In other news, CHE partners with Walgreens, a Massachusetts hospital deal comes with strings attached, and a federal judge rules on the fate of a struggling Long Island, NY hospital.
Two physician-led, not-for-profit health plans serving different regions in upstate New York have formed a "strategic alliance" to develop strategies around managing population health.
Independent Health, a Buffalo-based plan serving 375,000 people, and Albany's CDPHP, serving 24 counties around the state capital, announced the deal this month.
"This strategic alliance will allow each of our plans to remain independent and highly responsive to the needs of our respective communities," Michael W. Cropp, MD, president/CEO of Independent Health, said in prepared remarks.
"This is not a merger, but a unique alliance to exchange and implement ideas and strategies that are essential to continue driving sustainable healthcare. The learning and discipline that will come from working together will greatly accelerate our respective abilities to meet the needs of our provider partners and our customers."
The two plans said the alliance would allow them to:
Develop tools to help providers efficiently manage populations;
Partner with physicians using technology and clinical innovation within the mantra of right care, right place, right time and right cost;
Invest in new technology to improve consumers' access to information and services they need and to navigate the fragmented healthcare system.
"By combining the talents, resources and expertise in both of these companies, the alliance will allow us to build innovative products, tools and services for providers, employers and individuals from Albany to Buffalo," John D. Bennett, MD, president/CEO of CDPHP said in a joint media release.
"Yet, we will be able to continue to provide the same personalized and high-quality customer service that our customers in the Capital District and Western New York have come to recognize and value from these two companies."
Partners HealthCare Deal Comes with Stipulations
Massachusetts Attorney General Martha Coakley has approved Partners HealthCare's acquisition of South Shore Hospital and Hallmark Healthcare, but with a decade's worth of strings attached to the deal. The AG's office has disclosed the following conditions:
Allowing payers to split Partners into separate contracting entities for up to 10 years;
Preventing it from contracting with affiliate physician groups that are not part of its owned hospital for 10 years;
Capping health costs at the rate of inflation across the entire Partners network through 2020;
Capping its physician growth for five years; and
Blocking further hospital expansion in eastern Massachusetts, including Worcester County, for the next seven years.
An agreement made public by Coakley must be finalized between the providers by June 16 and then approved by a court.
"Suing Partners would potentially block further expansion of its network, but would also maintain the status quo in the market," Coakley said in prepared remarks.
"We believe this agreement will do much more. It fundamentally reduces the negotiating power of Partners for the next 10 years to better control health costs for families and businesses, and help level the playing field in the market."
The Attorney General's Office and the Department of Justice have been conducting an antitrust investigation into Partners Healthcare for months. In February, the Health Policy Commission released a report concluding that Partners' acquisition of South Shore would result in increased costs and referred the report to the AG's Office for further investigation.
A more detailed account of the proposed settlement may be viewed here.
CHE Trinity Health, Walgreens form Care Collaborative
Livonia, MI-based CHE Trinity Health and drugstore chain Walgreens will have announced they will collaborate on innovative models of care in select markets served by CHE Trinity.
The collaboration links retail clinics, outpatient pharmacy services, and expanded prescription and disease management programs to improve population health and access to care while lowering costs. Walgreens pharmacists and Healthcare Clinic nurse practitioners will work with CHE Trinity providers to coordinate patient care, while offering care services at Walgreens and CHE Trinity Health sites.
"Coordinated care programs are vitally important to help ensure patients have access to the quality, convenient, affordable care they need before, during and after a hospital admission," Alan E. London, Walgreens vice president of strategic clinical partners, said in prepared remarks.
"Working with an integrated health system such as CHE Trinity Health offers an ideal opportunity to further leverage Walgreens healthcare assets to coordinate patient care across multiple regions of the country."
CHE Trinity Health is one of the largest multi-institutional Catholic healthcare delivery systems in the nation, in 20 states from coast to coast with 86 hospitals, 109 continuing care facilities and home health and hospice programs that provide nearly 2.8 million visits annually. The organization was formed in May 2013, when Trinity Health and Catholic Health East merged.
Walgreens has 8,209 drugstores in 50 states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands.
NYBankruptcy OKs Long Island Medical Center Deal
A federal bankruptcy judge has approved South Nassau Community Hospital's amended asset purchase agreement to acquire storm-damaged Long Beach Medical Center.
Under the amended APA, South Nassau acquires LBMC's assets, including land, buildings, and equipment, with the exception of the Komanoff Center for Geriatric and Rehabilitative Medicine, which will be acquired by another bidder at a separate closing.
The closing is scheduled for June 30. South Nassau Community Hospital said it will hold community forums after the closing to get public input about a plan to improve the accessibility of healthcare for South Shore residents.
LBMC was closed because of damage sustained when Superstorm Sandy smacked Long Island and the Tri-State Region in late October, 2012. At the request of state officials, South Nassau and LBMC opened talks in June 2013 to develop a new healthcare delivery model to restore medical services in Long Beach. The discussions continued into 2014, and resulted in the APA between South Nassau and LBMC.
South Nassau's redevelopment of the LBMC campus will start with a new family medicine-urgent care center providing treatment and triage for urgent medical conditions and ambulatory care with subspecialty backup supported through an integrated information technology system connecting the center to South Nassau's main campus in Oceanside.
Laboratory and radiology imaging services will be provided on-site, as well. Care will be provided on a walk-in basis, with no appointments required. Patients who are assessed as in need of further emergency care or hospitalization will be transported to South Nassau or the hospital of their choice via on-site ambulance services. Following the sale closing South Nassau will convert and expand the urgent care center to a freestanding 911-emergency receiving facility.
There are rumblings that federal lawmakers may be willing to repeal Medicare's burdensome rule requiring physicians in critical access hospitals to make an educated guess that the patients they're admitting will be either discharged or transferred in less than four days.
I am loathe to write about pending legislation in Congress.
The bills with the most promise for healthcare providers usually are ignored or tabled or lost in some silly legislative procedure or held hostage for some unrelated reason or session adjourns with hopes dashed and no action taken.
Lawmakers who are occasionally called into accountability for doing nothing lament not passing a bill that would have helped rural providers in their states and blame the impasse on the other party.
Then they go home to raise money and get reelected and start the entire process all over again.
Still, there are rumblings coming out of Washington, DC that lawmakers may be willing to repeal Medicare's burdensome and staggeringly dumb 96-hour rule that requires physicians in critical access hospitals to make an educated guess that the patients they're admitting will be either discharged or transferred in less than four days.
Yes, I know. We've been to this rodeo before. Earlier this year, for example, Sen. Pat Roberts (R-KS) co-chairman of the Senate Rural Health Care Caucus, introduced the Critical Access Hospital Relief Act of 2014, in February. It was assigned to committee, and no further action has been taken. The bill tracking Web site Govtrack.us gives S.2037 a 1% chance of clearing committee and a 0% chance of passing.
That is not encouraging.
Not easily deterred, Sen. Roberts has filed another bill to eliminate the 96-hour rule and there is some buzz about Congress that S.2359 may have some legs.
The Craig Thomas Rural Hospital and Provider Equity Act(R-HoPE), named in honor of the late Sen. Craig Thomas (R-WY), is cosponsored by Sen. Tom Harkin (D-IA), chairman of the Health, Education, Labor, and Pensions Committee, along with Sens. Al Franken (D-MN) and John Barrasso (R-WY).
"The R-HoPE Act recognizes that rural healthcare providers have very different needs than their urban counterparts and that healthcare is not one-size-fits-all," Roberts said in remarks accompanying the bill.
"I am glad we were able to include provisions to get rid of Medicare's 'condition of payment' known as the burdensome 96-hour rule, which is particularly troubling for critical access hospitals and in turn, their patients."
The bill actually helps rural hospitals and providers in other ways, too. For example, it calls for the removal of a 12% cap on Medicare disproportionate share payments for rural hospitals serving higher populations of poor patients.
And It reinstates hold harmless provisions for rural hospitals under the Medicare Outpatient Prospective Payment System at 100% of payment difference through Jan. 1, 2015. It also extends and expands the Low Volume Hospital Adjustment program to 2,000 discharges through Jan. 1, 2016.
Actually, the 38-page bill is sweeping and has about 25 sections that enhance and improve funding for rural healthcare delivery. I don't have the time or space to detail every provision. Read it and judge for yourself.
The American Hospital Association is most definitely on board. In a letter of support to Sen. Harkin, AHA Executive Vice President Rick Pollack said the bill "would extend critical rural provisions that are set to expire or have expired and implement new provisions that would benefit rural hospitals."
All of this is tremendous good news for rural providers, but let's not forget to exhale. This is Congress, after all, where many promises are made and few are kept. Govtrack.us also gives S.2359 a 0% chance of passing. To put that in perspective, the Dallas Cowboys have a better chance of winning the Super Bowl in 2015 than S.2359 has of passing.
AHA says there are signs that the bill's chances are improving. It has broad bipartisan support in both chambers, with 27 co-sponsors signed on so far in the Senate, and 65 co-sponsors in the House.
Unfortunately, all of that is just cheerleading and wishful thinking until we know how much this all will cost. The Congressional Budget Office has yet to score R-HoPE. The AHA and other proponents don't think it will cost that much. But that's what the American Medical Association said about the cost repealing the SGR right before Congress slapped another temporary patch on the reviled payment scheme.
Maggie Elehwany, vice president, government affairs & policy at the National Rural Heath Association, and a veteran Congress watcher, plays the long game when it comes to bills such as R-HoPE.
"The hope is that we continue to gain co-sponsorship because leaders in both the House and Senate realize the importance of this bill and the economic vitality that these hospitals provide for their rural communities," Elehwany says.
"But it does score and obviously that will present challenges and we are just hopeful. The 96- hour rule should not score so we are cautiously optimistic that we can get that common sense fix to occur before the end of Congress."
At this point, Elehwany says, rural healthcare advocates might have to settle for a piecemeal approach.
"We are going to do absolutely everything we can to get these bills passed. But speaking honestly, it is going to be more doable to get the 96-hour rule done. That is something that every member of Congress understand shouldn't have a score. It should be such an easy fix to help the critical access hospitals in their home states," she says.
"We are going to do everything we can to get R-HoPE passed, but we realize we will probably have to get it introduced in the next Congress. But hopefully we can lift out bits and pieces since it is divided into several sections and we are OK if we have to do it in a piecemeal fashion. It's great to have a big enchilada bill, but we are fine with doing it section by section as well."
Flat or declining deal volume doesn't indicate that the M&A market is cooling, but increasing deal values indicate that larger deals are in the works, says a PwC analyst. At the same time, hospitals and health systems are slowing their pace of physician practice acquisitions.
The volume of deals in health services mergers and acquisitions for everything from physician practices to health plans in the first quarter of 2014 held pace with the same period in 2013, even as the total deal value rose 152% to $12.3 billion, according to PwC's Q1 2014 US health services deals insights report.
Brett Hickman, partner and PwC's U.S. healthcare deals leader, says he expects healthcare services M&A's to continue at a strong clip in the near term as the sector adjusts to value-based reimbursements, lower inpatient volumes, and federal mandates.
"The biggest issue is sustainability, especially as payers and providers look at how they can compete in a population health world, whether it is a high-deductible plan that is impacting utilization, or appropriate medical management being done on a medical home model. All of those things have large implications on utilization of traditional settings of healthcare," Hickman says.
"Organizations realize that not only do they need to invest significant capital to make the journey to a new model, one that is less acute but provides better and more frequent access at a much lower cost. They realize they are going to have significantly larger population to take that risk. To do that they have to be in an environment where the economics are totally different to be able to take on that risk."
Larger Deals in the Works
"Size does matter. Market share matters. You have to have a broader population to spread that risk. You need access points across a broader continuum and you have to be able to do that in a highly efficient and cost effective manner."
Hospital deal volume in the first quarter of 2014 fell 43% when compared to the first quarter of 2013, from 21 to 12. However, deal value increased from $320 million in the first quarter of 2013 to $388 million in the first quarter of 2014.
Hickman says declining deal volume doesn't necessarily indicate that the M&A market is cooling, but increasing values indicate that larger deals are in the works.
"We are going to move from systems buying individual hospitals to systems buying systems. There will be fewer deals, but the deals are going to start to get bigger and much more complex," he says.
In the managed care sector, M&A activity was up slightly in the first quarter of 2014 as deal volume increased 150% compared to the first quarter of 2013. Deal value was not disclosed for any of the deals announced this year.
Physician Management Companies Lead Practice Takeovers
The PwC US report shows that the ground is shifting in physician practice acquisitions, with physician management companies taking over the dealmaker role once held by hospitals.
Hickman says hospitals and health systems are slowing their pace of acquisitions. In 2011, hospitals and health systems accounted for 51% of all physician practice volume, but by 2013 accounted for 14%.
Physician practice announced deal volumes were down slightly in the first quarter of 2014 when compared with the first quarter of 2013. However, physician management companies accounted for all nine of the reported practice affiliation deals reported in the first quarter of 2014.
Hickman says this trend will likely continue in the near term because specialty physician groups are adjusting to higher regulatory costs and reimbursement changes.
Only So Many Physicians Can be Leaders
"Physicians want an alternative to selling out in their minds to a health system and the deals aren't as sweet as they used to be," Hickman says. "Hospitals have become a lot more wary of promising too much. You can only make so many physicians in your system leaders. Like all Type A personalities, everybody wants to be the boss and there are only so many roles for that."
"I like the fact that there is some alternative for physicians. Competition is healthy. It keeps everybody honest," he says. "The reality has set in that from the physicians' perspective, their value to care delivery has never been greater and yet they have never been treated worse from a reimbursement perspective, from the government, from leadership, from the media. All of those."
"Now they are finally waking up and realizing they are the only ones who can do this and they can do it better if they do it around the clinical delivery system."
In this new dynamic, Hickman says, independent physician organizations such as California's Monarch Healthcare are becoming more integrated on the care management side and taking on risk.
"The competitive model to the institutionally driven accountable care organization or the clinically integrated network or population health systems are going to be physician driven; Kaiser Permanente models without bricks and mortars," Hickman says.
"The payer and the physician together are thinking 'we can buy a hospital bed anytime we need it. If we move to population health we have too much institutional assets. So, it becomes a commodity that can be purchased on a needs basis.'"
In our Annual Industry Survey, leaders cited monitoring quality along the care continuum as their single greatest challenge regarding clinical quality improvement. How is your organization addressing this challenge?
Kathleen Sanford, DBA, RN
Senior Vice President and Chief Nursing Officer
Catholic Health Initiatives
Englewood, CO
On identifying solutions: We started mostly as a hospital company and we are growing more into a continuum company so we knew we needed an infrastructure that wasn't just hospital-based. And we knew we needed to have the tools and the metrics to make that happen. So we set up a national and a regional infrastructure for that. And we actually restructured or retooled job descriptions
at the national office to make sure that we had people who are actually responsible for that.
On expanding the continuum: Each of our seven regions has a CEO and we decided each region needed a CMO and CNO, and a large part of their job is building the infrastructure to make sure that whatever quality measures we decide on, whether in the hospital or throughout the continuum, they are responsible for making sure the practices are put in place and that everything is done the same way across the country. All of our quality metrics come up through our service lines. And if we partner with someone who is not employed by CHI, part of our due diligence is seeing what they are doing in those areas. We want to make sure we're partnering with people who are working on quality.
On involving patients: We determined about three years ago that patients need to be a part of this, so we have national and regional patient and family advisory councils. They advise us on how to make things better. They look at the quality results in our regions. They also have experiences that they can share with us.
Mary Anna Sullivan, MD
Chief Quality and Safety Officer
Lahey Health
Burlington, MA
Quality along the care continuum and readmissions are really the same thing. It is figuring out how to take care of all of our patients in what we call the interstices. It's not when they are in the office or in the hospital; it is all those in-between times where we need to figure out how to offer real longitudinal care and be able to assure ourselves and our patients that we are offering the highest-quality care in the right setting.
That includes a huge focus on patient engagement and recognizing that we can have the best of intentions and follow great standardized evidence-based medicine and get everybody doing it just right, but unless we are really partnering with our patients and they are truly engaged in their own care, then we are not going to be hitting our mark either.
We are looking now at total medical expense, which means you can't just look at the hospital and clinic visits. You have to focus on whether the patient is getting the best care possible in the least costly appropriate setting.
We're looking at the patients who are dealing with multiple comorbidities including behavioral health and figuring out how to embed behavioral health into primary care and do community outreach so that the folks who are not doing well and who are least likely to get themselves to appointments don't get lost.
Alan H. Rosenstein, MD, MBA
Internist and Medical Consultant
for Healthcare Management
San Francisco, CA
The most important thing is to recognize, given the complexities in the environment, that there are many different touch points for the patient. Physicians and care providers, the nurses and care managers and discharge planners and pharmacists, all need to coordinate and have a consistent plan for the patient that everyone is able to understand so they can set the expectations to provide the best possible care and reduce any chance of complications or hospital readmissions.
Determining who leads the care coordination is a critical issue. I've done a lot of work trying to get physicians to understand the importance of communicating and coordinating with their peers and the staff and with the patients and their families. Unfortunately, what happens is when patients get into the hospital they may be taken over by a hospitalist or an intensivist, and they may bring in a cardiologist, a disease specialist, or a surgeon, and everybody is either treating a disease or an organ but somebody has to take responsibility for the overall management of the patient, and that needs to be the primary care physician.
Pam Harmon
Chief Nursing Officer
Rooks County Health Center
Plainville, KS
When it comes to clinical quality, we identified several problems with our readmissions and we have been able to meet guidelines on lowering readmissions. We have a social worker who we now have call all of the patients and do follow-up surveys.
The day patients come in, we start discharge planning. We find out what they will need, what they have in place at home, what types of things we can set up to make it work for them. We get physical therapy, occupational therapy, speech therapy: We have them all evaluate our patients. Then our social worker does discharge planning reviews every two or three days until the patients are ready to go home, and we meet with all of the multidisciplinary people to make sure that all things that we can identify are identified. When they are discharged, we call and ask, "Did you get your prescriptions? If you're getting services, have they showed up? Are you able to function at the level you thought you should be able to function at?"
This is a small community and we know the patients and we know the families and we know where some of the weak links might be. Not everything is right here in our hospital and available for all of our patients. But before they go home, we have it set up and ready for them.
In our April Intelligence Report, the top challenge cited by leaders for their primary care redesign efforts is to get patients engaged in their own care. Why is this so difficult, and what steps is your organization taking in this area? E-mail John Commins at jcommins@healthleadersmedia.com to be featured in this future Council Connection piece.
Although the 5.4% growth is the lowest cost increase since the Milliman Medical Index began keeping track in 2002, it also represents the ninth straight year in which annual costs have increased by at least $1,100.
First the good news.
The 14th annual Milliman Medical Index reports that healthcare cost growth continues a decade-long slowing trend for a family of four enrolled in an employer-sponsored preferred provider plan.
Now the bad news.
Even with slower growth, healthcare costs for that family will increase 5.4% in 2014, which represents an average bump of $1,185 per family and a total cost of $23,215, with employers paying $13,520 and employees paying $9,695, according to Milliman, the Seattle-based healthcare actuarial firm.
Although that 5.4% growth is the lowest cost increase since MMI began keeping track in 2002, it also represents the ninth straight year in which annual costs have increased by at least $1,100. In 2013 growth was 6.3%, and in the past decade the cost of healthcare for that family of four as measured by MMI has increased by 107%, from $11,192 in 2004 to $23,215 in 2014.
"It's a shocking amount of money," MMI co-authorChris Girod said in a telephone interview. "At some point how can a family afford this stuff? Their costs keep going up $1,100 a year. They aren't paying for all of it, but as we saw in this recent economic slowdown that is a time when employers may push more of the costs onto their employees."
Regardless of the pace of cost growth, Girod says these inevitable annual increases have "built up from a lot of different components. At a fundamental level, we have a problem in this country of people, all of us, spending and not always being directly accountable for the costs."
One of the biggest factors slowing cost growth of late has been the slow economy.
"As the economy tightens up, people cut back on their spending and become more conservative," Girod says. "Also, as the economy slows down, employers cut back a little on their healthcare spending and push more costs onto employees. It also creates an incentive for people to spend less because they have more out-of-pocket expenses."
The MMI measures total cost, including out-of-pocket expenses paid at time of service, and it separates the costs into portions paid by employer versus employee. The index found that since 2010, the total employee cost, which includes both payroll deductions and out-of-pocket expenses, has increased by around 32% while employer premium contributions have increased by 26%.
Healthcare costs are increasing at about three times the rate of growth for private sector wages and salaries, which increased 1.7% over the year ending in March, as measured by the Bureau of Labor Statistics. The rate of growth in healthcare costs also far outpaces inflation in the overall economy, which grew 2% over the past year, BLS reports.
In almost every year in the past decade, growth rates have slowed. Since the MMI began calculating healthcare cost growth in 2002, the annual increase in cost ranged from a high of 10.1%, in both 2003 and 2004, to a low of 5.4% in 2014. The rate of increase dropped by nearly a full percentage point, from 6.3% in 2013 to 5.4% in 2014.
Because MMI measures larger employer-based PPO costs, Girod says it's difficult to determine how the Patient Protection and Affordable Care Act is affecting cost growth. Also, PPACA hasn't been around long enough for its major provisions to affect costs.
"Obamacare so far has really all been about expansion of coverage, getting people into the market," Girod says. "What this country really needs is a phase two that focuses on cost control now that we have more people covered. It hasn't really happened yet."
If the weak economy and cost-shifting to consumers are the main drivers for slowing healthcare cost growth, then what—if anything—are healthcare providers and payers doing to reduce costs?
"That's a good question," Girod says. "Some of the movements that we think are helping to possibly control costs are providers taking on risks again through accountable care organizations. We don't know what sort of an impact that is having, but it is sort of managed care lite and a way for providers to start getting their feet wet."
"There are also some programs pushing bundled case rates, and lots of providers, at least on the West Coast, are talking about capitation even more than ever. They are wanting to come to the table to try to manage the costs, too."
Girod says it's not clear when, or if, healthcare spending growth will top out or consumers will reach a breaking point.
"We were having the same discussions back when healthcare spending in this country was 12% or 14% of Gross Domestic Product and now it's up at 18%," he says. "How much of the production pie can it consume? Nobody really knows, but at some point the tail is going to start wagging the dog."
As consumers take on more of the responsibility of paying for healthcare, the popularity of walk-in retail health clinics is surging. Tenet says it's set to double the number of its retail health clinics this year.
Kyle Burtnett
Senior Vice President, Outpatient Services of Tenet
In a nod to the growing influence of consumer-driven healthcare, Tenet Healthcare Corporation this week announced that it will double the number of walk-in clinics in its MedPost Urgent Care franchise by the end of this year.
Kyle Burtnett, Tenet's senior vice president, outpatient services, says MedPost is a key component in the Dallas-based for-profit hospital chain's push to grow its outpatient facilities. That growth is part of a broader corporate strategy to offer more services in faster-growing, less-capital intensive and higher-margin businesses.
Burtnett says MedPost is addressing healthcare consumer demand for access to more convenient, less-expensive care.
"Consumers are so used to having everything at the touch of their fingers, whether it is on their smartphones or just having things so conveniently located to where you live and work that when people are sick they want to be able to get care in the same day," Burtnett told me.
"The other thing is you also have patients bearing much more responsibility for the financial aspects of their treatment. Rather than go to an emergency department and incur higher costs, consumers bearing more of the responsibility are taking a much closer look at how they are spending their healthcare dollars. That plays right into urgent care's role as a much more affordable solution."
Tenet now operates 23 MedPost Urgent Care centers in Arizona, California, Florida, Georgia, Mississippi, Missouri, Tennessee and Texas. They were all recently rebranded under the MedPost name.
Placed in strip malls or as stand-alone facilities, the new clinics will be open seven days a week with extended daily hours. MedPosts will be staffed by primary care and emergency physicians, nurse practitioners, and other healthcare professionals, and will be equipped with imaging and lab services.
The following is an edited transcript of my conversation with Burtnett earlier this week.
HLM: Did the Patient Protection and Affordable Care Act influence your decision to expand?
Burtnett: We were looking to move forward and start developing urgent care centers before that happened, but I definitely view it as a plus. When you think about people today that don't have health insurance, they are able to access the acute care system by going to an emergency department because of (Emergency MedicalTreatment and Labor Act) requirements.
But the part of the system they are not able to access is the outpatient care area. Obviously, with the ACA, more and more people are getting coverage [and] that is opening up a whole new patient base to your services. So, we think that it's definitely a positive from the outpatient perspective.
HLM: Was part of your rationale for expansion the thought that if you didn't do it, someone else would?
Burtnett: Yes. You see a lot of activity in the urgent care space. The markets where we are operating with the hospital presence or the outpatient presence you are seeing a lot of activity. First of all there are a fair number of urgent care centers up and operating today. But you are also seeing de nouveau development activity in various markets. You are seeing other people expand on a more regional or a national basis as well.
HLM: Emergency departments are an important inpatient access point at many hospitals. Is there any way to estimate how MedPost will affect inpatient admissions at Tenet hospitals?
Burtnett: I don't think there is any firm data on the amount of referrals into the health system. We are making sure that patients receive the appropriate care at the time of service at the urgent care center. If they do need a referral, whether to the ED for a higher level of care or a specialist to follow up on a particular issue, then we are trying to do that within our family of services. That is something we are cognizant of.
HLM: How much does it cost to set up a MedPost clinic?
Burtnett: If you want a ballpark, it is probably between $600,000 and $800,000 to get one built out and operational.
HLM: Do you see MedPost as a low-cost opportunity for Tenet to expand into competitors' service areas?
Burtnett: Right now we are looking in our existing markets. Hopefully they will prove to be so successful that we think it is a great business opportunity and decide to expand. But first and foremost we have a lot of work to do as far as building out a robust network of urgent care centers within our pretty big geographic footprint at this point.
HLM: Can you build Tenet brand loyalty through MedPost?
Burtnett: First and foremost we need to take good care of people when they are there. They need to receive excellent care from our physicians and medical staff. Then hopefully they received not only great care but tremendous patient experience, [and] customer satisfaction. That's what we are counting on to build up brand loyalty.
HLM: How are you addressing price transparency?
Burtnett: I'm not entirely satisfied but we are making progress. The majority of our contracts we have a global rate. If you come into the center it costs you 'X' dollars whether you have an X-ray or not. You are still going to be charged that amount.
So it is very easy to understand and explain to the consumers who walk into the center. Where I would like to get more advanced, and we don't have this today, but we are working on it, is just more transparency related to self-pay or cash pricing and making sure we have that easily accessible on our Web site for consumers to view.
HLM: In what other ways do you expect Tenet will become more consumer-centric?
Burtnett: One of our early forays is just with the Web site and social media efforts. But you will see those types of forays in other areas in the more traditional hospital portfolio. That will be one thing. Focusing on ease of use and access. Making sure that people can not only find us but easily access us, whether that is on-line registration or scheduling. Those are things we are going to be focusing on in the future.
HLM: Are traditional healthcare providers laggards in customer satisfaction behind retail and other sectors of the economy?
Burtnett: As far as customer service and focusing on patient satisfaction, that is something that the healthcare system has done for a long time. It's now moved even more to the forefront with the (Hospital Consumer Assessment of Healthcare Providers and Systems) surveys.
But where I'd say where we've missed, is [in] being a little more retail oriented–outreach to consumers, going direct to consumers. We focused on that patient that comes into our center, making sure they receive good customer service, that they are treated well, etc. But it is that outreach that I think we've missed a little bit.
We are going to launch social media platforms that I hope engage consumers and potential patients, build a very robust Web site that will continue to make enhancements, and hopefully that will provide patients with a very easy and efficient way to access our system and find us.
The ability to have your Web site pop up and be easy to use on a mobile device is just incredibly important. That is another area we are focusing on.
More than nine out of 10 federally qualified health centers reported having electronic health records systems in 2013 compared with 30% in 2009.
The adoption and use of electronic health records in federally qualified health centers has grown by 133% in the past five years, thanks in large part to targeted federal funding and incentives, a survey from The Commonwealth Fund shows.
The survey of 679 senior executives and clinicians at FQHCs found that 85% reported advanced HIT capabilities in 2013, which meant that they could perform at least nine of 13 functions, such as ordering pharmacy prescriptions electronically. The rate was 30% in 2009, when The Commonwealth Fund conducted its last survey.
The pace of HIT implementation at many FQHCs has accelerated to the point where it is outstripping that of many larger physicians groups or integrated health systems. In 2013, 78% percent of office-based physicians used electronic health records, up from 48% in 2009.
In addition, 93% of FQHCs have EHR systems compared with 78% for larger practices and 71% for integrated delivery systems. On meaningful use, three-quarters of FQHCs reported that they meet federal criteria, which is about the same proportion as large, non-physician-owned medical practices and integrated systems, The Commonwealth Fund reported.
Survey coauthor Melinda Abrams, The Commonwealth Fund's vice president for delivery system reform, credited the surge in HIT adoption and usage over the past five years to targeted federal funding and incentives put forward under the legislation such as the HITECH Act.
"It is a targeted investment to adopt the electronic medical records and then the financial incentives to use them to help manage complex patients and new patients," Abrams says.
In another survey of FQHC leaders, The Commonwealth Fund found widespread concerns about staffing were a top issue in the near term, with 83% saying that physician recruiting will be problem, and 73% anticipating problems recruiting nurse practitioners and physician assistants.
Abrams says stakeholders must ensure that funding remains in place so that programs such as the National Health Service Corps will continue to provide a vital stream of clinicians to FQHCs and for other underserved areas.
"Recognizing and making sure that we continue to support and grow that program will go a long way in making sure we have enough primary care clinicians to staff our health centers," she says.
"We have generally a problem in this country across the board with attracting medical students into primary care because of the substantial amount of debt that most medical school students acquire and because of the differential in compensation between primary care physicians and specialists. That is something National Health Service Corps addresses. Programs that try to mitigate or provide loan forgiveness can go a long way toward attracting more clinicians to our FQHCs."
Instead of grilling Sylvia Mathews Burwell, who is expected to be confirmed as the next head of the Department of Health and Human Services, many Republican senators on the committee used their allotted time to rail against the Patient Protection and Affordable Care Act.
For the second time in a week, President Obama's nominee to lead the Department of Health and Human Services emerged unscathed from a Senate confirmation hearing.
For the most part, Sylvia Mathews Burwell was subjected to high praise from Senate Finance Committee members from both parties during the two-and-a-half-hour hearing on Wednesday afternoon.
A date for the committee vote has not been scheduled, but Burwell is expected to sail through the nomination process. Last year the Senate approved her nomination as director of the Office of Management and Budget on a 96-0 vote.
Instead of grilling Burwell, many Republican senators on the committee used their allotted time to rail against the Patient Protection and Affordable Care Act, which will be a critical issue in the upcoming midterm elections. Sen. Charles Grassley (R-IA), told Burwell that he was frustrated with what he said was the Obama administration's longstanding lack of accountability with Congress.
"As I said on the day you were nominated, you have a fresh start with the Congress and the public," Grassley told Burwell. "But if you are going to make the most of that opportunity you are going to have to do things differently than they have been done."
"I will use Marilyn Tavenner as an example. She sat in the same chair you're in a few months ago. She committed to do things differently. Now it seems like she's gone into the witness protection program, it's been so long since she was last in that chair or at my door. I hope that doesn't happen with you. I hope you don't disappear into the same bunker. Do you think it is possible for you to change the by-any means-necessary culture at HHS that some of us in Congress view as bordering on lawless?"
Burwell replied in part that her role as director of OMB often means that she has to present Congress with difficult news and that she expected to do the same while leading HHS.
"I take the issues very seriously. This is a space where I actually hope that there will be actually direct communications if there are concerns," she said.
The hearing got somewhat lively when Sen. John Thune (R-SD), questioned Burwell about "selective enforcement" of rules that he said favor political allies of the Obama administration. Specifically, Thune questioned why some labor unions were exempted from a tax imposed on self-administered, self-insured plans and whether other groups outside of the exemption would have to pay more in taxes to make up the difference.
"All I am simply saying is that as a matter of fairness in the way this is implemented, carving out favored groups shouldn't be the modus operandi…. and this particular one was a rule that was issued by OMB under your direction," Thune said.
Burwell replied that legislation as sweeping as Obamacare requires some leeway so that HHS can act on stakeholders' concerns.
"When one finds places where you can implement better within the law you seek to do that," she said. "What we heard was that the private sector was having difficulties in terms of doing the reporting requirements they would need to do to do this accurately. As one moves to implement you do listen and try to implement in a better fashion in terms of trying to hear and listen and make the transition one that is workable."
Burwell, who is well known and admired in the Senate through her work at OMB, nodded attentively and agreed with Senators from both parties when they raised concerns on issues ranging from Medicare solvency to Medicaid expansion, to the 96-hour rule on critical access hospital admissions. However, she adroitly avoided specifics on actions she would take as secretary of HHS.
In a typical exchange, Sen. Orrin Hatch (R-UT), asked Burwell if she foresaw any unilateral delays or rules changes from the Obama administration in the rollout for the Patient Protection and Affordable Care Act.
Burwell replied: "With regard to the implementation of such a large and complex thing that is part of such a large part of our economy I am not sure I can sit and predict. But I think what is important is as one moves along and is implementing is listening and learning as you go, making those common sense changes within the context of the law, and when there are changes that require legislative changes to work with the Congress to do it."
Sen. Pat Roberts (R-KS), asked Burwell if she would support repealing the Medicare Independent Payment Advisory Board.
Burwell replied: "With regard to the repeal, one of the things that is hopefully a helpful thing is having belts and suspenders in place to help us all get to the place we all need to with regard to reducing healthcare costs."
"I don't know about a belt and suspenders," Roberts replied. "Maybe barbed wire would be a better way to put it."
A revised federal rule allows registered dieticians who work in hospitals to practice at the top of their license. It's being welcomed by hospital associations as a way to save time and money.
Starting July 11, hospital registered dietitians will have the authority to write therapeutic diet orders for patients without necessarily getting prior approval from physicians.
The enhanced autonomy for RDs is part of sweeping rules changes that the Centers for Medicare & Medicaid Services believes can save about $3.4 billion over five years. The new rules respond to President Obama's 2011 Executive Order 13563 which encouraged the federal bureaucracy to reduce or revise antiquated and unnecessarily burdensome rules and regulations.
CMS says the rules changes for dietitians "save hospitals significant resources by permitting registered dietitians to order patient diets independently, which they are trained to do, without requiring the supervision or approval of a physician or other practitioner. This frees up time for physicians and other practitioners to care for patients."
Provider stakeholders appear to be OK with this new rule. Understandably, the Academy of Nutrition and Dietetics is delighted. The new rule validates their professionalism and expands their scope, allowing them to practice at the top of their license.
"CMS's new rule will eliminate burdensome and superfluous regulations that are adding to our nation's healthcare costs," AND President Glenna McCollum said in prepared remarks. "Allowing registered dietitian nutritionists to independently order therapeutic diets and monitor and manage dietary plans for their hospital patients will save the country hundreds of millions of dollars and also help hospitals provide better multidisciplinary care."
"The Academy and our members could not agree more with CMS's conclusion that 'the addition of ordering privileges enhances the ability that RDs already have to provide timely, cost-effective and evidence-based nutrition services as the recognized nutrition experts on a hospital interdisciplinary team.'" (For an exhaustive review of the new rule, check out AND's FAQ page.)
It appears that the American Medical Association is comfortable with the new rule, even though it nips at direct physician oversight. The AMA responded to my email query with this: "The AMA encourages physician-led healthcare teams where physicians and other health clinicians work together in the best interest of their patients. In this particular case, clear communication between members of the team is necessary as there are instances where patients require clinically appropriate dietary restrictions and the patient's physician has the most knowledge about the planned course of care."
The American Hospital Association is comfortable with the idea, too.
"We are happy with this in line with the general philosophy that we have which is that healthcare professionals ought to be allowed to practice at the top of their license or skill set," says Nancy Foster, AHA's vice president for quality and patient safety policy. "This allows dietitians to use their expertise to recommend and identify the right food regimen for our patients."
"The way CMS has implemented this, of course, means that in each individual organization the medical staff will have to review their criteria for how practitioners are privileged and credentialed to do any service they provide to patients."
In other words, this is not a passive rule change. Each hospital that choses to grant autonomy to its RDs must act to create new procedures to ensure that physicians and other clinicians and dietitians continue to communicate properly about patient nutrition.
"We think this creates the opportunity to provide better care, but it does require that coordination that wasn't required before," Foster says.
The rule is permissive, which means that each hospital can decide whether or not to grant these new privileges to their dietitians. "If a hospital is uncomfortable with that, or that physicians feel strongly that that is not the right way to go, one could chose to not implement the policy because it's up to the medical staff," Foster says.
She says AHA isn't recommending a specific course of action for the new rule because "that is not our area of expertise."
"We will look for guidance from others or best practices as organizations begin to implement this and share those with our hospitals. Many of our hospitals now belong to a patient safety organization that may help them as well with how to keep patients safe as you are making this transition in policy. We would promote those ideas."
CMS should be applauded for making these rules changes. Expanding the authority of RDs passes the common sense test. So too does the permissive nature of this rule change. This is not a mandate because some hospitals might not be in a position to implement this for any number of reasons. Each hospital clinical leadership team should be free to carry out the rules change at a pace that is appropriate with their circumstances.
Because the rule saves time and money, two precious commodities in healthcare, most hospitals will jump on the chance to implement it as soon as possible.
As the result of a multi-city operation, the Medicare Fraud Strike Force has brought charges against scores of people, including doctors, nurses, and other medical professionals allegedly involved in false billing schemes.
Federal prosecutors on Tuesday unveiled charges against 90 people in six cities for their alleged roles in Medicare frauds that resulted in $260 million in false billings.
The defendants include 16 physicians and 11 other people identified as "medical professionals," according to a joint media release from the Departments of Justice and Health and Human Services.
Acting Assistant Attorney General David A. O'Neil said in prepared remarks that the crimes identified in the investigation "represent the face of healthcare fraud today—doctors billing for services that were never rendered, supply companies providing motorized wheelchairs that were never needed, recruiters paying kickbacks to get Medicare billing numbers of patients."
"The fraud was rampant, it was brazen, and it permeated every part of the Medicare system. But law enforcement continues to strike back. Using cutting-edge, data-driven investigative techniques, we are bringing fraudsters to justice and saving the American taxpayers billions of dollars."
The investigations were led by the Medicare Fraud Strike Force in Los Angeles, Miami, Tampa, Houston, Brooklyn, and Detroit.
The defendants face charges including money laundering, conspiracy to commit healthcare fraud, and violations of anti-kickback statutes stemming from a number of schemes involving bogus medical treatments and services for home healthcare, mental health services, psychotherapy, physical and occupational therapy, durable medical equipment, and pharmacy fraud, federal officials said.
In Miami, 50 defendants were charged in various fraud schemes involving $65.5 million in false billings for home healthcare and mental health services, and pharmacy fraud. In one case, two defendants were charged in connection with a $23 million pharmacy kickback and laundering scheme.
In Houston, five physicians were among the 11 people charged with conspiring to bill Medicare for medically unnecessary home health services. The doctors allegedly were paid by co-conspirators to sign off on home healthcare services that were not necessary and often never provided.
In Los Angeles, eight defendants were charged in schemes to defraud Medicare of approximately $32 million. In one case, a doctor was charged for causing almost $24 million in losses to Medicare through his own fraudulent billing and referrals for durable medical equipment, including more than 1,000 expensive power wheelchairs, and home health services that were not medically necessary and frequently not provided.
In Detroit, seven defendants were charged for $30 million in false claims for medically unnecessary services, including home health services, psychotherapy, and infusion therapy. In one case, a physician and three other people were charged in a $28 million fraud scheme, where the physician billed for expensive tests, physical therapy and injections that were not necessary and not provided.
Court documents allege that when the physician's billings raised red flags, he was put on payment review by Medicare. He was allegedly able to evade detection by using the billing information of other Medicare providers, sometimes without their knowledge.
In Tampa, seven people were charged in schemes ranging from fraudulent physical therapy billings to a scheme involving millions of dollars in physician services and tests that never occurred.
In one case, five individuals were charged for their alleged roles in a $12 million healthcare fraud and money laundering scheme that involved billing Medicare using names of beneficiaries from Miami-Dade County for services purportedly provided in Tampa clinics, 280 miles away.
In Brooklyn, Syed Imran Ahmed, MD, was indicted in connection with an alleged $85 million scheme involving billings for surgeries that never occurred. Six other people, including a physician and two billers were charged in an alleged $14.4 million scheme that billed Medicare for medically unnecessary vitamin infusions, diagnostic tests and physical and occupational therapy supposedly provided to patients who allegedly were recruited to take part in the scheme.
Since its inception in March 2007, Strike Force operations in nine locations have charged almost 1,900 defendants who collectively have falsely billed the Medicare program for almost $6 billion.
