The shortage of physicians in community health centers is so great, that if all clinical vacancies were filled today, community health centers could serve an additional two million patients, research shows.
Researchers with the National Association of Community Health Centers found that 95% of community health centers are coping with at least one clinical vacancy at any given time, and that 70% of the time these centers are recruiting for at least one family physician. The report also found that:
56% of health centers report at least one behavioral health staff vacancy, such as a licensed clinical social worker, psychologist, or other mental health/substance abuse professional.
Health centers have higher average vacancy rates for physicians than hospitals.
More than half of all National Health Service Corps participants are providing care at a health center.
Health center providers make up 53% of current NHSC participants and 61% of currently listed NHSC vacancies are at health centers.
These pervasive shortages of clinicians come as 24 million people—more people than ever before—rely upon community health centers as a care access point.If all clinical vacancies were filled today, community health centers could serve an additional two million patients, according to estimates cited in the report.
(If I were writing for a general readership, this is about the point where I would segue into a few paragraphs about the inspired work that community health centers have done for more than 50 years to provide cost-effective care for vulnerable, underserved populations. We already know that. Let’s move on.)
Nothing in the report was terribly surprising to anyone paying attention, although it’s good to have the numbers in hand so that we can get a sense of staffing challenges that health centers face.
The Challenges
It’s also good to remind ourselves what community health centers are up against when it comes to recruiting and retention. For starters, primary care physicians, nurse practitioners, physician assistants and behavioral health specialists are in high demand everywhere.
Community health centers generally cannot offer the same salary and benefits as hospitals, physician practices, retail clinics, and other settings. Beyond that, community health centers are often located in remote rural areas or struggling urban neighborhoods, healthcare information and medical technology and clinic support systems are often lagging, work schedules are brutal and language barriers are rife.
Those are all daunting challenges, which makes you wonder why staffing shortages at community health centers aren’t far worse. “We are really fortunate that the providers we are able to recruit really want to be at the health centers,”Jana Eubank, associate vice president of Public Policy and Research at NACHC. “You have to be a special kind of person to want to work with underserved populations. They are incredibly committed to their communities and their patient populations.”
There are also palpable benefits that come with the job. “A lot of providers are open to it because they can be providers. They’re not having to deal with the administrative hassles you have in private practice,” Eubank says.
“Another thing they really appreciate is that our model of care is very comprehensive compared to most private practices, and even group practices. We address all of the needs of the patient, as well as special service needs. They are working in a care team, not only on the medical side, but there are behavioral and social services providers who can help with care coordination.”
Mission-driven Providers
When asked to “check all that apply,” community health centers told researchers that 58% of clinical staff hired over the past two years had trained at that same health center, 30% had worked in another health center, 30% were veterans, 18% were patients or former patients of health centers, 10% were former Community Health Corps/AmeriCorps/Vista volunteers, and 4% were Peace Corp volunteers.
Clearly, the people who work in community health centers are mission-driven, and when you take that into consideration, it’s not so surprising that the biggest single recruiting tool for bringing clinicians into community health centers, is the time these clinicians spend in community health centers.
“It’s the exposure to how important the work of the health center is,” Eubank says. “The providers that are attracted to centers tend to be more open-minded toward that anyway. Once they get exposed to that and see the good work they can do and the difference they can make in people’s lives, that makes a huge difference.”
Where residents do their training has a direct relation to where they practice. “It’s critical that they get out there in the community and get exposed to our types of practices,” Eubank says. “When they do we have a better chance of recruiting and retaining them.”
The obvious solution is more residency programs in community health centers. Unfortunately, it’s more complicated than that.
“It is definitely challenging,” Eubank says. “A lot of health centers don’t have the types of relationships they need with medical schools and residency programs. It’s costly and it takes space and time, and sometimes health centers don’t have access to those resources. And it does take a lot of time. If they have one supervisor who is taking time away from seeing patients, some health centers can’t afford to have those clinicians not seeing patients.”
No Silver Bullet
On the one hand, clinical trainees who spend time in community health centers have a far greater likelihood of practicing in a health center. On the other hand, community health centers frequently do not have the resources to provide adequate training. How is this dilemma resolved?
“There is not really one silver bullet to address all of these issues,” Eubank says. “In terms of community-based training, one thing we are going to be pushing in Congress is to continue to support the Teaching Health Center program that provides seed money and support for community based training and community health centers. We are also supporting additional residency dollars for nurse practitioner training programs. There are some programs in the books that could be funded more robustly to help training opportunities at the community level.”
Medical professionals who choose to practice in community health centers go into the job with eyes open, understanding that they’ll face hurdles they likely won’t see in private practice. Indeed, that is likely the attraction for many. At the same time, it’s unrealistic and unfair to ask these mission-driven clinicians to sacrifice their financial well-being in the service of society’s most vulnerable people.
Community health centers generally can’t match salary and benefits, but restructuring or forgiving outstanding medical school debts for medical and nursing school graduates, and providing medical trainees with the experience of working in community health centers will go a long way toward helping them fulfill their worthy mission.
The American Medical Association and two Florida medical associations argue that the proposed merger would "eviscerate" physicians' options to contract with other insurers and would raise costs.
State and national medical associations are asking Florida Attorney General Pam Bondi to reject a proposed merger between Aetna and Humana.
In a joint letter to Bondi, the American Medical Association, the Florida Medical Association, and the Florida Osteopathic Medical Association said that the merger would worsen an already anticompetitive environment among the state's largest health insurance providers, "eviscerate" physicians' options to contract with other insurers, and would raises costs and restrict access to care.
Last month, Florida's Office of Insurance Regulation gave Aetna approval to acquire Humana.
An AMA analysis found that that the proposed Aetna-Humana merger would run afoul of federal antitrust guidelines in highly populated metropolitan areas across the state. Even without the merger, the AMA found Florida's health insurance markets to be highly concentrated, with 19 of the state's metropolitan areas having two health insurers with at least a 50% share of the commercial market.
"Competition, not consolidation, is the right prescription for Florida's health insurance markets," AMA President-elect Andrew W. Gurman, MD, said in remarks accompanying the letter.
"Less competition in Florida's already consolidated health insurance markets will lead to price increases, not to greater efficiency or lower healthcare costs. Given the negative long-term consequences of the proposed merger, any remedy short of rejection would not adequately protect 2.4 million people in Florida."
On Feb. 15, the Florida Office of Insurance Regulation issued a conditional consent order for the merger that acknowledged a concentrated health insurance market in the state. However, state regulators said many of the anticompetitive concerns raised by the merger could be addressed by regulation.
The physicians' associations strongly disagreed. "The OIR appears to have been captured by Aetna's faulty arguments that existing state and federal regulation… mostly solve the competitive concerns and justify very limited remedies that are largely illusory," AMA CEO President James L. Madara, MD, wrote in the letter to Bondi.
Kristine Grow, a spokeswoman for Hartford, CT-based Aetna, says the insurers believe the merger "will improve the healthcare system and offer consumers more choices and greater access to higher quality, more affordable care."
"Our proposed transaction is primarily about the Medicare marketplace, where there is robust competition and choice. We are confident that our transaction will receive a fair, thorough, and fact-based review from the Department of Justice and the states," Grow says.
"Approximately two-thirds of individuals eligible for Medicare still choose a traditional Medicare plan. Aetna and Humana combined will operate a Medicare business with only 4.4 million Medicare Advantage enrollees, which is only 8% of the 54 million beneficiaries enrolled in the rapidly growing Medicare population."
The deal still has to clear state and federal regulation before the merger can be finalized. Federal scrutiny into the Aetna/Humana deal and into a proposed Anthem/Cigna merger is expected to veer from the agency's previous antitrust investigations.
Hospitals on the list had lower 30-day mortality and readmissions rates, fewer complication, and higher survival rates when compared with peer group hospitals that did not make the list, Truven Health Analytics said.
For the first time in the 23-year history of the rankings, the 100 Top Hospitals from Truven Health Analytics show a notable trend toward reduced expense per patient among the majority of top-performing hospitals.
Truven said its 100 Top Hospitals had lower 30-day mortality and readmissions rates, fewer complication, and higher survival rates while maintaining 3% lower per in-patient costs when compared with peer group hospitals that did not make the list. The study also found a year-over-year decline in total inpatient expense per discharge among the 100 Top Hospitals in the major teaching, teaching and small community hospital categories.
"Many of the 2016 100 Top Hospitals award winners are breaking the mold for high performance. Hospitals in three out of the five hospital categories actually reduced overall expense year over year, while improving patient outcomes," Jean Chenoweth, senior vice president at Chicago-based Truven said in prepared remarks accompanying the rankings. "Some of these hospitals also show a small degradation of operating profit margin. Hopefully this is not an indicator of a developing trend."
When compared with their peers, the Truven 100 Top Hospitals reported:
Better Survival Rates: As a group, 100 Top Hospitals had 23 percent fewer deaths than expected considering patient severity.
Fewer Patient Complications: Patients at winning hospitals had 21 percent fewer complications than expected considering patient severity.
Lower 30-Day Mortality and Readmission Rates: Mean 30-day mortality and readmission rates were lower at winning hospitals than non-winning hospitals across all comparison groups.
Shorter Length of Stay: Winning hospitals had a median severity-adjusted length of stay that was a half-day shorter than peers.
Higher Profit Overall Margins: Winning hospitals had a median operating profit margin that was nearly nine percentage points higher than non-winning hospitals.
If all Medicare inpatients received the same level of care as those treated in 100 Top Hospitals, Truven said:
More than 104,000 additional lives could be saved.
Nearly 48,400 additional patients could be complication free.
$2 billion in inpatient costs could be saved.
The average patient stay would decrease by half a day.
If the same standards were applied to all inpatient care, the impact would be even greater.
The Truven 100 Top Hospitals list evaluates clinical and operational performance in 11 areas: inpatient mortality; 30-day mortality rate; complications; core measures; 30-day risk-adjusted readmission rate; severity-adjusted average length of stay; mean emergency room throughput; inpatient expense per discharge; Medicare spend per beneficiary; adjusted operating profit margin; and Hospital Consumer Assessment of Healthcare Providers and Systems score.
The study has been conducted annually since 1993. Truven evaluated 3,000 short-term, acute-care, non-federal hospitals using Medicare cost reports, Medicare Provider Analysis and Review data, and core measures and patient satisfaction data from the Centers for Medicare and Medicaid Services Hospital Compare website. Hospitals do not apply, and winners do not pay to market this honor.
Here are the winning hospitals, by category.
Major Teaching Hospitals
Advocate Lutheran General Hospital – Park Ridge, IL; Cedars-Sinai Medical Center – Los Angeles, CA; Christiana Care Health System – Newark, DE; Froedtert & the Medical College of Wisconsin – Milwaukee, WI; Houston Methodist Hospital – Houston, TX; NorthShore University HealthSystem – Evanston, IL; NYU Langone Medical Center – New York, NY; OhioHealth Doctors Hospital – Columbus, OH; Providence-Providence Park Hospital – Southfield, MI; Rush University Medical Center – Chicago, IL; St. Joseph Mercy Hospital – Ann Arbor, MI; St. Joseph's Hospital and Medical Center – Phoenix, AZ; St. Luke's University Hospital - Bethlehem – Bethlehem, PA; University of Colorado Hospital – Aurora, CO; University of Iowa Hospitals & Clinics – Iowa City, IA.
Teaching Hospitals
Aspirus Wausau Hospital – Wausau, WI; Bethesda North Hospital – Cincinnati, OH; BSA Health System – Amarillo, TX; Carolinas Medical Center-Mercy – Charlotte, NC; Good Samaritan Hospital – Cincinnati, OH; Kendall Regional Medical Center – Miami, FL; Kettering Medical Center – Kettering, OH; LDS Hospital – Salt Lake City, UT; McKay-Dee Hospital – Ogden, UT; Mercy Health Saint Mary's – Grand Rapids, MI; Mercy Hospital St. Louis – St. Louis, MO; Mercy Medical Center – Cedar Rapids, IA. Mid-Michigan Medical Center-Midland – Midland, MI; Park Nicolett Methodist Hospital – St. Louis Park, MN; Parkview Regional Medical Center – Fort Wayne, IN; Poudre Valley Hospital – Fort Collins, CO; Riverside Medical Center – Kankakee, IL; Rose Medical Center – Denver, CO; Spectrum Health Medical Center – Grand Rapids, MI; St. Cloud Hospital – St. Cloud, MN; St. Luke's Boise Medical Center – Boise, ID; St. Mary's Hospital – Madison, WI; St. Vincent Healthcare – Billings, MT; The Christ Hospital Health Network – Cincinnati, OH; UnityPoint - Meriter Hospital – Madison, WI.
Large Community Hospitals
Advocate Good Samaritan Hospital – Downers Grove, IL; Asante Rogue Regional Medical Center – Medford, OR; Billings Clinic Hospital – Billings, MT; Centinela Hospital Medical Center – Inglewood, CA; Edward Hospital – Naperville, IL; El Camino Hospital – Mountain View, CA; EvergreenHealth Kirkland – Kirkland, WA; FirstHealth Moore Regional Hospital – Pinehurst, NC; Florida Hospital Memorial Medical Center – Daytona Beach, FL; Franciscan St. Francis Health - Indianapolis – Indianapolis, IN; Memorial Hermann Memorial City Medical Center – Houston, TX; Mercy Hospital – Coon Rapids, MN; Mosaic Life Care – St. Joseph, MO; Mother Frances Hospital Tyler – Tyler, TX; Roper Hospital – Charleston, SC; Sarasota Memorial Hospital – Sarasota, FL; Scripps Memorial Hospital La Jolla – La Jolla, CA; St. David's Medical Center – Austin, TX; West Florida Hospital – Pensacola, FL; West Georgia Medical Center – LaGrange, GA.
Medium Community Hospitals
Alhambra Hospital Medical Center – Alhambra, CA; Aurora BayCare Medical Center – Green Bay, WI; Blanchard Valley Hospital – Findlay, OH; Bon Secours St. Francis Hospital – Charleston, SC; Chino Valley Medical Center – Chino, CA; Clermont Hospital – Batavia, OH; Dupont Hospital – Fort Wayne, IN; French Hospital Medical Center – San Luis Obispo, CA; Holland Hospital – Holland, MI; Houston Methodist Sugar Land Hospital – Sugar Land, TX; Lawrence Memorial Hospital – Lawrence, KS; Logan Regional Hospital – Logan, UT; Mercy Iowa City – Iowa City, IA; Ochsner Medical Center - Baton Rouge – Baton Rouge, LA. Sentara Williamsburg Regional Medical Center – Williamsburg, VA; Sherman Oaks Hospital – Sherman Oaks, CA; Sycamore Medical Center – Miamisburg, OH; Texas Health Harris Methodist Hospital Southwest Fort Worth – Fort Worth, TX; Timpanogos Regional Hospital – Orem, UT; West Valley Medical Center – Caldwell, ID.
Small Community Hospitals
Aurora Medical Center – Two Rivers, WI; Brigham City Community Hospital – Brigham City, UT; Fairview Northland Medical Center – Princeton, MN; Franklin Woods Community Hospital – Johnson City, TN; Hawkins County Memorial Hospital – Rogersville, TN; Hill Country Memorial Hospital – Fredericksburg, TX; HSHS St. Joseph's Hospital Breese – Breese, IL; Kansas Medical Center – Andover, KS; Lakeview Hospital – Bountiful, UT; Lakeview Medical Center – Rice Lake, WI; Mercy Defiance Hospital – Defiance, OH; Morris Hospital & Healthcare Centers – Morris, IL; OhioHealth Dublin Methodist Hospital – Dublin, OH; Parkview Huntington Hospital – Huntington, IN; Pomerene Hospital – Millersburg, OH; Renown South Meadows Medical Center – Reno, NV; Roper St. Francis Mount Pleasant Hospital – Mount Pleasant, SC; St. Luke's Hospital - Quakertown – Quakertown, PA;
By creating a new demand for previously unmet medical services, retail clinics are driving up medical spending, a study from RAND Corporation and Harvard University concludes. But one of the nation's largest retail clinic chains, MinuteClinic, refutes the findings.
Retail clinics by design provide easier access to basic healthcare services that cost significantly less than a trip to the doctor's office or the emergency department.
While that care may be less expensive, retail clinics still drive up medical spending by creating a new demand for previously unmet medical services, according to a study from RAND Corporation and Harvard University published in Health Affairs.
"The question before us was do these retail clinics substitute for more expensive options for care, in which case we might see a decrease in spending," says study lead author Scott Ashwood, an associate policy researcher at RAND. "Or, does that convenience drive people to seek care at clinics who would otherwise not have gone, in which case we might see an increase in spending?"
Ashwood and his colleagues examined enrollee data from health plans offered by a commercial health insurer in 22 cities between 2010 and 2012. They focused on 11 low-acuity conditions that account for more than 60% of visits to retail clinics.
The experiences of 519,542 enrollees with at least one retail clinic visit were compared with a random sample of 861,557 other enrollees who did not receive care at a retail clinic. Researchers estimated that 42% of the visits to retail clinics substituted for a visit to a physician office or emergency department, and 58% represented new use of medical services.
"Most of the visits appear to be new visits," Ashwood says.
The overall spending increase linked to retail clinics was $14 per enrollee per year. A further breakdown showed that each use of retail clinics for new medical services increased per-person spending by an average of $35 per year, which was partly offset by $21 in savings from people whose visit to a retail clinic substituted for higher-priced medical care.
Not Necessarily a Concern for Payers
Ashwood says the study findings should not be seen as a rap against retail clinics, which are fulfilling their mission, or necessarily a cause for concern for payers.
"If you just take that snapshot, then maybe it's a cause for concern. They're going to see an increase in spending by covering these clinics, but in the grand scheme of things it is not a massive increase," he says. "To the extent that these health plans care about their customers' well-being or potentially have the opportunity to take this initial entry into the system and do something positive with it, that might be something they'd be glad to see."
Previous research has shown that the people who frequent retail clinics are often younger, healthier, and don't have a primary care physician. If that's the case, Ashwood says the new use of medical services is undertaken in a cost-effective setting is a positive sign.
"That is an important insight as we think about the healthcare system," he says. "If plans and provider groups see this as an access issue that is driving people into healthcare, there is an opportunity there to bring people into a healthcare system and start to get primary and preventive care, the kinds of things we think of as very cost-effective care."
"If it is the case that you are now getting someone acquainted with the healthcare system in a positive way and that leads to a long-term cost-efficient relationship, that initial increase in spending that we are seeing is paid back in the long run."
Industry Reaction
MinuteClinic, operated by CVS Health, is one of the nation's largest retail clinic chains. It challenged the accuracy of the study.
"Half of our MinuteClinic patients do not have a physician and these patients need low-cost sites of care, such as retail clinics. The authors' conclusion that this represents new care and new costs is a step backwards, and fails to recognize that reaching this underserved population is not excess utilization; rather it is the underlying objective of many health system innovations," MinuteClinic said in a written response to HealthLeaders Media.
"In addition, millions of newly insured Americans are seeking care under the ACA. With the profound shortage of primary care physicians, retail clinics can help keep patients healthy and provide overall health care savings. A patient with the flu who does not have a physician can get convenient, inexpensive care at a retail clinic, even on the weekend, before their condition worsens. This care can prevent a costly hospitalization, improving health and saving resources that are not measured by this limited study design. Other peer-reviewed research has demonstrated the significant value and overall cost savings for patients who use retail clinics."
MinuteClinic said its retail clinic visits are 40 to 80% less costly than physician office and emergency room visits.
"According to the authors, the majority of retail clinic expenses replace more-costly sites of care, covering all but $14 per capita," MinuteClinic said. "This tiny difference, a little more than one tenth of one percent of total health care spending, is more than made up by overall total medical expense savings, which was not evaluated by these authors."
MinuteClinic said the study also relies on data that is 5 to 10 years old, and doesn't consider that 40% of retail clinic care now provided for preventative services, wellness and chronic disease, which keep costs down.
"For example, identifying a patient with high blood pressure at MinuteClinic and referring them for follow up care to a physician practice should be viewed as an investment in health and prevention of more-costly illness, not as an excessive cost," MinuteClinic said. "Despite the flawed conclusions of this study, many millions of patients and their insurers appreciate all the medical care access benefits and expense savings that retail clinics provide."
'Voting with Their Feet'
Rather than focusing on retail clinics adding costs, Ashwood says the rapid growth of the clinics across the nation show they're addressing an unmet demand.
"Patients are voting with their feet. They are coming to the clinic and using it when it's there," he says. "Some of the clinics view themselves as a source of community care. Some clinics are in urban areas that may not have convenient access to other kinds of care. We focused on a particular set of conditions, low-acuity care. In that case, retail clinics have met that need. If you spend more on it, then that's not such a bad thing because there is some value that is being added as well."
Jasmine Sulaiman, MD, started a rural clinic in an old flower shop a decade ago. Today she supervises four clinics covering a three-county service area. The next goal she's set for herself: Improve access to mental healthcare through a tele-psychiatry program.
When Jasmine Sulaiman, MD, was interviewing for a job as the only primary care physician at the nascent Health Center of Southeast Texas, she couldn't help but look toward the heavens for guidance.
That's because there was no roof on the Cleveland, TX bank where the interview took place. It was 2005 and Hurricane Rita had just blown through the small town of 7,707 souls located 45 miles north-northeast of Houston.
Coming from Ivy League-affiliated St. Elizabeth's Medical Center in Utica, New York, and with a family practice specialty, Sulaiman, 54, knew she could have her pick of jobs in physician-starved rural Texas, where she and her husband had relocated to escape winter's grip.
She picked Cleveland, where the local hospital was in financial straits (it closed in 2014), and where she hired on as the sole physician, earning considerably less than the market could demand, and working at a health center that as yet didn't exist. The hospital served a patient mix that included 70% uninsured.
"I was interviewed by a group of people all from the community," she says. "They formed a board to start a clinic because the hospital was losing a lot of money through the ER. This is one of the poorest counties in Texas. When I came, they held hands, about 10 of them, and they prayed, and I was thinking 'OK, I really want to be here and see if I can make it work.'"
"They didn't have a clinic. Actually, they didn't have anything. They had one person from the hospital to help set up the clinic," Sulaiman says. "I said 'OK. I'm going to take this job.' My husband said 'it's a 40-mile drive.' I said 'I don't mind. I want to take this job.'"
Within a few months, a clinic opened in a converted flower shop. Sulaiman began seeing 40 patients a day, and remained on call 24/7 as the center's sole physician. Not surprisingly, the federally qualified Health Center of Southeast Texas quickly grew to meet the urgent demand. Today it includes seven physician assistants and nurse practitioners, all of whom rotated through her practice during their training. The center moved out of the flower shop and now operates in a 6,300-sq.-ft. building with nine exam rooms.
But that's not all.
"I work more hours than usual, but I don't have any complaints. I really enjoy what I do." -- Sulaiman
In addition, HCST expanded to include three additional clinics in a three-county service area, all supervised by Sulaiman, who also continues to see patients in addition to her administrative tasks. She also created a program to upgrade medical care at the county jail, led the movement to designate HCST as a Level 2 Patient Centered Medical Home, helped develop an educational program that exposes local high school students to careers in healthcare, and volunteers once a year to provide free care in Mexico.
The newest challenge for Sulaiman is improving access to mental healthcare through a tele-psychiatry program.
"We have no psychiatrists practicing in this county or the adjacent county," she says. "We serve a population that is 70% uninsured. There is a lot of mental illness, a lot of substance abuse. We see it more and more. We couldn't afford a psychiatrist, and so we got a grant from HRSA for behavioral services. We hired a counselor. We just signed a contract with a tele-psych services and that should be operational in a couple of months.
Sulaiman has to provide diagnostic services for mental health "every single day" because there is no other path to treatment. "It's not fun at all. Yesterday a patient was verbally abusive to me because I couldn't help her," she says.
Recognition
"If they don't have access to care, then they don't have access to treatment. It affects these individuals, their families and their communities. Even when we are here providing access to care, often they don't have the money to pay for the medication. That's a gap in treatment and continuity of care. It's frustrating. I feel helpless, they feel helpless, and some days I wonder what am I doing here!"
Frustrations aside, Sulaiman's accomplishments have not gone unnoticed. In 2012 she was named Texas Family Physician of the Year by the Texas Academy of Family Practice. This month she was named the 2016 Country Doctor of the Year by physician recruiters Staff Care, which is providing HCST with a temporary physician for two weeks, so that Sulaiman can take a vacation. She plans to use the time off to travel to India, where she was born.
"I work more hours than usual, but I don't have any complaints. I really enjoy what I do," Sulaiman says, when asked if she worries about physician burnout.
"This is the two-sided coin," she says. "I knew that what I was getting into was going to be totally different than a regular cookie-cutter practice. It is not time equals money. There are a lot of frustrations, but at the end of the day you've helped someone or you've started some new program, and you've provided access to care for people who otherwise have none."
Hospitals have seen a short-term boost in volumes, revenues, and improved payer mix thanks to the Affordable Care Act, says Standard & Poor's.
Despite ''significant transformation'' in the healthcare market that includes long-term declines for inpatient admissions and reimbursements, and the uneven transition to value-based care, the credit outlook remains stable in 2016 for the nation's not-for-profit healthcare sector, according to Standard & Poor's Rating Services.
Kevin Holloran, a credit analyst with S&P, says hospitals have seen at least a short-term boost in volumes, revenues, and improved payer mix thanks largely to the commercial and government health insurance expansions under the Patient Protection and Affordable Care Act.
In addition, S&P says hospital leaders continue to improve management and performance, and thus improve the ledgers through efficiencies and economies of scale gained in mergers and acquisitions.
''While our outlook remains stable, and credits are responding well to numerous pressures, Standard & Poor's acknowledges that numerous challenges still exist, and that the industry remains in the midst of significant transformation," Holloran said in remarks accompanying his report.
S&P credits the Medicaid expansion with a recent uptick in patient volumes but said that's like a ''temporary surge.''
''While the majority of the improvement has been in Medicaid expansion states, even non-expansion states saw modest increased Medicaid enrollment as previously uninsured—
but qualified—people have signed up for coverage in light of the publicity surrounding the ACA,'' S&P said. ''For some providers, especially those in expansion states with a previously high level of uninsured patients, this has been remarkably significant and is reflected in a notable drop in the level of uninsured care, and typically, a commensurate rise in Medicaid revenue.''
S&P also noted that there is little evidence to suggest that new Medicaid enrollees are generating high medical costs "although there have been a few anecdotes to the contrary."
On mergers and acquisition, S&P said, the rationale is evolving. At first M&A's were seen as a way to gain market share, leverage with payers, and economies of scale.
Now, hospital leaders see M&A's as a good way to develop more comprehensive care models for the geographical regions they serve. S&P cautioned, however, that these M&A's are often taking place in a fee-for-service environment, and that only a handful of consolidated systems are operating in an at-risk payment model. In addition, hospital and health system M&A's are coming under increasing regulatory review by state and federal officials.
While the outlook is stable, S&P identified several areas of concern:
The rollout for healthcare reforms such as value-based care has been uneven and slower than expected, with fee-for-service remaining the dominant payment model.
In addition, a "credit gap" continues to grow between larger providers with specific market skills and smaller providers that can't leverage their smaller size and scale.
The reemergence of inpatient utilization pressures as volume and payer mix improvement are absorbed into baseline performance.
The volatility of the investment income linked to recent declines in the financial markets.
The growing cost and price consciousness of healthcare consumers when choosing health insurance and care networks.
"We believe growing price consciousness on the part of healthcare purchasers, including individual consumers as well as large insurance payors, will continue to challenge many hospitals' payor mixes in the absence of meaningful wage growth," S&P said.
"This could lead to declining patient volumes, particularly elective procedures, partly because more people have to bear the first-dollar cost of their healthcare through higher deductibles and copayments but also because more people have lost employer-sponsored insurance."
The Top 50 hospitals, representing the top 1% of all hospitals, were located in 22 states. No hospitals cracked the Top 50 in 28 states, nor the Top 100 in 23 states. California had the most Top 50 hospitals, with nine, and 11 other California hospitals were in the Top 100. Illinois followed with all seven of its selections in the Top 50.
Massachusetts placed only one hospital on the Top 50 list: Baystate Medical Center, a 716-bed independent academic medical center in Springfield. Eight other Massachusetts hospitals made the Top 100 list.
This year's report comes with an infographic titled Hospital Choice: Your life may depend on it, which, not surprisingly, encourages healthcare consumers to use Healthgrades before deciding on a provider.
"We are pleased to recognize those organizations that have achieved this distinction and urge all consumers to do their homework when selecting a hospital—especially as it relates to emergent conditions—since hospitals do not perform equally," Evan Marks, Healthgrades' chief strategy officer, said in remarks accompanying the report.
A description accompanying the 2016 list claims that America's 100 Best Hospitals had an overall 26.5% lower risk-adjusted in-hospital mortality rate for 19 procedures and conditions, compared with other hospitals. If those lesser hospitals had performed at this level, Healthgrades estimates, more than 170,000 lives could potentially have been saved from 2012 to 2014.
During the 2016 study period, the top hospitals showed superior performance in clinical outcomes for patients in the Medicare population across at least 21 of 32 of the most common inpatient conditions and procedures as measured by risk-adjusted mortality and in-hospital complications.
As a group, the Top 100 hospitals received five-star ratings that correlated with better outcomes than lower-rated hospitals in key areas, including:
Heart Attack: 63% of America's 100 Best Hospitals had a five-star rating (statistically significantly lower mortality rate) for the treatment of heart attack compared to only 12% for all other hospitals
Stroke: 60% of America's 100 Best Hospitals had a five-star rating for the treatment of stroke compared to only 13% for all other hospitals
Pneumonia: 80% of America's 100 Best Hospitals had a five-star rating for the treatment of pneumonia compared to only 14% for all other hospitals
COPD: 46% of America's 100 Best Hospitals had a five-star rating for the treatment of COPD compared to only 6% for all other hospitals
Sepsis: 94% of America's 100 Best Hospitals had a five-star rating for the treatment of sepsis compared to only 21% for all other hospitals
The 22 states without hospitals on the Healthgrades Top 100 list were
ALABAMA
ALASKA
ARKANSAS
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
HAWAII
KENTUCKY
MAINE
MISSISSIPPI
MONTANA
NEBRASKA
NEVADA
NEW MEXICO
NORTH DAKOTA
OKLAHOMA
RHODE ISLAND
SOUTH DAKOTA
TENNESSEE
UTAH
VERMONT
WEST VIRGINIA
WYOMING
Healtgrades designates Top 100 hospitals as those have been "in the top 2% of hospitals in the nation for exhibiting clinical excellence for at least three consecutive years." The Top 50 hospitals are those have been in the "top 1%... for at least six consecutive years."
The Kansas Hospital Association estimates that about 150,000 Kansans who would have been eligible for coverage under Medicaid expansion make too much for Medicaid, but can't afford private coverage.
The state of Kansas this month stumbled across an inauspicious threshold.
Since Jan. 1, 2014 the state has forfeited an estimated $10.75 per second with its decision to reject Medicaid expansion under the Patient Protection and Affordable Care Act.
Cindy Samuelson
Those forfeited federal dollars can add up, and according to a live ticker at the Kansas Hospital Association's website, the total of could-have-been funding surpassed $1 billion sometime over this past weekend.
"That is very tangible money going out the door," says Cindy Samuelson, vice president for political fundraising and public relations at KHA. "It has affected not only individuals in Kansas and the folks who could be served by those programs, but also the communities that serve them, which are businesses, healthcare providers, and hospitals. The whole economic impact that healthcare has in our state is large, so there is an impact broader than just the population being served."
KHA estimates that about 150,000 Kansans who would have been eligible for coverage under Medicaid expansion have now fallen into the coverage gap. Even though they're working poor, they make too much for Medicaid, but they can't afford private coverage.
"Many of these are working Kansans that work sometimes more than one job, but who don't make enough money to be part of the exchange," Samuelson says. "These are low-income folks, dishwashers, daycare providers, health aides, construction workers, fast-food service workers; people who are working hard in our state, but who don't have an opportunity for coverage."
The loss of funding has also made life difficult for the state's hospitals. A report this month from iVantage Analytics identified 31 rural hospitals in Kansas as vulnerable, almost twice as many as the 17 Kansas hospitals flagged the last time the iVantage study was done in 2014.
KHA estimates that the state's 84 critical access hospitals will lose an average $255,469 in funding in 2016 from the non-expansion, while 16 rural, non-CAH hospitals will lose $913,418, and 28 urban hospitals will each lose $6.2 million on average.
"It may be a lot smaller for critical access hospitals than the dollar amount for urban hospitals, but it has a huge impact on the bottom line in the communities they serve," Samuelson says. "It would make a big impact because they are struggling with so many different things now and this is just one factor that has been a harm versus a help."
A Non-Obamacare Alternative
Republican Gov. Sam Brownback as recently as during last month's State of the State address continued to blame Obamacare for the financial problems dogging rural providers, and to oppose any expansion of the program. Instead, Brownback called for a "working group" to provide him with an alternative to the Medicaid expansion by early 2017.
Hoping to be that alternative, the KHA is backing what it's calling a budget-neutral Bridge to a Healthy Kansas plan, which is modelled after the market-based HIP 2.0 Medicaid waiver program in Indiana.
The Kansas Bridge program would extend coverage to nondisabled Kansas adult residents earning less than 138% of the federal poverty level, and working 20 or more hours per week, or in work training programs. Exemptions would be made for students and stay-at-home parents. Those enrollees earning more than 100% of the federal poverty limit would pay a portion of their healthcare costs through monthly contributions to a health savings account.
"We have in the legislation this path to personal responsibility and accountability, which means there is some skin in the game," Samuelson says. "This is a hand up, not a hand out. It has an opportunity for folks to pay a portion of their costs, just like many folks who are employed and have insurance through employers. But it is also designed to be that bridge between nothing and being part of the marketplace and have some opportunities for coverage."
Samuelson says KHA is trying to convince the governor and state legislators that, above all, their Bridge proposal "is not Obamacare."
"There is no support in our state for Obamacare," she says. "We are looking for a unique Kansas solution, one that meets the needs of Kansans by being budget neutral, not using any of the state general fund, a program that would also have skin in the game and provide a path toward health and personal responsibility. These are very important to Kansans. Our plan, a bridge to a healthy Kansas, takes those elements that our legislature and governor think are very important."
Even if the legislature and Gov. Brownback sign on, Samuelson says it's highly unlikely that any sort of Medicaid waiver program could be operational until at least 2017, or later. All the while, through the coming months and years, the live ticker will be running up the tab. Before Kansas can craft a waiver and get federal approval, the state's healthcare infrastructure could lose another $1 billion.
As the late, great US Congressman and later Senator Everett Dirksen (R-IL) once said, "a billion here, a billion there and pretty soon you're talking about real money."
Even after controlling for severity of illness and socio-economic status, safety net hospitals still had slightly worse outcomes and significantly higher costs than other hospitals, according to a JAMA Surgery report.
Complex elective surgeries at understaffed, underfunded safety net hospitals have slightly worse outcomes but significantly higher costs than at more-specialized hospitals with a more selective patient mix, according to a study published this month in JAMA Surgery.
The hospitals were compared on postoperative mortality, 30-day readmission, and total direct cost of care. In seven of nine complex elective procedures, the "high-burden hospitals" had the highest proportion of emergent cases and the longest lengths of stay.
After adjusting for patient characteristics and hospital volume, the HBHs still had higher odds of mortality, readmissions, and highest costs of care. An analysis of Hospital Compare data also found that HBHs had inferior performance on Surgical Care Improvement Project measures, higher rates of surgical complications, and inferior markers of emergency department timeliness and efficiency, the JAMA report said.
Study lead author Richard S. Hoehn, MD, a general surgery resident at University of Cincinnati Medical Center, says the researchers went into the study assuming that there were differences in outcomes at safety net hospitals when compared with conventional hospitals, but they wanted to determine if the patient mix was driving these differences or the hospitals themselves.
"We found that after controlling for severity of illness and socio-economic status these safety net hospitals still had slightly worse outcomes, but they had significantly higher costs for seven of the nine procedures we examined," Hoehn says.
"That this persists after adjustment tells us two things. One, there are probably some inherent inefficiencies of the systems' inability to be a jack-of-all-trades in an efficient cost-effective manner. But there are also a lot of nuances with how sick a patient really is, what their resources are, [and] their ability to handle a major surgery that we just simply can't capture with that kind of risk adjustment."
Hoehn says safety net hospitals start with an immediate disadvantage of being understaffed and underfunded, when compared with conventional or more-specialized hospitals that have the resources to perform cost-effective surgeries and invest in money-saving enhanced recover pathways and patient education initiatives.
"Safety net hospitals have to treat anyone who comes through the door and they are not in a financial position to invest in quality improvement initiatives such as those," Hoehn says. "When we analyzed the Medicare data, we found that they have slower, less efficient emergency rooms. In other studies we are doing now, we are finding they have inferior staffing, lower numbers of physicians and nurses per bed, things like that that certainly contribute to their inability to be cost effective."
Hoehn concedes that the study's findings are hardly counter-intuitive. "Anybody who's ever spent time in a safety net hospital knows that is the case," he says. "While it is very intuitive, it doesn't make sense that the people who make policy haven't taken this into consideration. All these programs assign a one-size-fits-all metric or bundled payment for procedures that doesn't take into consideration the handicaps that are encountered at institutions designed to take care of the safety net population."
Bruce Siegel, MD, MPH, president and CEO of America's Essential Hospitals, says the study raises good questions about the role of safety net hospitals, but he questioned the data upon which the findings are based.
"The administratively derived Medicare Hospital Compare metrics are not clinically validated in many cases, and CMS no longer captures Surgical Care Improvement Project metrics because the agency found those measures fail to reflect the actual care delivered," Siegel wrote in an email exchange with HealthLeaders Media.
"Also, the study examines surgical complications from a set of AHRQ patient safety indicators never intended for this type of comparison," Siegel said. "Our hospitals' analysis has shown that PSIs, which are based on billing and disconnected from the actual care delivered, greatly disadvantage academic medical centers due to the severe acuity of their patients."
Siegel said his "larger concern" is whether or not the study "reliably adjusted for socioeconomic status (SES), when even CMS cannot risk adjust for SES because the determining variables have yet to be defined."
Hoehn agreed that trying to factor-out socio-economic status is difficult, "especially with 30,000-foot level data."
"You have someone who, whether they are on Medicaid or no insurance, their primary care and their overall health status is probably inferior to someone with commercial insurance and better access to care," he says. "Even if they have government insurance that reimburses more poorly at a lower level than private insurance, the hospitals seeing these patients who are sicker are going to be reimbursed less for seeing the sicker patients. So there is no way to account for that."
Hoehn says he believes the report provides more evidence that corrective measures are needed to level the field for safety net hospitals.
"It is important to do two things. First, adequately risk-adjust reimbursement policies so we are not applying the one-size-fits-all reimbursements or outcome penalty to every hospital in the country," he says.
"The other thing is to investigate for these safety net providers how to invest money wisely into improving their systems and elevating their performance to the level of more financially solvent institutions. There is plenty of research that shows that financial penalties for hospitals who are underperforming only exacerbates their position. If you could strategically invest in quality improvement initiatives for these hospitals that take care of these sick patients you might have better success improving outcomes."
As for individual safety net hospitals, Hoehn says being proactive is difficult on a limited budget.
"If this were a purely capitalistic market I would say these hospitals need to get rid of expensive cumbersome service lines that are dragging down their bottom line, but that is not possible because of the mission of safety net hospitals," he says. "Likely, it might be finding the most cost-effective, biggest-bang-for-the-buck initiatives you can invest in with pre- and post-operative care for these patients."
Three areas where the use of evidence-base care is particularly lacking are prostate cancer screenings, breast cancer screenings, and feeding tube placement for Medicare recipients with advanced dementia.
Medicare beneficiaries with multiple chronic conditions spend what amounts to one month each year in a doctor's office, hospital, or some other healthcare venue but often do not receive well-coordinated or evidence-based care, according to a new study from the Dartmouth Atlas Project.
"Our healthcare system is fantastically designed to provide skilled and specialized care and is able to rally the best technology to cure diseases," study lead author Julie P.W. Bynum, MD, associate professor of The Dartmouth Institute for Health Policy & Clinical Practice, told reporters in a conference call Wednesday.
Julie P.W. Bynum, MD
"For older age groups, the problem is not curing a single disease but managing multiple diseases and helping people to live as well as they can as their health status changes, and their life expectancy declines."
Using Medicare enrollment and claims data from 2012, Bynum's report identifies where the nation is making progress in patient-centered care and where improvements need to be made for older adults, a population that will grow from 43.1 million in 2012 to 83.7 million by 2050.
In 2012, the average Medicare beneficiary was in contact with the healthcare system on 17 days, and 33 days if they had two or more chronic conditions. The results varied significantly from region to region within the 306 hospital referral regions identified by the Dartmouth Atlas. For example, Medicare beneficiaries in East Long Island and Manhattan, spent 24.9 and 24.6 days, respectively, in contact with the healthcare system, while patients in Marquette, MI, and Lebanon, NH, only spent 10.3 and 10.2 days, respectively, the report showed.
For patients with multiple chronic conditions and dementia, Manhattan and East Long Island tied for the highest rate of contact days among patients with two or more chronic conditions, at 46.2 days. Patients in East Long Island also had the highest rate of contact days among patients with dementia, at 44.9 days, the report said.
"It's often a joke that with elderly people all they want to talk about is their healthcare, but healthcare has become a substitute for their social life," Bynum says. "That may be a joke, but these numbers should give us pause to ask whether as an older adult or a family member if we want to spend our time this way, shuttling back and forth between visits and lab tests? Would it be possible to organize our care such that we can reclaim some of those days to take care of ourselves?"
The report shows that only 57% of Medicare beneficiaries in 2012 had a primary care physician as their predominant provider of care—the healthcare professional with whom the person has the most outpatient visits. This trend continues despite evidence that primary care physicians can lower costs and reduce avoidable hospitalizations.
Specialists and Unnecessary Care
"Forty percent of older adults see a subspecialist such as a cardiologist or an oncologist as their predominant provider. In some areas of the country, such as Louisiana and Mississippi, 60% of people sought specialists most often," Bynum says.
"It's unclear whether the specialists view themselves as providing the coordinating services typically associated with primary care, or whether the patients think of them as a primary care doctor, but this is an important caution for healthcare systems and policy makers as we start to reorganize care around primary care specialties."
Bynum noted three areas where the use of evidence-base care was particularly lacking, including prostate cancer screenings, breast cancer screenings, and feeding tube placement for people with advanced dementia.
With prostate-specific antigen screenings, for example, the national average rate among older men, ages 75 and older, was 19.5%, and regional discrepancies were significant, from 9.9% in Casper, WY, to 30% in Miami, even though the American Cancer Society and the American Urological Association recommend against PSA tests for older men.
With breast cancer screenings, the Dartmouth Atlas found that the national average rate of screening for mammography for woman age 75 and older was 24.2%, even though the screenings are not recommended by the U.S. Preventive Services Task Force. The rates varied from 15.3% in Miami, to 37.2% in Sun City, AZ.
On positive fronts, the report showed that adherence to diabetes testing guidelines increased by 10% in 2012 when compared with data from 2003-05.
The biggest improvement, however, came from preventable hospital admissions, which fell 23% from 5.5% of Medicare beneficiaries in 2003 to 4.2% in 2012. The rates declined in nearly every hospital referral area but varied threefold, from 2.2% in San Mateo County and San Luis Obispo, CA, to 7.3% in Monroe, LA.
