Cash flow growth in the healthcare sector jumped in 2014 and remained strong through June 2015, prompting Moody's to upgrade the sector's outlook from "negative" to "stable." But key drivers are not performing as strongly now, signaling a potential slowdown.
The nation's not-for-profit healthcare sector will likely see diminished cash flow and patient volumes in 2016, although the overall outlook in the sector for the next 12 to 18 months is "stable," Moody's Investors Service says.
"We expect the current strong growth in patient volumes and cash flow will return to normal levels (3% to 4%) over the outlook horizon because some of the factors driving recent strong performance, such as gains in insurance coverage and strong patient volume growth, will not be repeated in 2016," Moody's says.
Cash flow growth in the sector had been relatively flat for several years but jumped to 12.3% in 2014, and growth through June 2015remained strong at 10.5%. That prompted Moody's in August to upgrade the sector's outlook from "negative" to "stable." Moody's says key drivers of cash flow growth in previous quarters are not performing as strongly, signaling a potential slowdown.
"For example, inpatient volume growth has been boosted by gains in insurance coverage and recent growthcomes after years of declines, likely reflecting some pent up demand," Moody's says. "Although patient demand remains strong compared to thelast five years, patient volume growth began to slow by June 2015, and many hospitals are projecting flat growth in 2016.
Moreover,hospitals continue to see more patients in the outpatient setting, due in part to regulatory changes from payers and advances inpatient care that require fewer hospitalizations. Reimbursement for outpatient services is significantly lower than for inpatient care."
On other fronts, not-for-profit providers continue to see bad debt falling, although at a slowing rate. The reductions in bad debt are credited to the increased health insurance coverage under the Patient Protection and Affordable Care Act. Nearly all of the reductions in bad debt are occurring in states that expanded Medicaid, while bad debt reduction in non-expansion states "has slowed considerably."
Moody's says Medicare and Medicaid enrollment is expected to expand over the next two years as the population ages, and more states expand their Medicaid rolls.
"However, government payers reimburse at rates below commercial insurance, pressuring margins; reimbursement from the government is not typically subject to negotiation," Moody's said. "The question of if, and when, additional states expand Medicaid eligibility will affect future financial performance as costs increase; two of the most populous states (Texas and Florida) remain opposed to Medicaid expansion, but will face continued pressure from the hospital industry and others to change course."
Another potential source of pressure on margins will be the expansion of population health programs designed to reduce inpatient services and lower costs. Moody's says the sector could lose money on population health "unless hospitals successfully enter into risk sharing contracts or make investments to capture volume in lower cost settings."
Effects of Payer Consolidation
"Strategic investments, like physician practice acquisitions and insurance company start-ups, are low margin businesses and can lead to large operating losses during the initial phase," Moody's says. "Additionally, necessary investments in information technology and electronic health records are a significant and growing expense."
Not-for-profit providers could also see more pressure coming from a consolidated commercial health insurance sector, especially the mega-mergers of Anthem Inc. and Cigna Corp., and Aetna Inc.'s acquisition of Humana.
The sector will also have to weather the growing pains of the health exchanges created by the ACA, many of which are under financial stress.
"Most major health insurers reported losses on their exchange business and many insurance co-ops (not for profit insurance companies founded under the ACA) have failed in recent months under mounting losses," Moody's says. "Additionally, the risk corridor program, established to stabilize premiums by having insurers share gains and losses on qualified ACA plans, will pay only 12.6% of the amount owed to insurance companies."
Moody's notes that some larger not-for-profit health systems that are building their own insurance platforms will face the same challenges as traditional insurers in these low-margin business lines.
The not-for-profit sector could also see significant competitive challenges from non-traditional providers in the urgent care arena, such as Walgreens Health Clinics and CVS MinuteClinics. In addition, Moody's says political and regulatory challenges in the coming years, including the imposition of the "Cadillac Tax" in 2018 could reduce benefits for people with commercial plans.
Moody's says the sector's status could upgrade to "positive" in the coming months "if the operating environment continues to improve, allowing for above average growth inoperating cash flow. We would consider changing the outlook to positive if we expect sustained operating cash flow growth above 4%over a 12 to 18 month period, after accounting for healthcare inflation."
On the other hand, the outlook could downgrade to negative if cash flows are flat or negative.
"Some factors that would contribute to a negative outlook include: states significantly reducing Medicaid reimbursement, a significant increase in the uninsured rate, or legislative or regulatory changes that significantly alter the healthcare market," Moody's says.
Market consolidation remains active as the year winds to a close. Recent deals span from acquisitions announced by Kaiser Permanente in the northwest and WellStar in Atlanta, to a sale by Tennessee-based Community Health Systems.
Kaiser Permanente has announced that it will acquire Seattle-based Group Health Cooperative, a member-governed, nonprofit health system, in a deal worth $1.8 billion.
Bernard J. Tyson
In a joint press release, KP and Group Health Coop said the acquisition would expand KP's reach to an additional 590,000 people in Washington and northern Idaho and advance the growth of an integrated care model. When the deal is finalized, Group Health will become the eighth KP region.
Because Group Health is governed by individual corporate members, and "owned" by the communities it serves, the funds from the $1.8 billion transaction will go toward the creation of a not-for-profit community foundation dedicated to improving community health, the two systems said.
"This agreement is a natural extension of our long, successful working relationship with Group Health and it provides us with the opportunity to expand access to high-quality, affordable care and coverage," Bernard J. Tyson, chairman and CEO of Kaiser Foundation Health Plan and Hospitals said in prepared remarks.
"Kaiser Permanente and Group Health Cooperative are a natural fit. The opportunity to unite will allow us to best serve the current and future needs of our members, customers and employees. We look forward to welcoming the people of Group Health Cooperative into the Kaiser Permanente family."
Susan Byington
Susan Byington, chair of the Group Health board, said the cooperative entered the acquisition as "a highly sought after, financially strong, and nationally recognized healthcare organization.
"I believe this opportunity to join with Kaiser Permanente creates even greater assurance that the committed teams and care delivery system that has kept me and my family healthy will be serving families for decades to come," she said.
KP and Group Health have a relationship that precedes the acquisition through shared best clinical practices and the development of non-profit innovations. They also have allowed each health plan's members to receive care in the other's service areas.
Scott Armstrong, president and CEO of Group Health, said the deal provides "a unique opportunity to accelerate our growth and potential through a vastly deepened relationship with Kaiser Permanente by tapping into their exceptional resources, skills, track records, and reach. Through this acquisition, we'll better be able to tackle rising healthcare costs and implement even more powerful technologies to serve our members."
WellStar Buys Tenet's 5 Atlanta Hospitals
Tenet Healthcare Corporation is selling its five Atlanta-area hospital to WellStar Health System in a deal valued at up to $500 million.
The hospitals in the sale are Atlanta Medical Center and its South Campus, North Fulton Hospital, Spalding Regional Hospital, Sylvan Grove Hospital and 26 physician clinics. The companies began exclusive negotiations for the sale last summer, and the deal is expected to be finalized in early 2016.
Candice Saunders
"We are pleased that our hospitals will join a leading regional healthcare network like WellStar," said Keith Pitts, vice chairman of Tenet. "This agreement will better position these facilities for long-term success, benefiting all stakeholders."
WellStar president and CEO Candice Saunders said that "with addition of Tenet's metro Atlanta hospitals, we will be better able to provide world-class healthcare to our patients for years to come."
When the deal is finalized, Tenet will no longer operate hospitals in Georgia. The Dallas-based for-profit hospital chain pulled up roots in North Carolina earlier this year.
In a May 5 conference call with analysts, Tenet CEO Trevor Fetter explained the exodus.
"There are markets where we don't see a path either by acquisition or partnership to develop the scale we believe will be necessary as healthcare delivery continues to evolve. In those markets, we believe our hospitals would be better positioned under another operator," he said. "For example, we continue to pursue strategic alternatives for our hospitals in Georgia and North Carolina and expect this process will likely result in sales of these facilities."
Providence Health, St. Joseph Health to Merge
Catholic health systems Providence Health & Services and St. Joseph Health have signed definitive agreement to merge. The new parent organization will be called Providence St. Joseph Health.
Deborah Proctor
"Together, we can invest more in the needs of everyone we serve, especially the most vulnerable," Rod Hochman, MD, president and CEO of Providence Health said in prepared remarks. "Our commitment is to improve affordability, enhance clinical care, and improve access to much-needed services."
Deborah Proctor, president and CEO of St. Joseph Health, said the two health systems share common mission and similar histories. "We are two mission-focused organizations that have the potential of being better together, delivering outstanding clinical care and providing a compassionate presence in all the communities we serve," she said.
Providence St. Joseph Health will focus on a shared mission and vision, and the strategic, financial, and operational direction for the system overall.
Hochman will serve as the CEO of the parent organization, which will be based in Renton, WA. There will be two system offices – in Renton and in Irvine, CA. The board of directors of the parent organization will include seven members appointed by Providence and seven members appointed by St. Joseph Health.
Rod Hochman, MD
Providence and St. Joseph Health serve different communities, but together they form a contiguous geography. Providence operates 34 hospitals, 475 physician clinics, senior services, supportive housing and other health and educational services. The health system and its affiliates employ more than 76,000 people in Alaska, California, Montana, Oregon and Washington.
St. Joseph includes 16 hospitals, physician organizations, home health agencies operating in California, Texas and New Mexico.
CHS Sells NJ Hospital to Prime Healthcare
Franklin, TN-based Community Health Systems, Inc. will sell the 126-bed The Memorial Hospital of Salem County (NJ) and related outpatient services to Prime Healthcare Foundation in a deal that is expected to be completed by June, 2016.
Financial terms were not disclosed.
"Prime Healthcare looks forward to continuing The Memorial Hospital's history of quality and success because we believe exceptional healthcare should be part of every community," said Prem Reddy, MD, chairman, president, and CEO of Prime Healthcare. "The experienced team of physicians, nurses, and staff at The Memorial Hospital of Salem County are recognized for their exceptional care and will be a welcome addition to the Prime Healthcare family of hospitals."
Prem Reddy, MD
Ontario, CA-based Prime Healthcare Foundation is a 501(c) (3) public charity and an affiliate of for-profit Prime Healthcare Services, which operates 38 hospitals in 11 states.
CHS is one of the largest for-profit hospital companies in the nation and owns, leases, or operates 198 affiliated hospitals in 29 states.
The proposed partnership is not yet final. Both health systems are working with the California Attorney General's office on next steps and hope to complete the review and approval process in 2016.
Providence Health & Services is a not-for-profit Catholic health system. It operates 34 hospitals, 475 physician clinics, and employ more than 76,000 people across five states – Alaska, California, Montana, Oregon and Washington. St. Joseph Health is a not-for-profit, integrated health care delivery system that includes 16 hospitals, physician organizations, home health agencies, hospice care, outpatient services and community outreach services.
After five years of historic low growth that averaged about 3.7% per year, spending growth accelerated to 5.3% in 2014, largely in part to the addition of 8.7 million people to government and private health insurance rolls under the Patient Protection and Affordable Care Act.
Healthcare spending in the United States crossed the $3 trillion threshold in 2014 and now represents 17.5% of the nation's gross domestic product, the Centers for Medicare & Medicaid Services said Wednesday.
A further breakdown by CMS's Office of the Actuary shows that after five years of historic low growth that averaged about 3.7% per year, spending growth accelerated to 5.3% in 2014, largely in part to the addition of 8.7 million people to government and private health insurance rolls under the Patient Protection and Affordable Care Act.
Spending on healthcare breaks down to $9,523 per person, according to the study, which was published in Health Affairs.
"Some of the primary drivers of the growth include acceleration in private health insurance and Medicaid expenditures due to the expansion of health insurance coverage under the Affordable Care Act," Anne B. Martin, an economist in the Office of the Actuary at CMS and lead author of the Health Affairs article, said in conference call with media.
The expansion added 8.7 million people to the insurance rolls, and lifted the share of the insured population from 86% in 2013 to 88.8% in 2014, the highest share since 1987.
Martin says another factor was the "rapid growth in prescription drug expenditures, fueled in part by the introduction of new specialty drugs, particularly those used to treat Hepatitis C. Overall, spending on prescription drugs grew by 12.2% in 2014, compared to 2.4% growth in 2013.
On a per-enrollee basis, overall spending increased 3.2% in private health insurance, 2.4% for Medicare and decreased 2% in Medicaid.
Despite the accelerated growth, CMS said consumer out-of-pocket spending grew by 1.3% in 2014 compared to 2.4% in 2013. Overall, healthcare spending grew 1.2 percentage points faster than the overall economy in 2014, resulting in a 0.2 percentage-point increase in the health spending share of gross domestic product – from 17.3% to 17.5%. From 2000 to 2009, before the PPACA, healthcare spending grew by an average of 6.9% annually, 2.8 percentage points faster than GDP.
The report showed that:
Total private health insurance expenditures (33% of total health care spending) reached $991.0 billion in 2014, and increased 4.4%, faster than the 1.6% growth in 2013 (the slowest rate since 1967). The faster rate of growth reflected the impacts of expanding coverage through Marketplace plans, health insurance premium tax credits, new industry fees, and changes to benefit designs. Per-enrollee spending increased by 3.2% in 2014. Average growth in per-enrollee spending was 7.4% from 2000-2009.
Medicare spending, which represented 20% of national health spending in 2014, grew 5.5% to $618.7 billion, a faster increase than the 3% growth in 2013. The 2014 rate of growth was driven by increased spending growth for retail prescription drugs and in Medicare Advantage. Per-enrollee spending increased by 2.4%. Average growth in per-enrollee spending was 7% between 2000 and 2009.
Medicaid spending accounted for 16% of total spending on health and grew 11% in 2014 to $495.8 billion, a faster increase than the 5.9% growth in 2013. Medicaid growth in 2014 was driven by coverage expansion under the Affordable Care Act, as 26 states plus the District of Columbia provided coverage for individuals with incomes of up to 138% of the federal poverty level. An estimated 6.3 million newly eligible enrollees were added to Medicaid in 2014. Per-enrollee spending decreased by 2%.
Out-of-pocket spending (which includes direct consumer payments such as copayments, deductibles, and spending not covered by insurance, excluding premiums) grew 1.3% in 2014 to $329.8 billion, slower than annual growth of 2.1% in 2013. The slowdown in 2014 was influenced by the expansion of insurance coverage and the corresponding drop in the number of individuals without insurance.
Retail prescription drug spending accelerated in 2014, growing 12.2% to $297.7 billion, compared to 2.4% growth in 2013. Rapid growth in 2014 was due to increased spending for new medicines (particularly for specialty drugs such as those used to treat hepatitis C), a smaller impact from patent expirations, and price increases for brand-name drugs. Private health insurance, Medicare, and Medicaid spending growth for prescription drugs all accelerated in 2014.
The COO of a small Mississippi hospital says he was frustrated—and surprised—to read of its endangered status in a non-profit organization's report after all the money and energy that the hospital's parent company has committed to improvements.
The Center for Mississippi Health Policy noted that 31 rural hospitals in the state were at risk of closing. Nine hospitals were placed at greatest risk of closing. (Pioneer Community Hospital was not on the Center's endangered list, even though the critical-access hospital closed three weeks after the report was released.)
To find out more, I called on one of the nine hospitals that made the most-endangered list: Highland Community Hospital, a 60-bed hospital in Picayune, MS. I wanted their perspective on what they're doing to turn things around. Doug Jones, COO of publicly-owned ForrestHealth, the Hattiesburg-based five-hospital parent system that owns Highland, says the Health Policy study is accurate based on the narrow methodology they used, but he says that the methodology doesn't tell the entire story.
"They based their report on 2012 data and they didn't look at any of the outliers that were going on in 2012," Jones says. "We were building a $58 million hospital, which we moved into on July 28, 2012. We had a lot of costs associated with staffing, training, and activating the new hospital that you are not able to capitalize. There were some high expenses associated with that."
"The other thing you may remember is we were going through this little thing called meaningful use at that time. So, we were implementing electronic health records. A lot of expenses hit that year and they made our financials look worse."
To be blunt, the financials still don't look that good at Highland. In 2014 the hospital generated nearly $104 million in gross patient revenues, but accrued net losses of $16.9 million, although Jones says the hospital has made incremental improvements on its financials and will have a positive cash flow in 2015.
To appreciate Highland, Jones says you have to look back to about 2006, when ForrestHealth assumed hospital operations after Hurricane Katrina.
Slow Progress, But Encouraging Signs
"The hospital was damaged and there was a lot of population shift," Jones says. "People were moving out of New Orleans, Slidell, getting away from the coast, Gulf Port and other places and moving into the community, which created a lot of issues with the high charity load at that time."
Local doctors in Picayune had purchased the bankrupt hospital in 1998. "After Katrina, the damage to the hospital became a great financial burden to the doctors and we took over," Jones says. "The intent at that time was to replace the facility, but the [economic] downturn of 2007 happened shortly after that and remember that nobody could issue bonds at that time."
In 2009 Jones went to Highland as interim administrator and made a community needs assessment. Ultimately, the ForrestHealth board in 2009 authorized the construction of the new hospital that opened on July 2012.
"The board decided that in order to serve the community we needed to build a new hospital and replace the hospital that had been there since 1952 and we needed to recruit new medical staff. Investment in recruiting medical staff is expensive also," Jones says. "On average to recruit and move in a doctor and get them up and running and subsidize them for the first two years of practice can run you $500,000 to $700,000. This is a health professional shortage area, even though we've been fairly successful recruiting doctors into the community, and we still have more to recruit."
Jones says the board at ForrestHealth determined that Highland's patient migration to out-of-county providers was a key issue that could only be addressed with significant facility and staffing upgrades, starting with a new hospital.
"Could we make gains and maintain the people in the community at the old facility? The answer was no," Jones says. "On top of that the old facility had structural, mechanical, electrical issues that would have to be addressed from a codes standpoint. We could easily see investing $14 million to $15 million into a 60-year-old building, not to make it function or look any better, but just to deal with the structural/mechanical issues associated with it."
"The question was could we make it work financially," Jones says. "We went about an analysis, looking at the patient population, looking at the financial projections, being very conservative on what we thought we could gain from revenues, our ability to recruit physicians, the ability for those physicians to build practices, and a lot of factors. It was a big risk, but the board at that time felt they needed to do something."
While the financials are still wobbly, Jones sees encouraging signs that the hospital has turned things around.
"Every year we pick up a little more volume," Jones says. "If you go back to 2009, we saw about 15,000 ER visits. This year we are right at 24,000. In 2009 we didn't have specialists coming to the hospital. We have cardiologists now five days a week, and ENT, neurosurgery, [and] orthopedics two days a week. We have general surgery, ICU, [and] the physical therapy is there on site. There are a lot of changes in the way we operate."
Frustration and Surprise
When the Mississippi Center on Health Policy report was issued in early November, most media outlets in the state didn't look at it as an economic impact analysis. The Associated Press lead read: "At least nine rural Mississippi hospitals are at risk of closing down, according to a new study." The nine hospitals were identified in the second paragraph.
Jones says he was frustrated—and surprised—to read of Highland's imminent demise, especially after all the money and energy that ForrestHealth has committed to improve the hospital.
"We have done a lot of work to increase community confidence in that hospital and the services that are being offered and anytime something like this comes out it can be damaging," he says.
"All it takes is for someone to think 'Oh the hospital is closing. I don't want to be a patient of this or that doctor because they won't be here long because the hospital is closing.' We've responded. The local paper did an article about it. The hospital has seen steady improvement since 2012, continues to grow, and that was the intent when we made the decision to build a new hospital. We were going to grow that hospital and the services it provides for the community."
Data collected by the Agency for Healthcare Research and Quality shows that hospital-acquired conditions such as adverse drug events, pressure ulcers, and catheter-associated urinary tract infections declined sharply between 2010 and 2014.
Federal officials say safety and quality measures linked to the Patient Protection and Affordable Care Act resulted in 2.1 million fewer hospital-acquired conditions, saved 87,000 lives, and reduced healthcare costs by nearly $20 billion between 2010 and 2014.
"In 2014 alone we had 800,000 fewer patient harms, preventing nearly 37,000 deaths at hospitals and saved $6.8 billion for patients, families and the system," Patrick Conway, MD, principal deputy administrator/CMO at the Centers for Medicare & Medicaid Services, said during a conference call Tuesday.
"This is welcome news for patients and their families. These results represent real people who did not die or suffer infections or harm in the hospital."
Data collected by the Agency for Healthcare Research and Quality shows that HACs fell from 145 per 1,000 discharges in 2010 to 121 per 1,000 discharges in 2014, a 17% decline.
Hospital-acquired conditions include adverse drug events, catheter-associated urinary tract infections, central line associated bloodstream infections, pressure ulcers, and surgical site infections, among others. The Agency for Healthcare Research and Qualityanalyzed the numbers of avoidable HACs compared to 2010 rates using baseline estimates of deaths and excess healthcare costs developed by Partnership for Patients.
AHRQ Director Richard Kronick says the 37,000 lives saved from reduced HACs in 2014 were "approximately equivalent to a one-year hiatus from all deaths from breast cancer in the United States."
The biggest reductions seen in the four-year span were among three of the most common HACs or adverse events, Kronick says. Adverse drugs events fell by 16% and contributed 40% of the overall reduction; pressure ulcers dropped 23% and represented 28% in the overall reduction; and catheter-associated urinary tract infections (CAUTIs) dropped 38% and accounted for 16% of the overall reductions.
"Overall, other important hospital-acquired infections showed reductions in addition to the CAUTIs. Most notably there were very large reductions in central line-associated bloodstream infections, (CLASBIs)" Kronick says. "These infections are relatively rare, but quite deadly. In 2010, the rate of CLABSIs was 0.55 per 1,000 hospitalizations. By 2014 this rate was reduced by over 70% down to 0.15 per 1,000 hospitalizations. We are clearly not yet at zero but we are getting close."
Of the four most frequent HACs measured, falls was the only adverse event that did not improve over the four-year span.
"Falls are a double-edged sword," Kronick says. "Part of what's important for many patients is getting them up and about and having them move more, which increases their exposure to falls. A reasonable hypothesis might be that there are more patients moving more, which is a good thing, but also increasing exposures to falls, and that may be part of what is going on here."
6 Ways to Combat HACs
The report noted that after making considerable gains between 2010 and 2013, the improvements "held steady" between 2013 and 2014. Why that is so is not known. "We don't have a full answer to that question," Kronick says. "Part of the answer is that the dramatic improvements we saw in the earlier years were the relatively lower-hanging fruit and hospitals are now working on more difficult problems."
"Some of this is a timing issue," he says. "We adopted in 2014 the national action plan for adverse drug events modeled on the 2009 action plan to reduce healthcare-associated infections. That plan was just adopted in 2014 and it will be taking some time before we see the results of that and similarly a recent adoption of the national action plan for combatting antibiotic resistant bacteria. We need better evidence for reducing some kinds of harm as well as the continued effort from folks in hospitals around the country to try to figure this out."
While specific tactics are needed to combat specific HACs and adverse events, Conway says the safety and quality movement shares at least six common themes.
"One, it's important to have the evidence on how to improve patient safety," he says. "Two, we are seeing it is important to have a culture and a focus on patient harm across the board. You are not just working in one area. You are working in the whole culture and the whole system. Three, high-reliability methods that are really focusing on every single time delivering the right care. Four, data and transparency at a macro level for hospitals but also down to the unit level so they are able to drive improvement on that unit. Five, the right technical assistance and quality improvement support. Six is the right incentives. We are increasingly tying incentives to quality and safety results, and we're seeing when we do that combined with the previous items you move a national needle in patient harm in a way we have never seen before in this country's history."
Pioneer Community Hospital is the third to close this year in Mississippi, a Medicaid non-expansion state. It's upsetting to learn about these closings because they don't just provide necessary care, but also vital jobs, and a sense of community in the rural areas they serve.
I hadn't planned on writing back-to-back columns on rural hospital closings, but these events are becoming far too common. Last week it was Bowie, TX. This week, it's Mississippi. The situations aren't quite the same, but the endings are all too familiar.
Mark Norman
Pioneer Community Hospital of Newton, MS, said it has lost its critical access status and will close on Dec. 1. The Centers for Medicare & Medicaid Services last year rescinded Pioneer's critical-access status, effective Dec. 1, 2015, after determining that the hospital did not meet the 35-mile distance requirement from other hospitals.
Pioneer CEO Mark Norman did not return calls for comment, but he issued a statement explaining that the hospital could not survive without the cost-plus-1% enhanced payments that come with critical access status.
"[In] September of 2010, USDA allowed Pioneer Community Hospital of Newton to purchase the hospital from the previous owner, with the CAH designation being an essential requirement for the transfer to occur," Norman said. "The loss of the CAH designation makes the operation of the hospital no longer financially feasible. This revised interpretation of the mileage regulation, 1820(c)(2)(B)(i)(I) and (II), is a complete reversal of CMS's original interpretation that allowed the facility to remain financially operational for the past five years."
Pioneer's emergency department will close on Dec. 1, and the hospital will accept no more admissions after Dec. 1. "Patients already admitted to the facility will be discharged upon the completion of their care and treatment," Norman said.
Pioneer plans to maintain a clinic in Newton with extended operating hours, but Norman said "residents of Newton County in need of future emergency medical care will need to seek the attention at another hospital in Forest, Meridian or Union."
Red Ink
Even with critical access status, Pioneer was running in the red. American Hospital Directory data for 2014 shows that the hospital generated $32 million in total revenues, but lost $580,000.
It's upsetting to read about these rural hospital closings because most of us understand what critical roles they play, not just in providing care, but also for fostering a sense of community and generating and facilitating local economic development.
A study out this month by the Center for Mississippi Health Policy identified nine hospitals in the state that were in danger of closing and estimated that those hospitals represented more than 2,600 jobs, generated more than $8.6 million in state and local taxes, and close to $290 million in economic activity. Ironically, Pioneer was not on that endangered hospitals list because the Center used 2012 data for its analysis.
Pioneer's closure means the money generated by scores of relatively well-paying healthcare jobs will no longer circulate throughout the tiny community, located 64 miles due east of Jackson.
"We really don't know how this is going to play out, but there were about 130 jobs that were full-time and part-time," Newton Mayor David Carr told me. "We're a small town, about 3,400… most of [the 130 of] them full time and a lot of them paying pretty good for small town Mississippi."
"Also, it was a part of the community as far as events and things like that," Carr says. "They sponsored health fairs, a lot of stuff like that that you usually don't think about. They had a nice cafeteria. I'm a member of the Lions Club and the Rotary Club. We had our meetings there every week. That's a minor thing, but it's all part of it when you add it all up."
Pioneer is the third hospital to close this year in Mississippi, a Medicaid non-expansion state. Kilmichael Hospital shuttered converted to a health clinic. Natchez Community Hospital closed this month as part of a consolidation with Merit Health Natchez.
In the Crosshairs
Whenever I hear about these rural hospitals closing I am reminded of a conversation I had in 2012 with James E. Orlikoff, then a senior consultant at the Center for Healthcare Governance. He warned that critical access hospitals were in the crosshairs as federal regulators looked to trim costs.
"Anytime you face an economic crunch when you have carve-out artificial protections, they can't last," Orlikoff told me three years ago. "Is it evitable? Yes. 'When' and 'how' are the questions… I tell my critical access hospitals to strategically plan on three years to be off the cost-plus model."
Orlikoff said then that the critical access funding cuts will come sequentially, rather than all at once. "Many critical access hospitals don't fit within the rules, so first they will be the first to lose their protected reimbursements. Then the cuts will migrate to all critical access hospitals, especially as other markets can show the efficiencies that can be taken."
Orlikoff warned in 2012 that many critical access hospital leaders were in denial.
"Many of the leaders here are so embedded in that protective philosophy, that they don't know what their finances are. They don't know how much inefficiency they have in the system. So when the time comes, they are going to be paralyzed," Orlikoff explains. "If they start thinking about it now, maybe they can get ahead of the curve."
I tried to contact Orlikoff this Thanksgiving Week to update his prescient comments. He didn't return my call. Then I thought why bother? It's clear that what he told me in 2012 applies now.
The not-for-profit healthcare sector is not immune to cyber security threats, particularly as they relate to patient records and the disruption of medical technology, Moody's Investors Service says. And larger healthcare systems are more vulnerable than stand-alone hospitals.
The dramatic rise in IT system security breaches across all sectors of the economy – from banking to government and including healthcare, has prompted Moody's Investors Service to include "cyber risk" as a "stress-testing scenario" when assessing credit scores.
"A cyber threat's severity and duration determine how we reflect the risk in our analysis and ratings," the bond rating agency said in a report this week. "To be clear, we do not explicitly incorporate the risk of cyber attacks into our credit analysis as a principal ratings driver. But across all sectors, our fundamental credit analysis incorporates numerous stress-testing scenarios, and a cyber event—like other event risks—could be the trigger for those stress scenarios. A successful cyber event's severity and duration will be key to determining any credit impact."
The not-for-profit healthcare sector is not immune to the threat or its consequences, particularly as it relates to patient records and the disruption of medical technology, Moody's says.
"An information breach would likely not materially disrupt services and the financial impact would be limited," Moody's says. "A breach in medical technology security would present more immediate risk and impair the hospital's reputation, volumes, and financial performance. Whether or not such a cyber-event would be covered by a hospital's medical malpractice insurance is untested."
Lisa Goldstein, associate managing director, public finance group at Moody's, compares preparing for cyber risks to preparing for Medicare or Medicaid cuts. "We look at it through the lens of any hospital's next year's operating and capital budget; what the expenditures are going to be; what the pressures on operations may be," Goldstein says.
"When it comes specifically to cyber security, what component of your annual expense budget does that represent? Are you even talking about it? Are you pretty far down the road in trying to contain this risk, or just starting?"
While any hospital could be the target of a cyber attack, Moody's says larger healthcare systems are more exposed than stand-alone hospitals. "This is largely due to the highly centralized IT function at many of these regional and national systems that have domain over more patient records and medical technology than a stand-alone hospital. As a mitigant, however, many of the large systems have access to external liquidity, such as lines of credit, in addition to their own cash reserves."
Goldstein says the response to cyber risk has varied greatly from hospital to hospital. "We are not hearing from all of our rated hospitals and health systems that this is a key concern to them. Some are talking about it. Right now most are not," she says.
"That speaks to where they are on their IT cycle spectrum. There are hospitals and health systems that 10 years ago went through their major IT conversion and are in a better position now to focus on cyber security. Then there are others on the side of the fence who are just gearing up in 2016 for their IT electronic medical records. Cyber security is way out there."
Overall, Moody's said the not-for-profit healthcare sector maintains a higher risk awareness of cyber security than other sectors of the economy, which is a credit positive.
"Most hospitals have completed or are in the process of installing new patient information systems which likely have better safeguarding features than prior technology," Moody's said. "We estimate that one-quarter to one-third of a hospital's annual capital budget is for information technology needs. In step with the capital budget, a growing portion of the operating budget is related to IT upgrades, warranties, security, and training."
Goldstein says hospitals also are aware of the increased need for strong internal protocols as more information is increasingly shared with external parties, such as vendors, patients, payers, and physicians.
"You have a lot more fingers in the pot with exchanges accessing data, traditional insurers, and the government systems are now linked electronically," Goldstein says. "Now the patient can access their own data so they have their fingers in the pot as well."
Goldstein says it appears that hospitals and health systems that make cyber security a standing agenda item at board meetings generally have a stronger grasp of the problem and are often farther along the road toward protecting data.
In other news: Two western New York state hospitals are affiliating, and in Oregon, publicly owned and financed OHSU says it will convert a $50 million debt from Moda Health Plan Inc. into a 25% equity stake in the privately owned, financially troubled insurer.
Providence, RI-based Care New England Health System and Southcoast Health System, Inc., based in Fall River, MA are discussing a "strategic partnership" that, if consummated, would create one of the largest not-for-profit health systems in New England.
"We believe the complementary services of Southcoast and the geographic span of their service area will enable us to advance the high quality, high value continuum of care we have been building," CNE President/CEO Dennis D. Keefe said in a joint media release.
"We already see the common ties to community and an unwavering commitment to mission and values both our organizations share, and we look forward to further study of the partnership potentials that could come to fruition in a new vision for healthcare delivery for our region."
CNE's four hospitals saw about 228,000 inpatient days and generated more than $1 billion in revenues in 2014, and finished the year $8.5 million in the black. The slightly smaller four-hospital Southcoast Health recorded 178,000 inpatient days and generated about $968 million with $5 million in surplus.
A unified healthcare system would include eight hospitals, a network of ambulatory sites, two accountable care organizations, more than 1,700 aligned physicians and providers, and a continuation of the academic relationship with The Warren Alpert Medical School of Brown University.
"Southcoast has long been focused on providing the very best care within our region of Southeastern Massachusetts and Rhode Island, finding ways to remain highly competitive, cost effective, and at the forefront of technological and strategic change," Southcoast President and CEO Keith A. Hovan said. "We believe that Southcoast can be a strong and complementary partner for Care New England, and that together our respective organizations could form the foundation of a highly competitive, community-based and value-driven integrated health care system throughout southern New England."
Care New England was founded in 1996, and today it is the parent organization of Butler Hospital, Kent Hospital, Memorial Hospital of Rhode Island, Women & Infants Hospital of Rhode Island, the VNA of Care New England, The Providence Center, CNE Wellness Center and Integra, a certified ACO created in collaboration with the Rhode Island Primary Care Physicians Corporation. Care New England includes 970 licensed beds and 216 infant bassinets.
Southcoast Health System includes Charlton Memorial Hospital in Fall River, St. Luke's Hospital in New Bedford and Tobey Hospital in Wareham; and Southcoast Behavioral Health in Dartmouth, a joint venture hospital with Acadia Healthcare, an international leader in psychiatric and addiction care.
Oregon Health to Buy 25% Stake in Moda Health Plan
Publicly owned and financed Oregon Health & Science University said it will convert a $50 million debt from Moda Health Plan Inc. into a 25% equity stake in the privately owned, financially troubled insurer.
Last year, OHSU said invested $50 million in Moda to promote vertical integration of its health care system. The investment was in the form of a 4% surplus note—a common financial instrument in the insurance industry specifically designed to provide capital. The note matures in 2024. Under a letter of intent, OHSU may convert the surplus note into an equity position in 2016. Any final agreement would require approval by the boards of directors of both OHSU and Moda, and regulatory approval from the Oregon Insurance Division.
Moda borrowed the money from OHSU last December, but suffered a large financial hit this year when the government reneged on the risk corridor program created under the Affordable Care Act. Moda was anticipating nearly $90 million from the payments, but received only $11 million.
In October, the insurer was placed "under review with negative implications" by the insurance rating firm A.M. Best Co.
Two NY Hospitals Join UR Medicine
Jones Memorial Hospital, a 70-bed hospital in Wellsville, NY, and Noyes Health, a 67-bed hospital in Dansville, NY will join UR Medicine now that affiliations have been unanimously approved by each hospital's board. With the affiliations, UR Medicine's network now includes five hospitals in western New York state, including Strong Memorial, Highland Hospital, and Thompson Health.
UR Medicine is also working with St. James Mercy Hospital in Hornell to preserve its inpatient services and to obtain state funding to build a new outpatient services facility that would also provide 15 inpatient beds for complex patients.
Jones, Noyes, and St. James Mercy hospitals already collaborate to bring UR Medicine oncologists, cardiologists, neurosurgeons and other specialists to all three communities. Two weeks ago, construction began on the new Ann and Carl Myers Cancer Center in Dansville, part of the Wilmot Cancer Institute that will provide oncology services for the region.
"The changes taking place in America's healthcare system have significant implications for rural hospitals and the communities they serve," University of Rochester President Joel Seligman said in prepared remarks. "The regional approach of UR Medicine ensures that these hospitals remain the cornerstone of local healthcare and also an economic anchor for their communities."
Financial terms were not disclosed, but when the deal is finalized Avera will become the second-largest health insurance company in South Dakota, serving nearly 200,000 people. However, Avera will operate Avera Health plans and DAKOTACARE as two separate organizations.
DAKOTACARE's provider network includes 100% of South Dakota's hospitals and more than 98% of the state's physicians and pharmacies.
"Avera is committed to maintaining the DAKOTACARE brand, the broad network of providers, and the positive relationships with the more than 400 insurance agents across the state," said Rob Bates, senior vice president of Avera Health.
With the acquisition, Avera says it can now offer consumers a choice provider network through DAKOTACARE and a value network plan through Avera Health Plans.
Avera has more than 16,000 employees and physicians in more than 330 locations and 100 communities in a five-state region.
Northwestern's KishHealth Acquisition OK'd by IL
The Illinois Health Facilities and Services Review Board has unanimously approved Northwestern Medicine's previously announced plan to acquire DeKalb-based KishHealth System.
With the regulatory approval in place, Northwestern Medicine will grow to more than 90 locations, including six hospitals, with a combined workforce of 26,500 employees and physicians in eight Illinois counties. Kevin Poorten, president and CEO of KishHealth, will remain in that role after it becomes part of Northwestern Medicine.
With regulatory approval in place, Northwestern Medicine said it anticipates KishHealth joining the health system before the end of this year.
Newly Merged VHA, UHC to Be Called 'Vizient, Inc.'
VHA Inc. and UHC merged this Aprilto create the nation's largest member-owned healthcare company, and on Jan. 1, 2016 the new company will be known as Vizient, Inc.
"The new name represents the full capabilities of the combined organization, from supply chain expertise to forward-thinking insights into cost and quality performance," the Irving, TX-based company said in a media release. "The comprehensive products, services and expertise of Vizient will help members significantly improve their financial, clinical, and operational performance and achieve greater value for patients and communities."
The merged company represents more than $50 billion in annual purchasing volume and serves more than 5,200 health system members and affiliates and 118,000 non-acute healthcare customers, from independent, community-based healthcare organizations to large, integrated systems and academic medical centers.
Unlike many rural hospital closures that occur despite public outcry and angst, the people of Bowie, Texas had the opportunity to save their hospital. They literally elected not to.
Nearly 50 years after it opened, the doors have finally closed for good at Bowie Memorial Hospital, a 51-bed independent community hospital serving Bowie, TX.
Employees gathered Monday morning for a brief closing ceremony that included lowering and folding the flags at the entranceway, goodbye hugs and handshakes for colleagues, and locking the doors to the emergency room that since 1966 had provided this community of about 5,100 souls 24/7/365 access to care. A handful of administrators will spend the next two weeks in the empty building clearing up paperwork before the lights flicker off one last time.
Larry Stack
The closing means that many of the hospital's 138 employees will have to find jobs elsewhere, and many are expected to leave this town located midway between Fort Worth and Wichita Falls. Other town residents who require easier access to care are also likely to uproot to leave.
The Bowie residents who stay and require hospital or emergency care must now travel either 19 miles northeast to Nocona General Hospital or 28 miles southeast to Wise Regional Health System. Hospital closings have become far too common in non-urban America these days. Researchers at the University of North Carolina report that at least 59 rural hospitals have closed since 2010, almost all under financial duress. Bowie Memorial reported that it had lost $900,000 last year.
Unlike many of these rural hospital closures that occur despite public outcry and angst, however, the people of Bowie had the opportunity to save their hospital.
They literally elected not to.
A Nov. 3 referendum to create a hospital taxing district that would have raised property taxes by 17 cents (about $150 a year on a $100,000 house) was defeated by 53% of the voters.
Local media reported that Bowie residents who opposed the tax hike feared that there were no guarantees that the hospital wouldn't come back in future years with demands for more.
Bowie Mayor Larry Stack says he remains "totally baffled" that town residents did not support the tax increase, even though town and Bowie Hospital Authority officials made it clear that the hospital would shutter without the new revenue stream.
"We were one of two rural hospitals in Texas that did not receive tax support," Stack says. "Really, it's pretty amazing that the hospital was able to remain operational for as long as it did. It's hard to get that point across to people about how the payment system works, especially when you have a high Medicare census that's nearing 80%."
Mayor Stack spoke with HealthLeaders Media about the closing and its effect on the community. The following is an edited transcript.
HLM: What do you do now? Stack: That's a good question! We have only one choice currently and that is to transport our citizens to Nonona or Decatur. Our city medical director has told us to continue to use the same medical directives that he had provided previously, which is to take the patients to the closest adequate facility.
Now as far as what we do with the hospital, the hospital board is working on that. I don't know what is possible at this time. Our hospital is needed here because of the large amount of Medicare patients and uncompensated care we have.
The long-term fix was tax support to generate the revenue to keep the hospital viable, and of course that did not happen. My suspicion is that an urgent care clinic at some point will come to Bowie, but I don't know how that business model will fit in here. It's my understanding that urgent care clinics' emergency rooms are not recognized by Medicare. Only emergency rooms associated with hospitals are recognized by Medicare.
And when the hospital was open, the Medicare census was nearing 80%. I don't see how that would be viable for an urgent care center here. I know they do that in urban areas where the population is younger and you have a higher percentage of private insurance."
HLM: How did Bowie Memorial find itself in financial straits? Stack: I served on the hospital board for 16 years until 1996. This hospital opened in '66. It was chartered as a non-taxing entity. So the hospital always operated close to the vest and kept costs real conservative. We cash-funded our depreciation. It was very financially successful.
In 1993 when the government passed the Medicare Reform Act, the board knew at some point it was going to greatly affect the revenue of the hospital because we didn't have any room to cut costs. In '94 we told our administrator to set up a hospital taxing district. We weren't going to have a vote right then, but we wanted it in place because at that time you had to go to the state legislature to get that set up and our legislature meets every other year.
We didn't know when we needed to have that vote but we wanted it taken care of. The mistake we made then was not to have a referendum right then for a very small tax increase.
We decided to come up with all other ways to generate revenues. We started a physical therapy program. We started a home healthcare program. We started durable medical equipment rental. We built an assisted living center that was very profitable that offset our loss of revenues and it all worked pretty good. But as time went on, the payments got less and less and the Medicare census grew. So, that was a problem.
HLM: Why did voters reject the tax increase? Stack: We had our first vote four years ago and it didn't pass. So the hospital really struggled to get to this point. In addition to all that stuff, our economy is heavily oil field related. Over the past six to nine months, there is one large employer here who had 600 people and now it's down to 300 and that was spread to a lot of other people who were doing oil field-related activities.
So, a lot of people didn't have jobs, or had their hours cut way back. It was hard for those people to support the tax increase because honestly, they didn't have the money.
And then the opposition bunch, which was basically citizens that lived outside the city limits, ran a hard campaign against it. A lot of the information they put out was not entirely accurate and the bunch here that was running the 'for' campaign tried to combat it as best they could.
But sometimes it's difficult to change people's minds. If you take all that into consideration, it's the perfect story type deal. But for the life of me, I cannot understand why people in a town this size of over 5,000 would not want to have a hospital. I don't know if people just thought it wouldn't close, but I am baffled. I am totally baffled.
HLM: How will local government respond to the closure? Stack: This will have to be paid back in some other way. There is no free lunch. One of the things we had done, if you are a citizen of Bowie proper and our ambulance picks you up to takes you to the city hospital and let's say that trip is $1,500 and your insurance only pays $500 we accept that as full and final payment. We don't hassle you for the difference. That is a benefit you get for paying your taxes. Or if you don't have insurance we do the same thing. We don't hassle you. We let it go.
Well, that costs us about $350,000 to $400,000 a year and you can kind of justify that by the fact that you are taking those patients to your hospital. That is going to go away. Now we cannot afford to create a deficit to take people to places further away. The city council is considering an ordinance change that says you have to pay your own tab when you go to the hospital, and we will file liens. That's a perfect example of what is going to happen.
Montague County only pays us $18,000 a year to provide ambulance service for the southern half of the county. Well, we are going to have to take a hard look at that. That doesn't even begin to cover the associated costs.
HLM: How do you think not having a hospital will affect Bowie's ability to recruit new businesses?
Stack: It's going to be difficult. Available medical care is one of the top things people look for. My first line of defense is to look at every possible avenue. I am writing letters to our state and federal elected officials to see if there are programs they can help us with and get this thing put back together as some sort of hospital of some size. I don't know at this point, but it is a definite negative.
Unfortunately most of those people who worked at the hospital with their specialties will not be able to find work here if they decide to stay in that same field, so we are going to lose population too. It's a gut punch.
HLM: Is there anything else you'd like to mention? Stack: Only that if anybody has any suggestions about what we might do I'd be more than happy to listen to them.
Despite some differences based on size, academic medical centers, community hospitals, and for-profit and not-for-profit hospitals have all seen quality improvements since 2002, says the head of The Joint Commission.
Nearly one-in-three hospitals that submitted quality and performance data to The Joint Commission earned a coveted spot on the accreditor's Top Performers on Key Quality Measures list.
"Achieving top performer status is not easy and for many hospitals it took years of hard work," Joint Commission President Mark R. Chassin, MD, said on a Tuesday conference call. "More than ever, hospitals are focusing on what counts. This represents real progress. We clearly have a long way to go on these and other measures of healthcare quality."
The Joint Commission's 2015 report used 49 accountability measures to determine how hospitals perform on evidence-based care processes for conditions such as heart attack, surgical care, inpatient psychiatric services, perinatal care, pneumonia and stroke.
The report will not be published in 2016, Chassin said. "For 2016 we've decided to take a one-year hiatus and assist our accredited hospitals in managing the journey and evolution of electronic clinical quality measures. In January the Joint Commission will launch Pioneer in Quality, a program focused on helping customers reach top performer status in the electronic clinical quality measures world."
Of the more than 3,300 hospitals that submitted data for the 2015 report, 1,043 hospitals (31.5%) made the Top Performer list, which required them to achieve a cumulative performance of 95% or above across all reported accountability measures.
Chassin cautions that while the Top Performer program identifies hospitals that provide superior performance on specific measures, it is not a blanket endorsement of all services provided at any particular hospital.
"The evidence is crystal clear that quality varies quite a lot within individual hospitals from one service to another and from one measure to another," he says. "That is why we are very careful to specify in this report exactly which measures resulted in each top performer achieving their recognition."
This year's report added accountability measures for tobacco treatment and substance use, and inpatient psychiatric services.
Chassin says academic medical centers, community hospitals, and for-profit and not-for-profit hospitals all are seeing quality improvements.
"There are remaining some differences between hospitals depending upon how large or small they are. But the main trend is that everyone has improved dramatically, especially if you go back to 2002," he says.
Chassin said he doesn't think the financial incentives imposed by CMS have played a huge role in improving quality.
"The time during which the most dramatic improvement in performance occurred (was) well before the financial penalties were put in place by CMS," he says. "The only financial penalty that was in place in this period was the penalty for not reporting any data at all. Specific penalties attached to specific measures came long after hospitals had achieved the vast majority of this improvement. And that temporal observation is consistent with a bunch of research that shows that financial penalties tied to specific measures didn't really add much to the improvement that had already taken place."
Instead, Chassin credits The Joint Commission with providing the platform that empowers and incentivizes hospitals to measure and monitor their quality markers.
Standardized Measures
"The principle driver is that The Joint Commission going back to 2002 established the first standardized set of information that hospitals could collect across the nation," he says. "Indeed, we required them to as a condition of accreditation to measure quality in a selective number of conditions, and that number has gone up over the years. We were the first organization to publicly report the results of those data collection on quality measures. [Centers for Medicare & Medicaid Services] followed shortly after, and for a number of years in the 2000s, The JC and CMS were nearly perfectly aligned in the definition of measures, in the public reporting of those measures, and the public reporting really drove a huge amount of improvement."
Since then, he says, a lot of other organizations have jumped on the hospital ratings bandwagon.
"Now we have lots and lots of organizations reporting on quality," he says. "Leapfrog, Health Grades, Medicare's measures derived from their billing data, which we don't believe are valid measures of quality. So there are a lot more sources of information. We believe these accountability measures are still the best, but that public reporting period in the early and mid-2000s was the major driver that got hospitals' attention and they learned how to improve on these measures."
How TJC Criteria Differ
Chassin says the Joint Commission has a strict set of criteria that distinguish its ratings from other hospital raters.
"For example, we will not use measures like CMS uses that are derived from data from hospital bills because they don't pass our criteria for accurately identifying complications, or some patient subgroups," he says.
"We also will not use outcome measures like CMS and Healthgrades and others use because they rely on billing data to do risk adjustment. Those billing data don't have any information on the severity of the condition which is one of the most important things you have to adjust for in comparing different patient populations."
"Another player out there likes to label hospitals with one letter grade. That's demonstrably misleading. Quality varies enormously within hospitals, from one service to another, and from one measure to another," he says. "It just flies in the face of decades of hospital research which shows that variability does not allow that kind of measure to be accurate."
"There is a lot of noise out there in the hospital quality measurement field," he says. "We encourage hospitals to tune out the noise and to focus on measures that are most important to their own patient populations. The most important quality improvement that hospitals can do is to understand what risks their patients are facing, what improvements are necessary for their patients, and to act on those incentives."
