Republican President-elect Donald Trump has promised to repeal and replace Obamacare with 'something better.' Amid this upheaval, rural health advocates see opportunity.
More than any other demographic, rural American voters contributed to the unexpected election of Donald Trump. Alan Morgan, CEO of the National Rural Health Association, says Trump's election has put the issues facing rural America on the front burner after years as an afterthought. The following is a lightly edited transcript.
HLM: What was the message rural America sent in this election?
Morgan: It is the result of a lack of focus on a substantial population in America that's seen declining health, declining life expectancy, a rural hospital closure crisis that we are engaged in right now, and yet a lack of focus on how to bring access to high-quality healthcare services to 60 million Americans.
We are hopeful, recognizing the importance that health and especially hospitals play in rural communities from an economic standpoint too, that we can start looking at what we can change and modify to ensure that we maintain access in rural communities.
HLM: How big of an effect will this election have on rural health?
Morgan: We are hopeful it will have a substantial beneficial impact on rural health because of the national focus on what is happening in rural now.
We have been beating the bushes for the past 10 years about workforce problems and the declining life expectancy of rural populations and we just haven't been getting a lot of traction on that among policy makers.
So, I am hopeful that now that this refocuses attention on the population that has been largely forgotten at the national level.
HLM: President-elect Trump and Republicans controlling Congress have called for radical overhauls of healthcare. Are you concerned that proposals to eliminate Obamacare, block grant Medicaid, and privatize Medicare could harm rural America?
Morgan: It's always a concern when you're proposing significant changes in the healthcare system. You always run the risk of making things worse. We've always communicated that the rural safety net is like arctic tundra; you step on it and trample it and it may never come back.
You can look at this two ways: Things are already not well and we are looking to roll back some of these insurance coverage issues and what that will mean to rural. Or you can look at it from a more positive standpoint that you can't go ahead with reforming the healthcare system and having rural as an afterthought. There has to be a rural focus as we move ahead.
Our organization would oppose any Medicaid block grant proposals. We are concerned what that would mean for rural populations. We are concerned that if they do any major modifications to Medicaid, we don't make the situation worse. And the rural hospitals have closed in states that have not expanded Medicaid, so rolling back Medicaid isn't going to help things.
We are looking at trying to make the health exchanges work better in the rural context; what marketplace revisions need to be made. It is true that more people have health insurance now in rural America because of the exchanges.
But it's also been well documented that we haven't had the uptick sign on of the exchanges from rural populations that we expected, and with the high deductibles and high copays the future of the health exchange, even if Hillary Clinton had won, would've been problematic. That needs to be addressed.
HLM: Was there anything that Trump said in the campaign that shows he "gets it" with rural health?
Morgan: We are going to run with his pledge to invest in infrastructure. Obviously, if he maintains his commitment to the economy, to infrastructure, not leaving people behind that have been forgotten in the past, we can build on that, and how can we have a federal-local partnership in investing and transforming our healthcare system.
In the debates he referenced the need to invest in healthcare and hospitals. I know a lot of my peers question what the investment would be.
Certainly, from a rural standpoint, these old Hill-Burton hospitals that are designed for a large inpatient volume need to be restructured for 24/7 emergency services and an outpatient delivery system. If he maintains that focus on putting America first and investing in infrastructure there is a lot we can work with.
HLM: What signals will you look for in the first few months of the Trump administration?
Morgan: First and foremost, will this new administration be talking about the rural hospital closure crisis? I'll be honest, that is one thing we haven't seen the current administration acknowledge, that we have a rural hospital closure crisis on our hands.
We are hoping that they acknowledge that we are heading in the wrong direction when it comes to healthcare access in rural communities.
Second, as they talk about innovation and transformation of the healthcare system, are they going to include rural? A lot of the transformation efforts by the current administration have exempted critical access hospitals and rural health clinics from the reporting process and really put them over to the side. Are we going to embrace rural facilities as we move forward? That is something we will be looking for in public statements and signs from CMS, what directions are they going to head on.
If they go ahead with the ACA repeal and replace, I want to hear how they are going to replace these high deductibles and the problems with the insurance market in rural underserved locations.
This is putting a lot of emphasis on the Trump administration, and Republicans will control Congress, but I am optimistic that Democrats recognize that this is a tremendous opportunity for them as well. They too have a focus about ensuring that rural is not left behind. How do we change this perception that DC simply doesn't get it from a rural standpoint?
HLM: NRHA is apolitical, but at some point are you going to have to get political to advance your agenda?
Morgan: I hope not. We have worked really hard to keep rural health a nonpartisan issue. That is going to be difficult.
Looking at how strongly rural America supported a certain political party makes it more difficult to do that. At the end of the day, when you are talking about low-income populations with high health disparities and a large senior population, you have to have Republicans and Democrats find some common ground.
HLM: What are you telling your members in the "flyover" states?
Morgan: The key message is now's the time to strike while the iron is hot. We are pushing an optimistic message that this is a great opportunity now to focus finally on rural.
The medical establishment is praising the appointment of Tom Price, MD, to lead the Department of Health and Human Services. That enthusiasm is not shared by women's health advocates and some Democrats in Congress.
President-elect Donald Trump's nomination of Rep. Tom Price, (R-GA), an orthopedic surgeon and avowed opponent of Obamacare, was greeted with high praise by the major professional lobbies in the healthcare sector.
"As healthcare continues to evolve and as care becomes more patient centered, Dr. Price's experience both as a surgeon, along with practicing at Emory University and Grady Memorial Hospital, makes him uniquely qualified to lead the Department of Health and Human Services," said American Hospital Association CEO Rick Pollack.
"He has spent most of his career working in hospitals as an orthopedic surgeon, and his experience as a provider of care will serve patients well in this new role. We have worked with him as a member of the House Ways and Means Committee and as Chairman of the House Budget Committee. His clinical knowledge along with his congressional experience make him an impressively qualified candidate for HHS secretary."
Patrice A. Harris, MD, chair of the American Medical Association Board of Trustees, urged the Senate to "promptly consider and confirm Dr. Price for this important role."
"The American Medical Association strongly supports the nomination of Dr. Tom Price to become the next Secretary of Health and Human Services. His service as a physician, state legislator and member of the U.S. Congress provides a depth of experience to lead HHS," Harris said.
"Dr. Price has been a leader in the development of health policies to advance patient choice and market-based solutions as well as reduce excessive regulatory burdens that diminish time devoted to patient care and increase costs."
AHIP
Marilyn Tavenner, president and CEO of America's Health Insurance Plans, said that Price has for years "been committed to ensuring that patients and consumers are well-served. He will bring a balanced and thoughtful perspective to his role as Secretary of HHS. We look forward to working with him to promote competition, increase choice, and lower costs for every consumer."
Likewise, Tavenner praised Seema Verma, who was picked to serve as Administrator for the Centers for Medicare & Medicaid Services, a position Tavenner once held.
"We look forward to working with Seema Verma to strengthen our nation's healthcare system and empower Americans to improve their health and financial well-being," Tavenner said, "particularly those who depend on the valuable support and services provided through Medicare and Medicaid."
AAFP
John Meigs, Jr., MD, president of the American Academy of Family Physicians, noted Price would be the first physician to serve as secretary of HHS since 1989.
"With his background as a former practicing physician and as a legislator on both state and national levels, he will provide a much needed medical perspective to U.S. health policy at a time of health reform and global outbreaks of new health threats," Meigs said.
Association of American Medical Colleges President and CEO Darrell G. Kirch, MD, cited Price's academic career as a former assistant professor at Emory University School of Medicine and medical director of the Orthopedic Clinic at Grady Memorial Hospital in Atlanta.
"Rep. Price understands firsthand the work and challenges faced by our nation's medical schools and teaching hospitals, and has long been a proponent of academic medicine," Kirch said.
"We are confident that Rep. Price will bring a thoughtful, measured approach to tackling the wide range of issues affecting the nation's health—from funding for biomedical research to training the next generation of physicians to transforming the nation's healthcare system in order to provide all Americans with the care they need when they need it."
America's Essential Hospitals
Bruce Siegel, MD, president and CEO of America's Essential Hospitals said the selection of Price as HHS secretary demonstrates that President-elect Trump "has made experience a priority in his choices" of both Price and Verma.
"Rep. Tom Price has an extensive clinical, administrative, and academic background in healthcare and long experience in the legislative process," Siegel said. "Seema Verma, MPH, offers a deep understanding of healthcare delivery and policymaking and can contribute an important state-level perspective on Medicaid, insurance, and public health. We are especially proud of her accomplishments as a graduate of the association's Fellows Program.
"Particularly noteworthy about both nominees is their experience caring for low-income and other vulnerable people, shaped by their work at hospitals with a safety net role—essential hospitals," Siegel said.
AAOS
Gerald R. Williams, Jr., MD, president of the American Association of Orthopaedic Surgeons, was delighted that a AAOS member was picked to lead HHS.
"Dr. Price has decades of leadership on health care policy issues and firsthand experience caring for patients for nearly 20 years," Williams said.
"He has worked closely with AAOS on issues including repeal of the Medicare sustainable growth rate formula, oversight of mandatory bundled payment models, increasing flexibility within electronic health record programs, defending important in-office ancillary services, and protecting the patient-physician relationship. He has been an indispensable voice within the House Republican Doctors Caucus, making significant contributions to health policy reform and furthering the interests of patients. And he has been one of the most important champions in improving the care of patients in the specialty, rural, and small or solo practice settings."
CHIME
CHIME President and CEO Russell Branzell said Price "has been at the forefront of advancing important reforms to the nation's health IT policy landscape."
"He was a leader in pushing for greater flexibility in the Meaningful Use program, including the 90-day reporting period," Branzell said. "The shorter reporting period is a more realistic timeframe and will help hospitals stay focused on optimizing electronic health record systems for improved patient care. Dr. Price was also instrumental in 2015 in extending the timeline for providers to apply for hardship exemptions under the Meaningful Use program."
Concerns Over Access
Not everyone was pleased with Price's nomination. NARAL Pro-Choice America Senior Vice President Sasha Bruce said that with the nomination "Trump is sending a clear signal that he intends to punish women who seek abortion care."
"Tom Price is someone who has made clear throughout his career that he does not trust women to make our own decisions about our healthcare. Instead, he wants to punish us for the choices we make for our bodies, our futures, and our families," Bruce said.
"In Congress, Tom Price cosponsored some of the most offensive anti-choice legislation on record, legislation that could ban abortion for almost any reason. Not only has Tom Price tried to outlaw abortion nationwide, including in cases of rape, incest, and health of the woman, he has worked to put an outright ban on the most common forms of contraception. As chair of the Budget Committee, he has been on the front lines of the efforts to dismantle the lifesaving Affordable Care Act, as well as the dangerous attempts to defund Planned Parenthood. For the seven in 10 Americans who support legal access to abortion, this is an incredibly alarming pick."
Sen. Chuck Schumer, D-NY, who will lead the Senate minority next year, aired his disdain for Price's nomination on Twitter. "Nominating Rep Price @HHSGov Sec like asking a fox to guard the hen house; risks seniors, women, people w/ disabilities' healthcare access," Schumer wrote.
Contrary to researchers' expectations, data shows that for low-acuity ailments, the proliferation of retail healthcare clinics across the United States does not reduce patient volumes at hospital emergency departments.
Retail medical clinics located near hospital emergency departments do not reduce visits to the emergency departments for minor health ailments, a RAND Corporation study shows.
The study, published online this week in Annals of Emergency Medicine, examined five years of data from 2,000 emergency departments in 23 states for 11 low-acuity ailments such as respiratory infections and ear aches.
"One hope for retail clinics was that they might divert patients from making expensive visits to the emergency department for minor conditions such as bronchitis or urinary tract infections, but we found no evidence that this has been happening," said Grant Martsolf, lead author of the study and a policy researcher at RAND.
"Instead of lowering costs, retail clinics may be substituting for care in other settings such as primary care practices or spur some patients to seek care for problems they previously would have treated on their own," Martsolf said.
There are nearly 2,000 retail clinics across the United States now, and they receive more than 6 million patient visits annually. These clinics are often staffed by nurse practitioners, with prices that are often considerably lower than at a physician's office or an emergency department, often because fewer tests are performed.
Methodology
RAND used information from the federal Healthcare Cost and Utilization Project State Emergency Department Databases from 2006 to 2012 to combine emergency department use with information about the opening of retail clinics obtained from Merchant Medicine, a research firm that tracks trends in walk-in medicine.
Retail clinical penetration was measured as the percentage of an emergency department's catchment area that overlapped with a 10-minute drive of a retail clinic. The 11 low-acuity conditions studied are commonly seen in both retail clinics and hospital emergency departments.
According to the study, the number of retail clinics grew from 130 in 2006 to nearly 1,400 in 2012. The proportion of the emergency department catchment area that overlaps with a 10-minute drive radius of a retail clinic more than doubled between 2007 and 2012 among states in the study sample. One-third of the urban population in the United States now lives within a 10-minute drive of a retail clinic.
During the period studied, there were only about 17 fewer low-acuity trips to the emergency department in one year for privately insured patients living in areas where the retail clinic penetration rate increased by 40% in that year, which is less than a 1% reduction, the study found.
"Retail clinics may emerge as an important location for medical care to meet increasing demand as more people become insured under the Affordable Care Act," said study co-author Ateev Mehrotra, MD, an associate professor at the Harvard Medical School and an adjunct researcher at RAND.
"But contrary to our expectations, we found retail clinics do not appear to be leading to meaningful reductions in low-urgency visits to hospital emergency departments."
Walk-in Clinics Boost Utilization
An editorial accompanying the study suggested that the primary effect of opening retail clinics is to increase healthcare use, not substitute for emergency department visits.
"Given that convenience settings don't prevent ER visits, what can be done in an era where looming government reforms may soon restrict the very payments that support them?" said editorial author Jesse Pines, MD, of the George Washington University School of Medicine and Health Sciences. "The answer is not to build more convenience settings, but to improve the value of existing settings by increasing the connectivity among providers and with longitudinal care."
Retail Health Industry Reaction
In response to the RAND findings, the Convenient Care Association, the national trade association for the retail health industry, issued a statement.
"Retail clinics provide accessible, affordable high-quality healthcare in locations that are convenient for patients and consumers and today there are approximately 2,300 clinics in 41 states and the District of Columbia," said Tine Hansen-Turton, Executive Director of the CCA.
"The RAND Study relied upon old data from when there were only about 1,200 clinics in operation." Hansen-Turton explained that "with the growing number of retail clinics today and in the future, clinics will have a bigger effect on the reduction of low-acuity visits to emergency rooms."
She further noted that "the study did not take into account the more than 9,000 urgent care centers in the areas of the study, thereby leaving an opportunity to for additional research to better understand the complete picture of where low-acuity visits are taking place."
For the most part, the nation's major healthcare payer and provider associations are serving up predictable good-faith pledges to the president-elect, who has promised to upend the healthcare landscape.
One of the most contentious and shocking presidential elections in U.S. history has been greeted with safely worded platitudes by the nation's major healthcare provider and payer associations.
Republican President-elect Donald J. Trump has promised to repeal Obamacare and replace it with "something better," which could create chaos for the healthcare sector.
Nonetheless, it is hard to detect a sense of urgency or alarm based on the comments made so far by major players in the nearly $3 trillion healthcare sector, who greeted the new administration with business-as-usual bromides.
Hospitals
American Hospital Association President and CEO Rick Pollack issued a statement that could have been drafted before the votes were counted. He did not refer to Trump by name, but said the nearly 5,000 hospitals in his organization would continue to "work in a bipartisan manner advancing our agenda."
"We look forward to working with the new Administration and Congress on the nation's healthcare challenges and will continue to do everything we can to meet our commitment to the people and communities we serve," Pollack said in prepared remarks.
Bruce Siegel, MD, president and CEO of America's Essential Hospitals, congratulated Trump and urged him to make good on his "commitment to serve as a president for all Americans."
"By ensuring the best possible care for the least fortunate, our hospitals provide the best care to all people," Siegel said. "We must sustain federal support for this mission, reject policy changes that reduce spending at the expense of coverage and access, and continue progress toward transformative approaches to better quality and value."
Payers
America's Health Insurance Plans concedes that there "is still a lot to be learned about what policy changes will be proposed," but pledged to "work across the aisle - with every policymaker and the new administration - to find solutions that deliver affordable coverage and high-quality care for everyone."
Kristine Grow, AHIP's senior vice president for communications says the nation's commercial health plans maintain "a commitment to continuous coverage.
Consumers should be covered and patients should be protected – and sudden disruptions would jeopardize both. Consumers, patients, and plans should be given enough time, flexibility and support so that any changes ensure safe and stable coverage."
Blue Cross Blue Shield Association CEO Scott Serota said the "health insurers for one-in-three Americans look forward to working the new president and Congress.
"In particular, we are sharing ideas for improving the individual market, so that consumers have more choices, better prices and a robust private marketplace that is predictable and stable," Serota said.
BCBSA also posted a Tweet recommending that people who are feeling stressed "hug your pet." (#stressed, #stress )
Providers
AMA President Andrew W. Gurman, MD, said his organization "has a history of working in a bipartisan manner as we pursue policies," and that he looks "forward to working with President-elect Trump and a new Congress to improve the health of the nation."
"One of our long-standing policy objectives has been to reduce the number of Americans who lack health insurance coverage, because research demonstrates that those without insurance experience greater suffering and premature deaths," Gurman said.
"A key factor in our evaluation of future proposals is whether the result is more or fewer Americans with insurance and the extent of the coverage compared to existing policies."
American Academy of Family Physicians President John Meigs, MD, sent the president-elect a list of priorities for primary care that included: expanding access to care, ensuring delivery and payment reform, improving affordability, building the primary care workforce, and promoting wellness and prevention.
Even though Trump has supported the expansion of high-deductible health plans as an alternative to Obamacare, the American College of Emergency Physicians is urging him to close insurance coverage gaps that are leaving emergency patients with crippling debts.
"Many people don't realize how little insurance coverage they have until they need emergency care, and then they are shocked at how little their insurance companies pay," ACEP President Rebecca Parker, MD, said in prepared remarks.
"Health insurance companies mislead patients by selling so-called 'affordable' policies that cover very little, until large deductibles are met—and then blame medical providers for charges. State and federal policymakers need to ensure that health insurance plans provide adequate rosters of physicians, affordable deductibles and co-pays and fair payment for emergency services," Parker said.
American Nurses Association President Pamela F. Cipriano, RN, said her organization also looks forward to working with the new Administration that "has an opportunity to unite the country around a shared vision that puts protecting and promoting quality healthcare for all Americans above partisan politics."
Cipriano also noted that 83% of the 52 candidates endorsed by ANA's Political Action Committee won their election and will serve in the 115th Congress.
NNU Battles On
National Nurses United, which had fervently embraced the grassroots candidacy of Sen. Bernie Sanders, (I-VT), made it clear that it would not strike a conciliatory pose with President-elect Trump in a statement that read more like a political manifesto.
"The challenge to all of us now is to fight with every breath to expand, and coalesce that progressive, social change movement to resist the coming assault by the right, and reinvigorate our work for real change," NNU said.
"The agenda for real transformative change of our broken political and economic system is the only way to protect our nation and our planet."
IHI Acknowledges Angst
Institute for Healthcare Improvement CEO and President Derek Feeley was one of the few healthcare leaders to publicly acknowledge the angst that has fallen over large swaths of the population since Trump's victory.
"We share the sense of uncertainty and anxiety about the future that we are hearing from many of our friends and partners across the world," Feeley said. "At the same time, we are reminded that IHI's mission to improve health and healthcare worldwide can act as a beacon for us, and we trust for others, during unsettled times."
"Although health reform may now face some major challenges, IHI feels more determined than ever to work with partners, old and new, to demonstrate that change is necessary and that improvement is achievable."
More than 90% of the patients at a small Memphis clinic are on Medicaid. The physicians there were stunned to learn that federal auditors wanted a $400,000 refund for Medicaid overpayments.
"We are the dream team," says William Rodney, MD, founder of the clinic, and board certified in obstetrics, geriatrics, emergency, and family medicine.
The physicians at Medicos Para La Familia were stunned to learn that federal auditors wanted a $400,000 refund for Medicaid overpayments that were made under an initiative to expand primary care services in underserved areas–which is exactly what Medicos did.
The private clinic's bilingual staff provides healthcare for poor people in Memphis and Northern Mississippi. It's a full-service clinic with many of the same services as an emergency department, including imaging, and at a fraction of the cost.
More than 90% of the 40,000 patients that Medicos' five physicians and staff see each year are on Medicaid.
"We deliver babies. We provide prenatal care," Rodney says. "You can walk in seven days a week and if you are sick, you do not need an appointment. And I especially mean pregnant women. We lowered the rate of babies dying in Memphis because of this system."
When the Medicaid Enhanced Payments came along in 2013 and 2014, Rodney says, Medicos welcomed the windfall.
Unfortunately for Medicos, and the patients it serves, the Centers for Medicare & Medicaid Services added requirements that called for physicians receiving the enhanced payments to be board certified in primary care.
"We got caught in a trap because one of our older physicians was no longer board certified, even though he had practiced family medicine for 35 years," Rodney says. "His name is Rickey Carson. If you wanted a poster child for what a family doctor looks like you would see Rickey Carson's face. He is in the office every day, sees 30 to 35 patients a day. Patients love him."
"Ricky was down on the books for about 4,000 to 5,000 patients in both 2013 and 2014, but he gets a letter saying we want our money back," Rodney says.
"In the meantime, this primary care bonus has been spent for enrichments for poor people; more staff, more hours, some equipment we needed for pregnant patients. Now we are looking at a payback bill of $400,000 over two years. We don't have $400,000. We are going to close the practice if we don't get some relief."
With their appeals to common sense falling on deaf ears, Carson and 20 other primary care physicians from across Tennessee have filed suit in U.S. District Court in Nashville, asking a judge to halt efforts to reclaim more than $2.3 million that was paid out during the two-year enhancement period. [View the complaint.]
CMS 'Overreach'
The plaintiffs argue that the CMS rules change was arbitrary, runs counter to the intent of the law passed by Congress, and has the potential to greatly disrupt care access to thousands of poor people with few other options beyond the nearest emergency department.
The plaintiffs have the support of the Tennessee Medical Association, which has accused CMS of "blatantly overreaching its authority and misinterpreting the intent of Congress."
"These arbitrary actions by CMS punish doctors trying to do the right thing and put some of Tennessee's most underserved populations and communities at even greater risk," TMA general counsel Yarnell Beatty said.
Let's recap: The Medicaid Enhanced Payment Statute, which was designed to expand healthcare access to underserved areas by paying physicians more money, now threatens to do exactly the opposite; take money away from physicians and threaten the solvency of their practices, which would worsen care access in underserved areas.
How did such a well-meaning piece of legislation mutate into its evil twin? This is what happens, Rodney says, when policy makers and politicians working at the 30,000 feet don't understand how medicine is practiced in the fly-over.
"The road to hell is paved with good intentions," he says.
"Legislators really wanted to help and they did, kind of, but most legislators really don't understand medicine as it is practice outside of Boston or Washington or New York City. You have a policy elite running things, and once you get out of the Beltway, we have a saying down here, Massachusetts is a lot different from Mississippi."
The funds expected to be generated by the sales of hospitals, home health businesses, and non-hospital real estate will be used to pay down $15 billion in debt.
Community Health Systems is negotiating with seven entities to divest 17 hospitals, home care businesses, or non-hospital real estate properties, CEO Wayne T. Smith said in a conference call Wednesday with analysts. The transactions are expected to be completed by mid-2017.
"Estimate proceeds from these transactions include working capital projected to generate $1.2 billion," Smith said. "A substantial portion of these proceeds will be used for further debt reduction."
"It is also worth noting that the interest level in our assets is extremely high," Smith said. "We are receiving interest from a number of parties and we will provide updates as we receive definitive agreements and reach the close of the transactions."
The announcement came as Smith tried to put a positive spin on weak third quarter that saw $4.3 billion in net operating revenues, down 9.6% when compared with the same period in 2015. Smith blamed the drop on low volumes and higher-than-expected expenses.
"It goes without saying that we are not pleased with our performance in the third quarter," Smith told the analysts. "Over the years we have seen some variability but our inconsistent performance recently in the third quarter simply has not been good enough."
"Operationally, we have experienced a great deal of change over the past few quarters," he said. "Assimilation of the HMA hospitals has been more difficult than anticipated. The recent spin off of Quorum Health, realignment of our divisions, a number of new division presidents and vice presidents, the promotion of our new chief operations officers (Tim L. Hingtgen), consolidations of many of our back office functions and IT conversions, ultimately these changes will help to strengthen the company for the better long term success. Some of these changes have created challenges in the near term."
Smith said that the divestitures were not unanticipated.
"We knew when we bought HMA, just as when we acquired Triad, that we would have to rationalize our portfolio, that we had facilities that did not fit," he said.
"As we look to the future, we want to make sure we are in sustainable markets where we have good opportunities to deploy our resources and capital so that we can expand in those markets going forward. We will continue to look at properties. We will continue to evaluate our properties, in terms of ones that are beneficial."
Smith said that reducing debt is not the only motivation for the divestitures.
"We haven't set any specific target number in terms of debt pay-down," he said. "We are more concerned about having improved margins and ensuring that our operations work efficiently and that our performance improves as well."
Researchers challenge the usefulness of the plethora of perennial hospital rankings that are largely ignored beyond the executive suite and doctors' lounges.
Have hospital rankings reached the saturation point?
A research brief from the University of Michigan's Center for Healthcare Research & Transformation suggests that hospital rankings, ostensibly designed to enlighten healthcare consumers, have morphed into a confusing array of metrics and methodologies that are now largely ignored outside of the healthcare echo chamber.
"One of the overall messages we have is that we do have to take these rankings with a grain of salt because they measure different things and they do come out with different results when you compare them," says Kirsten Bondalapati, MPH, a co-author of the brief.
"Another thing we need to think about is how the consumer or patient perspective fits into this," Bondalapati says. "Some of the rankings are geared toward hospital quality improvements, and some are geared more toward patients, providing them information about what hospital to go to. One thing that could be improved is making those intentions a little clearer so we know what each ranking system is trying to do."
The research brief examined nine (yes, nine!) prominent hospital rankings that are published each year and found that individual hospitals ranked all over the board.
Among the findings:
In 2012, 37% of hospitals were highly ranked on one of nine hospital ranking systems;
In 2015, 53% of Michigan acute care hospitals received a high rank on at least one of nine hospital ranking systems, but only 22.5% received a high rank on at least two ranking systems;
Consumers in a CHRT focus group said they don't use rankings to choose a hospital because the rankings do not always include information that they're interested in and are not presented in a consumer-friendly manner.
Bondalapati believes much of the confusion could be cleared up if the ranking systems communicated with one another and standardized evaluation methods.
A Wide Variety of Ranking Systems
"It might be difficult for that to occur because all of these ranking organizations are different, with different missions and even in different markets. Some are nonprofits, some are for-profits, some are government organizations," she says.
"Another suggestion is to have a third-party unbiased entity that would look at the ranking and all the quality measures and do their own analysis to make this more understandable for patients," she says.
That makes perfect sense, but it's doubtful that will happen because there is little incentive to change.
In all likelihood, each of the ranking systems uses a different methodology specifically to differentiate themselvesfrom the other rankings. They're each carving out a niche because they know some hospital somewhere will score well on it.
Hospital marketing departments understand that if they don't earn a top grade from Ranking A, they can shop around and find a high score from Ranking B, C, D, E, F, G, or H, or I and hang a self-congratulatory banner atop their website.
"One of our strongest recommendations is that we incorporate a patient perspective more into these hospital rankings so that we know who is catering to the hospitals and who is catering to the patients," Bondalapati says. "And if they are catering to the patients then they should be addressing patient needs instead of their own needs."
Sorry, but if the primary incentive is to make things clearer for patients, don't hold your breath.
Clinicians at a federally qualified health center are collaborating with their colleagues at a nearby medical center to operate a four-bed labor and delivery unit.
They're bucking a trend in Centreville, AL.
Most rural hospitals in Alabama closed their obstetrics programs decades ago, owing to a combination of low volumes and high costs and liability. Instead, expectant mothers were sent to the nearest big city hospital for deliveries.
Last November, Centreville's Bibb Medical Center opened a new, four-bed labor and delivery unit that is on track to deliver about 100 babies in its first year. The opening marked the first time in 20 years that babies have been delivered in Centreville, located about 53 miles southwest of Birmingham.
Despite the low volume, averaging eight to 10 births per month, the program works because of a commitment and collaboration between Bibb administrators and clinicians and their colleagues at the nearby Cahaba Medical Care, the town's federal qualified health center, and the Cahaba Family Medicine Residency Program.
"We have a good relationship, and that is not always a foregone conclusion," says John B. Waits, MD, a family physician, CEO of the FQHC, and director of the residency program.
"It has been a very deliberate intentional relationship, where we have cultivated trust with each other, given a little, taken a little, and it is a very positive symbiotic relationship. Often there is a firewall between hospitals and ambulatory, but our model is completely different."
While there is risk and cost associated with such a low-volume service line, Waits says the hospital, the FQHC and the residency program each gain something, too.
"For the hospital, having a maternity center means having more volume in the hospital as a whole and better relationships for mothers bringing their children back for services," Waits says.
"That doesn't make them whole, but the second piece is that we have built a family medicine residency in a rural area to address the workforce disparities. To be accredited, we need to have maternity care happening. We put it in the budget for our health center. Obviously, our residency program can't fund labor and delivery, but that helps. Part of that cost is in the budget."
"For our community health center, we have written several portions of our grant portfolio around maternity care, around prenatal care, postnatal care and the first five years of life," he says.
"Some of the people we have hired in our community health center and in our residency program, nurse anesthetists, some of the labor and delivery nurses, we share some of the personnel costs it takes to run this labor and delivery unit."
"So, you have three relatively distinct but interwoven institutions with their own mission statements. It's a collaboration and we make ourselves whole with this low-volume unit."
Who Pays for What?
"We keep it very simple," Waits says. "We told the hospital that we would handle the medical staff costs. The hospital knew going in that they did not have to hire doctors to cover the labor and delivery. It's our group. If we are short a doctor, we work a little extra. We recruit our nurse partners. When we do a delivery, we bill for the physician fee like most groups do. But there are no hospital-employed physicians."
"The hospital bills for their stuff. They have put up the capital costs to build the unit. The hospital hires nearly two-thirds of the nursing. When a patient comes in, the hospital does the supplies, the equipment costs, which is traditional. The hospital bills Medicaid, BlueCross, whomever, for the facilities fees and per diems and that sort of thing."
The medical group includes nurse practitioners who function as midwives, and help hospital staff as needed. "The nurse anesthetists are on the faculty for the residency program, and they're teaching the residents to put in central lines and manage airways and lumbar punctures or help with the labor epidurals or the C-sections."
Why Bother?
Waits says delivering babies helps preserve the community's care continuum.
"Numerous studies in lots of rural contexts have shown that the loss of a rural labor delivery unit worsens infant mortality rates and portends the loss of many other services," he says. "In Bibb County, once labor and delivery went, so did local prenatal care. Similarly, care in the first five years of life became more difficult to achieve."
And when hospitals stop delivering babies, they're no longer prepared for emergency or even precipitous deliveries, Waits says.
"Institutional memory is lost. Harm comes because people aren't prepared for these routine things," he says.
"Then, there are emergencies and urgencies and care that needs to happen in the first year of life for the child, the first five years of life, etc. The focus tends to turn away from mother/baby in those first five years and that's when you lose that knowledge."
"The final part of that answer is just the reality of doctors and nurses who train and fall in love with this time of life as a part of their profession," Waits says.
"If these services aren't being rendered, you're not able to recruit and retain that work force. They're going to go somewhere where they're taking care of mothers and babies, not just nursing home patients."
A shortage of mental health resources is putting undue stress on hospital emergency departments as holding areas for some of the most vulnerable patients they serve.
It is no surprise to anyone working in a hospital that emergency departments have become the de facto dumping ground for patients in psychiatric distress.
An online survey released this week of 1,716 emergency physicians from across the nation paints a grim scene of psychiatric patients waiting long hours, and even days, for an inpatient psychiatric bed.
"Three-quarters of emergency physicians responding to our poll reported seeing patients every shift who required hospitalization for psychiatric treatment," ACEP President Rebecca Parker, MD, said in a conference call with journalists on Monday.
"The problem is that once the decision to admit is made, it can be nearly impossible to find an inpatient bed for these patients."
Parker said that more than 10% of respondents to the polls reported that they had six to 10 ED patients waiting for inpatient psychiatric patients during their last shift.
"All of these patients require care and monitoring while they are in the emergency department, which keeps our physicians from treating new patients who come through the door. This ripple effect is real," Parker said.
"More alarming is that almost one-quarter of our poll responded that they have patients waiting two to five days for a psychiatric bed. Can you imagine waiting in the ED for a bed for days at a time! It's awful! Yet, the inpatient beds for psyche patients just aren't there."
21% of psychiatric patients versus 13.5% of medical patients required admission to the hospital.
11% of psychiatric patients versus 1.4% of medical patients were transferred to another hospital.
23% of psychiatric patients versus 10% of medical patients stayed in the ED more than 6 hours.
7% of psychiatric versus 2.3% of medical patients stayed in the ED for more than 12 hours.
"We have a potential perfect storm," says Lippert. "Decreasing psychiatric inpatient beds. Insufficient accessible outpatient psychiatric centers for crisis stabilization, and then increased emergency department crowding. We are really seeing the growing crisis of unmet psychiatric need."
14-Hour Waits
Renee Hsia, MD, author of recent study on the topic that appeared in Health Affairs, attended the ACEP teleconference and noted that "the absolute number of psychiatric visits increased by 55%, from 4.4 million to 6.8 million between 2002 and 2011, far outpacing the growth of non-psychiatric visits."
"The disparities between [waits for] psychiatric and non-psychiatric patients are very stark. In 2011, the 90th percentile length of stay was 1,378 minutes for psychiatric patients, and 543 min for non-psychiatric patients, which amounts to a difference of almost 14 hours," Hsia said.
"This is especially disturbing when you realize that in 2002, psychiatric and non-psychiatric patients had virtually no difference in the length of stay for these patients."
Why is this happening?
"It's important to note that between 1970 and 2006 state and county psychiatric inpatient facilities went form around 400,000 beds to less than 50,000 beds," Hsia said.
"Starting in the 1960s there was a large deinstitutionalization of mental healthcare from the inpatient to outpatient facilities. Unfortunately, they closed a lot of inpatient beds without shoring up the outpatient resources."
HHS says the new payment system for Medicare clinicians provides flexible options that encourage 'pick-your-pace' participation by small practices and sole practitioners. It goes into effect in January.
The federal government on Friday finalized sweeping Medicare payment reforms for clinicians that were called for under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.
The new rules, which begin on Jan. 1, 2017, and which will take years to fully implement, replace the flawed and reviled Sustainable Growth Rate funding formula and are designed to reward quality over volume in the Medicare program that serves more than 55 million people.
The 2,398-page document is the end result of an arduous process that involved a months-long nationwide listening tour by officials with the Centers for Medicare & Medicaid Services who met with nearly 100,000 people and compiled nearly 4,000 public comments.
"This is a landmark effort to move the healthcare system forward," CMS Acting Administrator Andy Slavitt said at a Friday teleconference.
"Transforming something of this size is something we focused on with great care. The policy we finalized is the result of the user-driven policy effort where our staff put down our pens and went into the field to hear from physicians and patients."
"Overall, the comments we received from across the country can be summed up this way: Make the transition to MACRA as simple and as flexible as possible," he said.
The centerpiece of MACRA is the Quality Payment Program, which creates two pathways that over the next year will let clinicians pick their own pace in the transition from a fee-for-service to payment models that reward quality over volume.
Payment Path 1: APM
The first path, called the Alternative Payment Models (APM), begins in 2019 and gives clinicians the opportunity to make more money if they're willing to take more financial risks for performance, use electronic medical records, and report quality measures to CMS.
In the first year, APM also provides a flexible performance period, so that clinicians can dive in immediately. Those who need more time can prepare for participation later in the year.
Clinicians who receive 25% of Medicare covered professional services, or 20% of Medicare patients through a fast-tracked Advanced APM in 2017 can earn a 5% Medicare incentive payment in 2019. Slavitt said that about 100,000 clinicians are expected to try this more aggressive payment model, and the hope is that more clinicians will join in the coming years as the program evolves.
Payment Path 2: MIPS
As many as 500,000 clinicians are expected to travel the second, more gradual path, called the Merit-based Incentive Payment System (MIPS). The financial incentives for accountability and the use of electronic medical records, are not as generous, but the risk is not as great. However, physicians who don't submit any data to Medicare in 2017 risk a "negative 4% payment adjustment."
Slavitt said MIPS is designed to allow physicians "to focus on patients not paperwork. We've made major steps which will continue over the coming year, but cutting the number of measures in half and simplifying how the program works."
Medicare is expected to pay about $1 billion in bonuses for high-quality care to clinicians in both Advanced APMs and MIPS in 2017, in addition to a positive payment adjustment of .5% under MACRA.
CMS estimates that 380,000 clinicians will be exempted from the new payment models because of their low volume of Medicare patients and billing.
To broaden participation to include small practices and specialties, CMS in 2018 will roll out an Accountable Care Organization Track 1+ model that provides more flexibility for clinicians. CMS is also considering reopening some existing Advanced Alternative Payment Models for application to allow more clinicians to join these types of initiatives. Slavitt said about 25% of eligible clinicians will be a part of the second path of Advanced APMs by 2018.
MACRA also provides $20 million each year for five years to train clinicians in small practices of 15 clinicians or fewer and those working in underserved areas. Beginning December 2016, local organizations will offer free, on-the-ground, specialized help to small practices using this funding.
CMS has also launched a Quality Payment Program website to explain the program and help clinicians identify the measures most meaningful to their practice or specialty.
In a conference call with reporters, Slavitt stressed that MACRA was very much a work in progress that would evolve with the practice of medicine, and with new medical technologies.
"The bottom line is we are trying to get doctors back to what they do best, care for patients, through a lot of simplification and support," Slavitt said. "We view these coming years as the first steps into a program that will continue to improve, not an attempt to create a perfect system."
