Georgia's new 23-hospital collaborative, with its focus on operational initiatives and improving population health, "represents a formidable force with substantial bargaining power" and may be the first stage of something bigger, says one healthcare analyst.
Ninfa Saunders, CEO/president of Central Georgia Health System
Twenty-three hospitals and health systems and about 1,500 physicians in central and south Georgia on Tuesday announced the formation of a clinically integrated non-equity partnership called Stratus Healthcare.
Ninfa Saunders, CEO/president of Macon-based Central Georgia Health System, which along with Tift Regional Health System in Tifton were among the original advocates for Stratus Healthcare, says the initial focus of the collaborative will be to improve population health using best practices, networking, shared services, and coordinating primary and specialty care needs for the region.
"The one thing that is different about this part of Georgia is that every hospital wanted to remain independent," Saunders said in an interview. "So mergers and acquisitions, unlike a lot of areas, were not in the recipe for this area. What was desired was more independence and a focus on local healthcare by local physicians and to develop a collaborative or a strategic partnership that allows us to do as many things as possible in an aligned way to meet the health needs of the population."
Healthcare economist Adam Powell believes Stratus Healthcare has been created as the precursor to something else.
"Although it has been formed as an alliance, the press release announcing its creation mentions that it intends to eventually transform into an LLC. I see this as a merger in the making that may have been announced early for strategic reasons. Given the number of organizations involved, it may have been easiest to accomplish this in stages," Powell wrote in an email exchange with HealthLeaders Media.
"Furthermore, Tift Regional Health System is currently actively seeking a new COO through the executive search firm Witt/Kieffer. Given the operational changes associated with this alliance, the announcement may have been made rapidly so that progress would be underway before the installation of a new COO. Tift is operating from a position of strength, as it held $336 million in net assets at the end of 2012, $42 million of which had been accumulated during the year. Participating offers it the opportunity to continue its success," Powell wrote.
Saunders says she expects that Stratus will evolve to include more operational initiatives, and grow to include more hospitals in the coming years.
"What I see in terms of strengthening the partnership is a slight movement from non-equity partnership to some shared equity, but not quite mergers and acquisitions," she says. "We may find some projects we want to invest in together. Now we are pooling resources specific to hospitals to meet the particular needs of that particular area or population. That is where I begin to see this sharing, which is joint projects, joint investments, joint collaboratives, with equity associated with it. As we are able to formulate systems of care that not only connect hospitals but also the post-acute and retail side, the outpatient ambulatory side, then it begins to define itself differently and it will be open to many other arrangements."
While plans are underway to form a group purchasing agreement, Saunders says there are no immediate plans to use the clout of the partnership to barter for better rates with health insurance providers.
"The focus right now is on four objectives: How do we get physicians and hospitals together so that our patients will have the right access to the right care at the right time at the right cost?" she says. "We said to ourselves 'let's go back to basics. How do we improve the quality of care with this population first? How do we put the processes in place so that we are evidence-based and we can measure processes in the same way and focus on outcomes, raise the bar in terms of our outcomes and then anything can come after that."
Saunders says another target is the development of a primary and specialty care networks for the region.
"We are spread out so we are concerned about recruiting to the region, given the shortage. We are looking at specialty care networks and what specialties are needed," she says. "The medical center that I run is a teaching hospital, the second-largest in Georgia. So one of the things was what specialists might we make available for our partner hospitals. Or if there is a need to hire in a particular hospital how could we join like-minded people that have the same needs so that not everybody is investing and capitalizing 100% of that expense," she says.
The partnership also plans to examine shared services. "How can we begin to look at the redesign of care together? How do we reduce the cost through group purchasing, maybe looking at running programs under one umbrella as opposed to everyone having one," Saunders says.
The partnership will also consider forming a regional emergency medicine consortium.
"That allows all of the emergency room physicians to identify how we can [provide] care without having to repeat things over and over again," Saunders says. "When a patient is transferred to another hospital we tend to repeat the diagnostics. Why do that if our processes of care and our algorithms of care have been agreed upon by all of the players. The same thing with hospitalist medicine, which is one thing we are interested in growing in a regional way so that not every hospital is attempting to manage this on their own."
Powell, president of Boston-based consultants Payer+Provider Syndicate, says this week's announcement builds upon several other recent partnerships in Georgia. "In April 2012, Central Georgia Health System developed a partnership with Tift Regional Medical Center to coordinate information systems, clinical services, and business services. Central Georgia Health System also recently partnered with Peach Regional Medical Center to build The Medical Center of Peach County, a new facility that will expand access to care in the community," he points out.
Powell says that by sharing information Stratus Healthcare hospitals will be able to manage risk and expenditures as they migrate to value-based payment.
"Under (accountable care organization) contracts, health systems are liable for the cost of care a patient incurs, even if the patient goes outside of the ACO to receive care. Poor information sharing can lead to duplicative testing," Powell says. "By pooling information, the health systems can avoid performing duplicative testing and can better coordinate care for patients seeking care at multiple institutions within the region."
"Stratus goes a step further," Powell explains, "by enabling its members to engage in collective purchasing and the sharing of business resources. Given the substantial proportion of Georgia hospitals in the alliance, it represents a formidable force with substantial bargaining power."
"Across the country, we have seen a wave of provider consolidation and integration. While Stratus is notable for the relatively large number of organizations it contains and its relatively loose nature, it is part of a greater trend of cooperation," Powell says. "While state governments have been forming regional health information networks, this alliance goes a step further, as it moves the organizations towards operational integration.
Stratus Healthcare member hospitals and their medical staffs include:
Bleckley Memorial Hospital (Cochran)
Central Georgia Health System, which includes: Medical Center of Central Georgia (Macon); Central Georgia Rehabilitation Hospital (Macon); and Medical Center of Peach County (Byron)
Coffee Regional Medical Center (Douglas)
Columbus Regional Health System, which includes: Columbus Regional Medical Center (Columbus); Doctors Hospital (Columbus); and Hughston Hospital (Columbus)
Crisp Regional Hospital (Cordele)
Dodge County Hospital (Eastman)
Houston Healthcare, which includes: Houston Medical Center (Warner Robins); and Perry Hospital (Perry)
Jasper Memorial Hospital (Monticello)
Oconee Regional Medical Center (Milledgeville)
Putnam General Hospital (Eatonton)
South Georgia Medical Center Health System, which includes: South Georgia Medical Center (Valdosta); Smith Northview Hospital (Valdosta); and Louis Smith Memorial Hospital (Lakeland); Clinch Memorial Hospital (Homerville); SGMC Berrien Campus (Nashville)
Taylor Regional Hospital (Hawkinsville)
Tift Regional Health System, which includes: Tift Regional Medical Center (Tifton); and Cook Medical Center (Adel).
Researchers report that the existing distribution model of organs for liver transplants is unbalanced and depends upon longstanding relationships among medical centers. Organ donor advocates are calling for a change in the allocation process.
David C. Mulligan, MD
Organ donor advocates want to copy the mathematical formulas that draw boundaries for political maps and zoning districts and use them to create a more equitable allocation of transplanted livers from deceased donors.
"Currently the geographic disparity for access to livers in this country is great," says David C. Mulligan, MD, director of Surgical Transplantation at Mayo Clinic Hospital in Phoenix, AZ. "We need to find better ways to improve our system of allocation to reduce this disparity so that in the end, access to liver transplants will be the same or as close to the same as possible no matter where you live in this country."
Geography can mean the difference between a 10% – 90% chance of dying while on a waiting list for a donor liver, researchers say. "The existing system is based on the geography of where a handful of centers that were performing liver transplantation were located," says Mulligan, who is also chair of the liver committee for the Organ Procurement and Transplantation Network/United Network for Organ Sharing.
Researchers at Johns Hopkins University School of Medicine reported this month that the existing "unbalanced" distribution model depends upon the longstanding relationships among medical centers.
Mulligan agrees.
"When liver transplantation was first developed in this country, the transplants were done at a handful of centers, five or six centers started the whole process," he says. "They were distributed across the country from Pittsburgh and Dallas and Los Angeles and Omaha NE so each of these programs as they were beginning to develop needed to try to determine where organs could potentially come from."
"They knew that the cold storage time had an impact on the outcome of the transplant so they didn't want to be pulling organs from one part of the country in those days and putting them in on the other coast into their patients. They tried to develop systems or regions so that organs when they were recovered by the organ procurement organizations as they were being developed could get placed into the patients on the transplant lists that were closest in proximity to get the best possible outcome," Mulligan explains.
"As the success of organ transplant continued, we could see that the ability for preserving these organs improved, the ability to do the transplants improved, the outcomes improved, and more and more centers started to perform liver transplants and there became a need for a more developed and complex way of trying to approve the allocation for these organs to get to their patients."
Dorry L. Segev, MD, an associate professor of surgery and epidemiology at the Johns Hopkins University School of Medicine is the author of a report that examines the use of mathematical formulas to create a more equitable distribution, which he calls "gerrymandering for the public good."
"We have applied to transplantation the same math used for political redistricting, school assignments, wildlife preservation and zoning issues," Segev said in a media release. His report was published this month online in the American Journal of Transplantation.
Mulligan says he supports the recommendations from the Johns Hopkins study and that the OPTN/UNOSliver committee is reviewing redistribution models. Now, however, he says the biggest roadblock towards a coordinated national system may be turf wars among transplants centers.
"I would love to say that everyone is on the page. We all agree that all of the transplant physicians and surgeons and organ procurement organizations want what is best for their patients. The biggest roadblock is getting buy-in for thinking in a different parameter, taking a step back and saying what is best for all patients in the United States," Mulligan says.
"The big piece is to get everyone to look at the big picture, to look at all patients in the country and not just their own. Because in areas where there is a huge disparity and long waiting times in liver transplants those centers are going to be excited to see a new opportunity for their patients to get organs more effectively and efficiently."
"On the flip side," Mulligan says, "centers and regions in the country that have very productive organ procurement organizations and a lot of organ donation and populations of donors who are very motivated, those centers look at this type of a proposal as a hurt to their patients, that their patients are now going to have to wait longer because they are sharing with other centers."
If it were up to him, Mulligan says he'd like to see a nationally coordinated allocation plan for donated livers in place within the next few months. "But realistically, I would like to see the first step of Phase 1 of a redistricting plan in place and out for public comment and going forward with board approval for implementation within the next two years," he says. "That is going to be a bold undertaking, but that is what we are trying to achieve. It may take longer, but I am going to do everything possible to make it as short a time as possible as I can."
If the coordinated effort works for donated livers, Mulligan says it could serve as a distribution model for other donated organs, which often have their own unique distribution networks.
"If this is successful in liver [allocations] we will need to study to see if there is something we can do to improve the way hearts are distributed, because they do a whole different system," he says. "They are distributed based on circle distribution from each donor hospital, how many hundreds of miles they go out and how sick they are. We would look to applying these types of mathematical models to all organs and maybe adjust the models to factors that are necessary for each of these organs to make the process better."
Observers believe such a change would result in potentially far-reaching consequences for companies that fall under the purview of the SEC, including private, for-profit hospitals, their directors, officers, and employees.
G. Derek Andreson
At The Wall Street Journal CFO Network's Annual Meeting in June, Securities and Exchange Commission Chair Mary Jo White said she would push to modify the commission's "no-admit no-deny" policy and require more admissions of guilt from defendants when settling enforcement cases.
White's proposal represents a pronounced departure from the SEC's longstanding no-admit no-deny policy under which defendants settle cases without admitting or denying wrongdoing. Currently, the SEC requires such admissions in a narrow array of cases where defendants admit certain facts as part of a guilty plea or other criminal or regulatory agreement.
White told the CFOs that the no-admit, no-deny policy will still be used in the "majority" of cases and that "having 'no-admit, no-deny' settlement protocols in your arsenal as a civil enforcement agency [is] critically important to maintain," according to a Reuters report.
The change comes after recent criticism of the policy from two federal judges and U.S. Sen. Elizabeth Warren (D-MA). Observers believe such a change would result in potentially far-reaching consequences for companies that fall under the purview of the SEC, including private, for-profit hospitals, their directors, officers, and employees.
G. Derek Andreson, a partner at the law firm of Pillsbury Winthrop Shaw Pittman LLP, and an expert on SEC enforcement matters, spoke with HealthLeaders Media about the potential effects of such an SEC policy shift.
HLM: Why is the SEC doing this?
Andreson: The SEC has been on the receiving end of some criticism both from the bench and others concerning the fact that this policy of 'no-admit no-deny' leads to perhaps a policy that is too lenient and that it really behooves both the government and the public to have a policy with a little bit more teeth. They tried to strike the balance here by including this option now, which gives the SEC more teeth certainly on the negotiating table. It remains to be seen what the effects are but it gives them the teeth they're looking for.
HLM: How will the SEC decide when to apply this new policy?
Andreson: You are going to see this policy evolve over time. They are going to be relatively conservative with how they roll it out. They will identify cases where the evidence is particularly egregious or particularly strong and they will certainly choose those initial cases to roll this out and you will see some flexibility built in down the road as it evolves and people become more aware of it.
More importantly, its significance will be at the negotiating table and perhaps give them results that they otherwise wouldn't be able to obtain for fear of simply the SEC pressing this issue.
HLM: Is there a set-in-stone implementation date? Do they require any legislation to do this?
Andreson: This is something that they have the ability to do on their own. It falls within their purview. I am not sure exactly when they are going to begin this process. This is something that I believe was spearheaded by Mary Jo White, a former federal prosecutor and U.S. attorney for the Southern District of New York.
It is consistent with her prosecutorial approach, a little bit more aggressive. It gives them more leverage. They really wanted to give some teeth to an agency that sometimes finds itself needing more leverage.
HLM: SEC commissioners are political appointees. Will we see uneven applications of this policy?
Andreson: Well, sure. Things change. Commissioners come and go and as leadership changes at the SEC the policy may be modified. It may be used more or less depending upon who is there.
But once they lay the groundwork for it and roll it out, presumably in the near future they are going to set certain bench marks. Consistency, particularly in enforcement matters, is one of the most important principles. So you are going to see them try to see some consistency applied through the years. But again it is certainly subject to who is running the show.
HLM: Would forcing some defendants to admit their guilt compel them to fight when they otherwise would have settled?
Andreson: Absolutely. That is one of the anticipated effects that remain to be seen. But you are already seeing some of the commentary out there referencing that fact particularly in parallel investigations where you might have private litigants waiting in the wings watching to see what happens.
Certainly in the case of parallel Department of Justice and SEC matters where admission of wrongdoing in an SEC enforcement matter may well embolden DOJ prosecutors. Perhaps they had shelved the case or perhaps they had hit a wall in the case as far as evidence.
This may embolden them to pursue further that target in particular. It may embolden private litigants to move forward particularly given the heightened procedural processes that they must go through. Having an admission like that certainly gives strength to the case for private litigants or at least their motivation and their conviction going forward.
HLM: Why is it so important for so many of these entities to have no admission of guilt?
Andreson: Without admitting guilt it doesn't give a leg up to private plaintiffs or DOJ. It is simply a neutral factor. That is what was so helpful to them, particularly in these parallel investigations. Now I think it is going to forestall those investigations or cause them to go to trial because if their hand is forced by the SEC to admit it then they are going to have other problems.
HLM: Could other federal regulatory entities, such as the Department of Health and Human Services, look at the SEC policy shift and do the same thing?
Andreson: Any regulatory body out there that relies on the same policy of no-admit no-deny is really going to take note of what the SEC has done and they are going to really pay attention to what effect that policy has in the short term to see how it is playing out.
HLM: What are the implications for investor-owned hospitals?
Andreson: I am not sure I could share observations about the specific effects this may have on that sector. It remains to be seen. They have crafted this new policy. They are getting ready to roll it out. They are going to choose their initial cases carefully and use them as benchmarks.
But I am not sure it is going to have sector specific implications at this point. It's going to depend upon the evidence in the case and how it reaches the conduct is at issue. Those are going to be the driving factors here, not so much the sectors.
HLM: How should businesses prepare as this policy is ramped up?
Andreson: Having an awareness that this new policy is about to be implemented is important. But if they find themselves on the receiving end of an SEC inquiry it certainly behooves them to take a look at what private litigation may ensue from that, whether there is any prospect of DOJ involvement or a parallel investigation by DOJ, and if so how that might be affected by this new policy.
Evaluating for themselves what potentially the evidence is and whether that new policy might be applied to them. The SEC has made clear that in the majority of cases going forward they are not going to be seeking this but that they are going to use this sparingly. We will see if that actually happens.
Secondly, recognize that the SEC has intimated that they are only going to be using this is a small subset of cases, at least initially. Assuming that is the case it is important for hospitals that might be subject to SEC jurisdiction to first and foremost be aware of the policy and second if they find themselves on the receiving end of an SEC inquiry, to do two things.
The first is to ask themselves if there are other agencies or parallel investigations that potentially may ensue, whether it is private litigants or DOJ, and be aware of the effect it may have on the parallel litigation. The second thing is to evaluate what the evidence may be in that case.
How strong is the case? A bit of introspection might be helpful at that point because if they are dealing with facts or evidence that potentially egregious from the perspective of the SEC it may be one of those cases where the SEC throws this new policy out on the table as leverage.
In our April Intelligence Report, the top challenge cited by leaders in pursuing a collaborative care model is "concerns about the ultimate cost savings." Members cited coding discrepancies, budget cuts, and convincing physicians to share the risks as barriers to incorporating a collaborative care model.
What do you see as the path to ensure cost savings in a collaborative care model, and what can leaders do to facilitate that?
Robert Ross, MD
Medical Director of Community Health Strategy St. Charles Health System, St. Charles Medical Group
Bend, Ore.
On behavioral health: We have four clinics that are Tier 3 medical homes and in three of them we have fulltime behavioral health folks. For example, if a physician or actually any member of the team identifies a patient as being depressed they can get help not just in terms of medication but also using both psychotherapy or some type behavioral therapy and medications, which results in better outcomes for patients.
On coordinating payments: One of the problems we encounter is that you have to divide up the billing and costs for the separate services. Ultimately to have the many services, not just behavioral health but other things like pharmacy services, you could name a billion things, especially with people who have difficulty with access, so combining those and paying for them with some sort of global fee, probably capitation, would make it easier for everyone concerned and not just physicians. It eliminates costs for insurers as well in terms of verifying that services were delivered. Ultimately that is where we are heading, but that is a guess.
On coding shortcomings: There is a huge unexplored area of what is not coded and what things that patients have or experience that potentially are in the notes but not discerned by payers. The data we mine is determined by the provider codes and that is not a particularly accurate way of getting at people's problems because you code for what you are paid for and not necessarily for all the problems that are contained in a patient visit. It's a very complex problem.
Andre Boyd
COO TriStar Greenview Regional Hospital
Bowling Green, Ky.
We are starting the whole process of clinical integration through our lead CMO for our division. We are garnering support from each of the physician practices in each of our cities that we provide services for.
With that, will have a true infrastructure to help manage the data collection as well as help manage the partnerships and the follow-up care that we need to do with our physicians.
In my organization typically collaborative care means partnering with our providers and other ancillary organizations to provide the best care possible for our patients. The biggest issue is getting doctors to understand that it makes a difference. When we talk about partnering to share risk it means we are taking an opportunity to move the quality agenda forward for our organization and for their patient population but doing it where if you are able to achieve this outcome, then you get incentivized.
It's also making sure that we are reducing or eliminating as much variation in clinical care as possible, and to do that we have to partner with doctors and get on the same path to make sure we understand that here at Greenview we do a process for congestive heart failure. Maybe that same process will work collaboratively at another hospital we own. So let's make sure we are standardizing our policies and programs appropriately."
Maureen Swick, RN, PhD
Senior Vice President, Chief Nurse Executive Inova Health System
Falls Church, Va.
At Inova we have utilized Lean teams looking at our care delivery model, ensuring that the right person is doing the right job with regard to roles and responsibilities. We have also implemented multidisciplinary rounds. It's really about team. From the efficiency and patient and family engagement perspective, that helps facilitate a more efficient process by engaging the patient and the family up front with the plan of care for the patient. The inpatient coordination becomes much more efficient for the patient and the family.
The amount of rework, phone calls, delays, testing, and coordination is huge when that is not done in an integrated and collaborative way right up front.
When we talk about the team with the physicians and everyone working collaboratively on the plan of care that helps with the length of stay. That is how we are monitoring whether or not we are successful.
From a cost savings perspective, when we looked at our care delivery model we were heavy with RNs and now we have implemented techs because we used our Lean experts and looked at having nurses function to their full license and training. If they had anything that did not require their license, we developed a role for the clinical technicians. That shift right there from a mostly RN model to a mixed model is a huge cost savings from a labor perspective.
Thomas G. Lundquist, MD
President and CEO, AnewCare Collaborative,
Chief Clinical Integration Officer, Integrated Solutions Health Network Johnson City, Tenn.
We are an ACO that was formed in the middle of last year, a Medicare shared-savings program. But we also have commercial lives that are starting to access our narrow network under the ACO.
A big challenge is to find the right partners and the finances that work, but we are marching down that path slowly but surely. Another challenge is devoting the resources to build effective teams within the physicians' offices that are participating in the integrated care model. There is a need to, especially on the primary care front, bolster the ranks of care coordination. That could be nurses or social workers or even public health student graduates who understand population health dynamics.
Not only do you need the people, but you need the right tools to be effective and reach out to patients in a consistent and coordinated manner that can be documented in terms of how they do their work. You have to make that investment in people and process tools or you will come up with a lack of a return on investment.
We are fighting all the pressures on healthcare in terms of budget cuts and its impacts of our organizations and how they are funded. That is the goal, to put the people and the teams together and design the processes for putting the people in place who can then reach out to the patients on behalf of the physicians and work with the physician in a team atmosphere.
Members of the U.S. Senate Finance Committee suggest that Farzad Mostashari, MD, the National Coordinator for Health Information Technology, has little or no idea of the challenges rural healthcare providers face as they grapple with Meaningful Use requirements.
With all of the fighting, delays, and splashy headlines surrounding the Patient Protection and Affordable Care Act, the evolving status of meaningful use and the adoption of electronic health records often take a back seat.
Yet, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 and the $33 billion that came with it are leading and funding the development of the complex HIT infrastructure that will make possible key components of PPACA.
There are rumblings, however, that rural providers are falling behind with HITECH implementation. For example, only one-third of rural hospitals have electronic medical records systems, compared with half of all urban hospitals.
Members of the U.S. Senate Finance Committee Wednesday sought answers on the status of meaningful use in rural America from Farzad Mostashari, MD, the National Coordinator for Health Information Technology. "I'm concerned about the digital divide may only get larger as rural hospitals are expected to take the leap into the more rigorous requirements of [Meaningful Use] Stage 2," Sen. John Thune, (R-SD), told Mostashari during the hearing.
"They have already expressed great concerns about Stage 2. I am of the view that [Office of the National Coordinator] and [Centers for Medicare & Medicaid Services] ought to develop a way for rural hospitals to achieve Stage 2 while allowing more advanced healthcare systems and providers to move on to Stage 3 if they are ready. The question would be will you commit to giving rural providers more time to achieve Stage 2?"
Mostashari replied that federal officials "have been quite open to dialog with the rural community and how we can help them achieve success and not necessarily accept that they are necessarily going to be further behind."
While challenges remain, Mostashari says that rural providers have made tremendous progress in adopting electronic health records. In fact, Mostashari says he is so confident in the advances that smaller hospitals are making, that deadlines have been moved up, not back.
"We set a goal of getting 1,000 critical access hospitals to meaningful use by 2014. We are going to revise that goal to get 1,000 critical access hospitals to meaningful use by the end of this year," Mostashari says.
"We think we are making good progress with those hospitals through the technical assistance and coordination that is possible. So, we are open to dialog. But I would much rather see the rural hospitals be able to keep up rather than me acknowledge that they are going to fall behind."
An independent review appears to back up Mostashari's claims that rural America is making progress on the electronic medical records front. A report from the Robert Wood Johnson Foundation, co-authored by Mathematica Policy Research and the Harvard School of Public Health, finds that the proportion of rural hospitals with at least a basic EHR increased from 9.8% to 33.5% from 2010-12. During the same time urban hospitals saw EHR adoption rates rise from 17% to 47.7%.
"The inpatient divide between rural and smaller hospitals compared to better resourced urban hospitals, particularly teaching hospitals, remains, but it is closing," says study co-author Michael Painter, MD, senior program officer at Robert Wood Johnson Foundation.
"The other thing we are finding is that the rate of adoption seems to be accelerating among the small and rural hospitals compared with the larger better resourced urban hospitals. That makes sense because the better-resourced urbans accelerated early on and now that is leveling off. The more-challenged small and rural hospitals are accelerating. Where this all plays out is hard to see. We will keep monitoring it in the coming years."
Painter says the percentages of hospitals that have achieved meaningful use actually could be significantly higher than what his report found because it uses data from 2012.
"Those numbers are a moving target. When we looked at 2011 data, only 4% were meeting Stage 1 Meaningful Use. From that dipstick to the next year it went to 44%. So we would expect that when we looked at who is close to pushing over on the Stage 1 criteria there is a huge number there."
"You can't get that mired down in what those snapshot-in-time numbers mean. What we are seeing is a trending all in the right direction, with some ongoing small and rural gaps, although that seems to be closing. But we are not out of the woods yet," Painter said.
Back in Washington, several members of the committee, including Sen. Pat Roberts, (R-KS), made jokes about Mostashari's trademark bow tie and suggested that he and other federal bureaucrats have little or no idea of the challenges that rural providers face as they grapple with meaningful use.
"My concern is I don't think we are getting the word west of Highway 81 in Kansas…," Roberts said. "It's like Paul Harvey used to do with Page 1 and Page 2. Page one and I will be back in just a minute. Well you've got Phase 1 and Phase 2. If we could just pause and make sure that most of the rural providers know what is going on."
"I get two sides of the story. I talk with the people in Topeka and they say everything is going as best as it possibly can. But I get a lot of calls from providers saying this is the proverbial wet horse blanket. My suggestion would be [to] take this show on the road. I would recommend Hayes, KS or Dodge City, KS. That is my hometown. I'm not sure I would recommend wearing a bow tie in Dodge City. But if you could go out and sort of take this digital show on the road that would be helpful. Or maybe have these folks come in because I know you are extremely busy."
That sentiment was shared by Committee Chairman Max Baucus, (D-MT), who urged Mostashari to "get out… of your offices and out to rural America. See it. Smell it and taste it, and know what it is. It is one thing to conceptualize it. It is something else to experience it."
"I mention you, Dr. Mostashari. I don't know why. I sense you are a Philadelphia guy, an eastern guy, a big city guy. There is a huge difference. Eighty percent of life is just showing up, just getting out there, being there, seeing it. Get out from behind your desk. It is well worth it. You're going to make fewer mistakes with respect to rural providers if you get out and see it."
The most well-known of a series of hospital rankings is a powerful marketing tool, but one observer says he is troubled that none of the various "rating schemes" use state and federal inspection data in their evaluations.
U.S. News & World Report released its much anticipated 24th annual Best Hospitals ranking Tuesday with familiar hospitals holding the coveted top spots.
The only drama came when Johns Hopkins Hospital reclaimed the No. 1 spot on the magazine's honor roll, a distinction it had held from 1991 through 2011, but which it lost last year to Massachusetts General Hospital. Mass General had to settle for silver this year, dropping to No. 2 on the list. The Mayo Clinic in Rochester, MN came in third.
Johns Hopkins Hospital officials were positively giddy with the news and issued a press statement crowing that the Baltimore hospital was "back on top."
"Given the competitive, rapidly changing health care environment and the realization that U.S. News evaluated more than 4,806 hospitals, we hope you share our incredible pride in achieving this top-tier ranking among the best hospitals in the United States," said a joint letter to employees and staff from Paul B. Rothman, MD, dean of the medical faculty and CEO of Johns Hopkins Medicine, and Ronald R. Peterson, president of The Johns Hopkins Hospital and Health System and executive vice president of Johns Hopkins Medicine.
Mass General officials took solace in noting that the Boston hospital was ranked No. 2 in the nation, No. 1 in New England, and placed highly in all of the 16 specialty areas identified by U.S. News.
"Of the nearly 5,000 hospitals evaluated, Mass General has consistently placed among the top hospitals on the Honor Roll since the survey began in 1990," the hospital said in its media release.
U.S. News ranks up to 50 hospitals in each of 16 medical specialties. Just 147 out of nearly 5,000 hospitals earned national ranking in one or more of the specialties, the magazine said.
"The mission of Best Hospitals is to help guide patients who need a high level of care because they face a particularly difficult surgery, a challenging condition, or added risk because of other health problems or age," Avery Comarow, U.S. News Health Rankings Editor said in a media release.
"Patient survival and safety data, the adequacy of nurse staffing levels and other objective data largely determined the rankings in most specialties." Comarow said another factor was a national survey that asked physicians in each of the 16 specialties to name the hospitals they consider best for the toughest cases in their specialty.
More impartial observers say that the U.S. News rankings are simply the most well-known of a series of hospital awards, all of which have their good and bad points.
"The problem is there are a number of awards given out to hospitals. There is Health Grades and U.S. News, and LeapFrog [Group] and Consumer Reports and they don't always match with one another," says Charles Ornstein, senior reporter at ProPublica, the nonprofit news organization, and president of the board of the Association of Health Care Journalists.
"Oftentimes they strongly disagree with one another and there are a number of cases where they recognize hospitals that are in serious violation of federal and state regulations related to quality of care. It is a concern that there is such a proliferation of rankings that they have almost become hard to decipher."
Ornstein says the U.S. News rankings in particular present "a great marketing tool for hospitals that are recognized."
"It is a name consumers recognize. And hospitals are looking for independent validation of their quality. So, this is something which, even though they may criticize the methods and especially criticize it if their ratings go down, they definitely want to make the list of top hospitals in their area or in the country," he says.
Ornstein says he is troubled that none of the various "rating schemes" use state and federal inspection data in their rankings.
"They certainly use quality measures from Hospital Compare and other places. But they aren't taking into account the findings that regulators have when they go into a facility and use their five senses to identify problems with quality of care, medication errors, wrong side surgeries, and other types of mistakes," he says. "So, it is really important that these rating systems figure out a way to include regulatory findings in the reports."
"Also, whether we like it or not, a lot of the numbers are self-reported by the institutions," Ornstein says. "There are places that have been found to have up-coded their billing to make their patients look sicker than they are, or provided unnecessary surgeries, whether they are stents or back surgeries. And the rating systems don't have a mechanism to take into account those types of things."
Ornstein says the various ranking surveys would better serve consumers if they started using independently verified measures available on Hospital Compare and other Web sites, such as Why Not The Best?, which provide historical information on quality metrics.
"They should look at our Web site, HospitalsInspections.org, which incorporates information about federal deficiency reports against hospitals. There is also information available in every state on state inspections of those hospitals," he says.
"So, if you have an acute condition you are not going to do a ton of research. You are going to call 9-1-1 and be taken to the nearest hospital. But if you are looking for a hospital for a knee replacement or a hip replacement or some elective procedure, there is an array of sites that are trying to draw attention to patient safety at hospitals. That has to be something that is very much in the mix as you think about what hospital you want to go to."
Richard "Buz" Cooper, MD, a healthcare economist at the University of Pennsylvania, calls the U.S. News list "an old game, but it has some merit for what it actually measures."
"It lists the hospitals in which various specialties are highly regarded nationally, and the one with the most is #1. These are places where specialists elsewhere in the country trained, and they hold them in high regard. They are also places that specialists and generalists refer their most complex patients. So, they deserve recognition," Cooper said in an email exchange with HealthLeaders Media.
"But other hospitals are just as good in the vast majority of circumstances. Yet even there, there is a pecking order. For a serious problem, the highly developed community hospital is a better place to go than the 20-bed rural hospital."
Tenet Healthcare's deal to acquire Vanguard Health strengthens Tenet's ability to make acquisitions of not-for-profit hospitals and "might prompt smaller, stand-alone hospitals to consider some sort of alignment," Moody's Investors Service says.
Tenet Healthcare Corp.'s $4.3 billion acquisition of Vanguard Health Systems, Inc. is a credit negative for not-for-profit hospitals, particularly for smaller, stand-alone hospitals that will have to compete within the service areas of the soon-to-be much larger for-profit company, Moody's Investors Service says.
"The reality is this just puts a very effective competitor in their back yard or their front yard, potentially," says Beth Wexler, vice president and senior credit officer at Moody's. "Bigger picture, these smaller hospitals that might have significant capital needs don't necessarily have great leverage with payers or alignment with physicians, particularly when you are talking about markets that are more secluded or rural or difficult to recruit to. They are going to be more and more challenged to have an operating platform that is sustainable."
A Moody's analysis notes that the planned acquisition "consolidates two large and powerful systems into a bigger company with pro forma revenues of $15 billion as of 31 March that will increase competition, particularly for smaller standalone NFP community hospitals that operate in the Tenet and Vanguard markets."
When the merger is finalized, Tenet will operate 77 hospitals in 30 markets, which includes Tenet's 49 hospitals in 24 markets and Vanguard's 28 hospitals in six markets.
Moody's says that "the potential shared savings and combined resources will allow Tenet to engage in new and enhanced competitive endeavors that could threaten NFP hospitals, especially those with fewer resources. In recent years, Tenet has diversified its business with financial consulting services to hospitals and other healthcare-related businesses. Both Tenet and Vanguard have aggressively expanded their outpatient presence and often compete with similar ambulatory strategies as NFP hospitals."
Moody's also notes that the merger "strengthens Tenet's ability to make acquisitions of NFP hospitals. Such acquisitions are typically credit positive for target hospitals, particularly distressed institutions, as the acquisition typically results in 100% redemption of the target's outstanding bonds."
Wexler says the Tenet/Vanguard merger might prompt smaller, stand-alone hospitals to consider some sort of alignment, "whether it is clinical alignment or strategic alignment around certain services, or just looking for the protection of a deeper pocket."
"Each market is different and will somewhat dictate what is needed but it is more and more challenging," she says. "Reimbursements are declining. Volumes are declining. To the extent that these are not really high-acuity hospitals to begin with they are going to be more challenged to keep the volumes, the heads on the beds, which is not the game anymore. Having an effective competitor in the market with deeper pockets and a greater expanse, taking that leveraging power of the two for-profit companies and having them come together, just makes these for-profits more effective competitors in these marketplaces where these independents are already feeling pressures and challenges."
HMA Fixes July 18 as Record Date for Shareholders in Glenview Vote
Health Management Associates, Inc. has fixed July 18 as the record date for Glenview Capital Management's consent solicitation, which gives shareholders of record on that date the chance to choose whether to replace sitting HMA directors with the nine nominees put forward by Glenview.
Glenview, which owns 14.6% of HMA common stock, issued a notice to shareholders that any shares on loan on July 18 will not be eligible to consent.
Glenview, HMA's largest shareholder, filed documents with the Securities and Exchange Commission calling for the replacement of its board of directors.
In the SEC filing, Glenview says, "…[W]e are setting forth a path that we believe creates the strongest future for HMA's patients, employees, and investors while minimizing the risk to each vital constituency. We suggest HMA shareholders consent to fully reconstitute the Board…"
Glenview recommended replacing the board with "highly qualified, independent, newly elected directors" which it dubbed the "Fresh Alternative."
Headquartered in Naples, FL, HMA operates 71 healthcare organizations in 15 states. The fight for control of the company comes as Reuters reports that rivals of HMA, including Community Health Systems, are discussing a potential deal to buy the $4 billion hospital operator.
Carolinas HealthCare System to Buy Stanly Health Services
The board of directors at Stanly Health Services has agreed to sell the Albemarle, NC-based health system to Carolinas HealthCare System after negotiating a deal that includes $70 million in upgrades and other investments over the next 12 years, the two systems announced.
If the deal is approved by state regulators and the Carolinas HealthCare board, the existing management services agreement between the two health systems that has been in effect since 2009 will be cancelled and the transfer of ownership will become effective Oct. 1.
Financial terms of the deal were not disclosed, but Carolinas said it will spend $70 million over 12 years to improve patient care services and facilities within Stanly. Targeted investments include an upgrade of the information technology systems, expanding the intensivist program at the 119-bed Stanly Regional Medical Center, expanding the emergency department from 18 to 28 beds, patient room improvements, and building an urgent care center in Albemarle.
"As board members, our top priority is to ensure the long-term sustainability of our organization so we can continue to provide healthcare services of the highest quality well into the future," Stanly board chairman Larry Baucom said in prepared remarks.
"Extensive due diligence and evaluation went into this decision and the board believes that formally becoming a part of Carolinas HealthCare System is in the best interests of our patients, our employees, our physicians and our community. In this time of tumultuous change in healthcare we are now aligning our two systems to meet future challenges and opportunities."
Carolinas HealthCare System will assess medical staff needs and recruit physicians to Stanly County. Two members of the Stanly Health Services Board of Directors will be appointed to a new SHS board, and the remainder will be appointed by Carolinas HealthCare System to a newly created advisory council.
St. Joseph's to Align with CHE Trinity Health
St. Joseph's Hospital Health Center will join CHE Trinity Health – the nation's second-largest Catholic healthcare system -- following the signing of a non-binding Letter of Intent by their boards, the two organizations announced.
Financial terms were not disclosed.
If the deal is finalized, it would change ownership of Syracuse, NY-based St. Joseph's from the Sisters of St. Francis of the Neumann Communities to Catholic Health Ministries, the entity that sponsors CHE Trinity Health. CHE Trinity Health was formed in May 2013 when Catholic Health East and Trinity Health merged operations in 21 states.
"When CHE and Trinity Health consolidated, we saw a new organization of which we wanted to be a part because of the promise its new ministry offers," St. Joseph's CEO/President Kathryn Ruscitto said in prepared remarks. Ruscitto said the sale will give St. Joseph's to access the resources and economies of scale provided by a large health system while retaining some sense of autonomy.
"Most importantly, St. Joseph's will retain its governance structure and continue to operate locally, while gaining additional support from the breadth of CHE Trinity Health's combined strength, educational opportunities and best practices," Ruscitto said.
Sister Roberta Smith, general minister of the Sisters of St. Francis, said "the Sisters of St. Francis fully support St. Joseph's decision to align with CHE Trinity Health. We strongly believe CHE Trinity Health will provide a strong vision, bound by faith, for the future of St. Joseph's and the benefit of the Central New York community. We remain committed to the mission of St. Joseph's and will continue to lend our spiritual support for the compassionate good works of the institution."
The two systems said they will work together during a due diligence period over the next several months before finalizing the sale.
St. Joseph's Hospital Health Center includes a 431-bed hospital and healthcare system that provides services to patients in 16 counties in Central New York State. CHE Trinity Health is in 21 states across the nation with 82 hospitals, 89 continuing care facilities and home health and hospice programs that provide nearly 2.8 million visits annually. It employs more than 87,000 people, including 4,100 employed physicians.
A report commissioned by the Parkland Health & Hospital System board of managers in Dallas makes a score of recommendations for improving governance practices at the troubled safety net health system.
The Parkland Health & Hospital System board of managers this week made public an outside consultant's report whose 20 recommendations include expanding the seven-member board to 11 members.
The report also recommends that board members at the Dallas-based public safety net system serve three-year terms instead of the current two-year terms, receive more training to better understand and perform their board duties, and that a "visitors committee" of outside observers serve as advisors to the board.
"These recommendations, taken together, provide a comprehensive road map for the board as we develop a sustainable governance model that is appropriate for a complex billion-dollar plus public safety net health system in the 21st century," Parkland Board of Managers Chair Debbie Branson said in prepared remarks.
The report was commissioned in May 2012 by the board, which hired The Saranac Group LLC consultants. Saranac issued the report in March, but the Parkland board put the report on its agenda this month, at which point the board voted to accept the report. The next step will be to start discussions on the individual recommendations, none of which have yet been implemented or rejected, Parkland officials said.
Some of the recommendations, such as the reorganization of board committees can be done through board action alone. Others, such as expanding the size of the board, will require legislative approval because Texas state law limits the size of governing boards for publicly financed hospital districts to no more than seven members.
"A great deal of research and reflection went into these thoughtful recommendations, and the board is committed to raising the governance bar for large and complex public safety net health systems," Branson said.
"It is about our professionalism, performance and accountability in fulfilling our oversight responsibilities. We will be more responsive to the needs of Parkland and its patients, as well as the expectations of the Dallas County community, that's the end-game here. We want to create a governance system that will serve Parkland well for generations to come."
The report comes as Parkland braces for a rigorous inspection this summer by surveyors from the federal Centers for Medicare & Medicaid Services, which was prodded into action after the February 2011 death of a patient in the hospital's psychiatric emergency department. The health system has been under a corrective actionfor more than two-years for myriad quality and patient safety concerns.
In 2011, CMS placed Parkland under a systems improvement agreement that allows it to continue to receive Medicare reimbursements as long as a third party is onsite to monitor and facilitate changes that need to be made.
The administrative burden of being a physician continues to fuel discontent among doctors. More than a third report having a negative outlook for the profession, and the majority would not recommend it as a career choice.
Nearly 60% of physicians wouldn't recommend the profession to young people, a survey shows.
The various sources of the doctors' discontent include decreased autonomy, lower reimbursements, administrative and regulatory hassles, corporate medicine, litigation fears, and longer work hours, much of which has meant that they're spending too much time away from patients.
Looking ahead, 36% of the 3,456 physicians who responded to a survey conducted this spring by Atlanta-based physician staffers Jackson & Coker reported a negative outlook for the profession, while 16% were favorable and 48% cautious.
"What we have begun to find is that pretty much across the board the physicians are becoming a little disenchanted with the business of medicine," says Edward McEachern, vice president of marketing Jackson & Coker.
"Not the practice of medicine, but the business of medicine, because of this overwhelming administrative burden that is very difficult for them to work through and still practice good patient care medicine. It's to the point where we ask 'would you be willing to recommend the medical career as a position to the younger generation' and for the first time we've really begun seeing them not recommend it."
"They are saying 'with all the investment I have to have in my education and all of that is the outcome really worth it?' They are telling these young people 'Hey this isn't the place to go. Stay in healthcare. It's a great industry. Just don't become a physician.'
If you look at (Certified Registered Nurse Anesthetists) versus anesthesiologists the money is almost the same, but the risk for the CRNA is dramatically less in terms of liability, the cost of the education, etc. So all of a sudden when you are looking at the balance you think 'I will just become a CRNA and I won't have those sleepless nights, but I am making a large percentage of what the doctor is making.'"
>>View report
Source: Jackson & Coker
McEachern says the movement toward employed physicians may ease some of the concerns about paperwork and haggling with insurers, but that it also creates its own sets of problems.
"One of the motivations for physician relocation at one point was dealing with immediate income versus potential income," he says. "What happened is 20 years ago, when we did this survey, potential income was among the highest ranking motivators. Now it is immediate income and the reason is doctors aren't building equity in a practice anymore like someone building equity in a home they plan to sell in 20 years from now. Even though employment model has less overhead and risk, you also aren't building any equity in your own future. So you have to take all the money on the table now as opposed to building a practice."
Scott M. Manning, director of HR/Provider Recruiting at District Medical Group, the largest physician group in Phoenix, AZ, with more than 300 providers, says he senses a lot of job dissatisfaction among physicians although the levels cited by the Jackson & Coker survey "sound a little high to me."
"But I am not at all surprised that there are a percentage of docs who don't see medicine to be as good a career today as they did 20 or 30 years ago," says Manning, who is also president of the Association of Staff Physician Recruiters.
"It is kind of a generational thing. If you were to talk to docs who came out of training 25 or 30 years ago the vast majority of them would go out and join a small group of two or three docs, they would hang a shingle and open their own practice. For those folks things like Obamacare and expanded Medicaid or more government rules are a definite dissatisfier. They result in lower rates of reimbursements. They also result in less control over how you decide to run your practice. But it is not like it is any one thing such as Obamacare. This has been going on for many years. If you went back a few years, you'd see the same thing although the percentage wouldn't be this high but that is probably true of the docs who are older and heading towards retirement age."
Manning says dissatisfaction among older physicians will not necessarily affect the decisions of younger people to enter medicine.
"The folks who are coming into the business today know what they are getting into," he says. "Most of them tend to lean towards employment instead of being out on their own. You see the numbers of physicians who prefer to have someone else run the business so they don't have to worry about the overhead."
Even with all the carping by physicians, Manning says it remains a good living. The key is to ensure that would-be doctors understand what they are undertaking from the onset.
"You have to educate the people on what the career is today, not what it was 30 years ago, and emphasize the positive things about being a doctor today which are still very much what they were before," he says. "If you are going into the business because you want to take care of people and make a difference it is still a great business. If you are going into it because you want to make a good living it's still a great business. Will you make as big a percentage difference over the norm than maybe you did 30 years ago? Maybe not. Maybe the gap is closer. But physicians still make a very nice living."
McEachern acknowledges that disgruntled physicians could be more inclined to answer questions about happiness and job satisfaction and that their responses could be a way of venting the frustration and uncertainty that comes with healthcare reform and other fundamental shifts in care delivery, employment, and reimbursement models.
"That is the blowing off steam part. That is our theory. There seems like a lot of frustration tied to that uncertainty," he says. "What we have found is that autonomy and satisfaction seem very closely linked. What does that mean? We really don't know the answer yet. We are still waiting to get a few years down the road to see. As more and more doctors choose employment they are still going to relinquish some autonomy. Are we going to see an increase in satisfaction and employed physicians over the years or is it going to flame out just like it has with private practice doctors?"
Surgical residents who completed a year in rural practice were more likely to enter general surgery practice than those who did not. They were also more likely to practice in areas with populations of less than 50,000, an Oregon Health and Science University study shows.
Evidence suggests that a good way to lure young physicians into rural practice is to provide them with that experience while they are medical residents.
A new study out of Oregon this month in JAMA Surgery, for example, finds that exposing fourth-year surgery residents to rural practices increases the likelihood that they will practice general surgery in a similar location, even if their initial plans were to further specialize or settle in more-urban areas.
Karen Deveney, MD, program director for OHSU's Department of Surgery
The study reviewed the records of 70 surgical residents Oregon Health and Science University in Portland who completed the general surgical residency at OHSU and entered practice since the rural rotation began in 2002. The numbers are small, but the study found that residents who completed the rural year were more likely to enter general surgery practice (10 of 11) than those who did not (28 of 59). They were also more likely to practice in a site of population less than 50,000.
Most residents who completed the rural year (6 of 11) entered residency with a desire to practice general surgery. Of the residents who entered training with a specialty career in mind, four of five who completed the rural year are practicing general surgery, while 13 of 45 who stayed at OHSU's university program for the entire five years are in general surgery practice.
The study's lead author, Karen Deveney, MD, program director for OHSU's Department of Surgery, says a rural rotation exposes medical residents to a "sense of community" that often isn't as well defined in urban areas.
"You have a more long-term relationship with a lot of your patients than is often the case in the higher-urban areas, particularly in a specialty where you have brief encounter to take out the gallbladder and you see them a couple of times and they are gone," Deveney says.
"In a small community you take care of them. You take care of their mother and father. You take care of their kids. You see them in the grocery store. You see them when you're getting your car fixed. You end up having this sense of community and people kind of seek that. A lot of our whole hectic life, particularly in urban centers has become fairly isolated and so, this combats that."
"The other thing is that you feel comfortable with a greater variety of procedures and diseases and things and that gives a sense of accomplishment. Sometimes in the urban academic medical centers we are sort of—brainwashed is too harsh a word—but influenced that you can't know it all and so you should focus more and more on a smaller and smaller area."
"Then you get such fragmentation of care that you become an expert in a small thing but that over the long term is less satisfying because it also gets confining. If someone goes into a rural area to do training and practice they see you really can perform at a high level and have a good capability of taking care of a broad range of problems capably."
Many of the nation's taxpayer-funded medical residency programs, most of which are located in urban settings, have come under fire for their failure to expose residents to rural rotations. Even though 20% of Americans live in rural America, a recent study from George Washington University School of Public Health and Health Services found that only 4.8% of new physicians said they planned to establish a practice in a rural area.
The GW study examined the career paths of 8,977 physicians who had graduated from 759 medical residency sites from 2006 to 2008. The researchers found that 198 of 759 institutions produced no rural physicians during the study period. And 283 institutions graduated no doctors practicing in the Federally Qualified Health Centers that serve low-income or destitute patients in underserved urban and rural areas.
Deveney says the nation's residency programs are creating "such a geographic mal-distribution that the urban areas are saturated and the competition of specialists in urban areas is fierce."
"It's counterproductive, particularly in Midwestern and Western states where there is a large expanse of rural towns and people. The urban programs really need to pay attention to the needs of their state. That is kind of why they were set up in the first place," she says.
Even if new general surgeons practice in exurban or smaller cities, that is still preferable to having a glut of physicians practicing in urban centers. "We used towns of 50,000 as the cutoff in our study but there are some who went out to general surgery practice in smaller towns that are between 50,000-100,000," Deveney says. "Those are still closer to where the real need is than in the middle of Portland or Chicago or Seattle."
Deveney readily concedes that the numbers of residents in the Oregon study who gravitated towards rural settings come nowhere near meeting demand. Even so, every little bit helps, and she says the Oregon rural residency rotation could be a model for other states.
"Our program only produces a small number but if you multiplied that by 250 training programs that each produced a couple that would increase the number," she says.
"Increasing the number of trainees entering general surgery practice in rural areas won't take care of the shortage entirely because we don't produce enough general surgeons every year in the entire country—even if all of them went into rural surgery—to do the job. But between our model within a training program and one or two existing programs that have carved out an actual rural track residency program we're mostly saying 'hey if you do this it will work and here is how you do it.'"
"Anything we can do to give greater exposure to the joys of a more generalized practice will have an effect on redistribution."
