of the oversight rule actually expired on Jan. 1, 2014, but Congress has signaled that it will continue to delay the rule while lawmakers work on a more permanent fix. (Sound familiar?)
Now, more than halfway through 2014, it looks like Congress will retroactively approve another stopgap measure for 2014 when lawmakers return next month following a long summer vacation.
The Senate approved the delay by unanimous consent this spring, and a House version is set for a floor vote after easily clearing committee in July. Also, there does not appear to be any fiscal note tied to the legislation.
So, about the time 2015 rolls around, hospitals will be covered for 2014.
It's not completely a moot point. Even retroactively, the delay means that rural providers will get some measure of protection when recovery audit contractors are resurrected.
"For instance, if the Medicare program or the Inspector General wanted to go back and go after the hospitals potentially for noncompliance with direct supervision requirement, this enforcement delay would not allow that to happen. So, it does protect hospitals," says Lisa Kidder, vice president of legislative affairs at the American Hospital Association.
Kidder says the rules around physician oversight are ambiguous.
"What does 'immediately available' mean? This can always be second-guessed," Kidder says. "Different Medicare contractors in different states may interpret the requirements a little differently, so hospitals are never 100% sure that what they have put into place would mean that they are in compliance according to their contractors."
Adopt a default standard of "general supervision" for outpatient therapeutic services and supplement with a reasonable exceptions process with provider input to identify those specific procedures that require direct supervision.
Ensure that for critical access hospitals the definition of "direct supervision" is consistent with their conditions of participation that allow a physician or non-physician practitioners to arrive within 30 minutes of being called.
Prohibit enforcement of CMS's retroactive reinterpretation that the "direct supervision" requirements applied to services furnished since Jan. 1, 2001.
Roslyne Schulman, director of policy at AHA, says PARTS has not been scored by the Congressional Budget Office, so it's not clear if the bill will carry a fiscal note, which would otherwise prove problematic. The biggest reason for kicking the can with the "Doc Fix" bill is the cost.
"We have talked internally on that and we don't think there would be a large score attached to it," Schulman says. "There really aren't any costs associated with it. It sets up a panel. It has some prohibitions on the OIG. But there really aren't a lot of things that cost money to the Medicare system."
Patient Safety Considerations
Another hurdle for PARTS includes provisions for patient safety. Schulman says that's been taken into consideration.
"PARTS adopts a default standard of general supervision, which means the services are furnished under the overall direction and control of a physician, but their presence is not needed while the services are being furnished," she says.
"The bill would adopt a default standard of general supervision for outpatient therapeutic services but they would be supplemented with an exceptions process, in which CMS could identify specific services that due to safety concerns would require direct supervision."
PARTS has a lot going for it. It appears to be a practical and effective provision to allow rural providers to operate at greater efficiency within the limits of their staffing. At the same time, it keeps in place critical standards for patient safety and provider accountability.
The bill won't get taken up before the new 114th Congress is called into session next January, so it's difficult to predict how it will be received. That shouldn't stop rural providers who support PARTS from contacting their Congressional delegation today. There's already been enough delay.
