Nestled in the massive immigration bill that's being debated now in Congress are a handful of provisions that could ease the process that allows foreign-born physicians to practice in underserved areas across the United States.
The sweeping Border Security, Economic Opportunity, and Immigration Modernization Act (S.744) is more than 850 pages long and covers everything from border security to passport fraud. However, the sections dealing with revisions to the Conrad State 30 Program for recruiting foreign-born, but U.S. trained physicians could be of particular interest to rural and urban hospitals and physician practices that have had little luck recruiting U.S.-born physicians for their underserved patients.
"I am excited about this bill for many reasons, but the section on physicians is particularly good," says Carl Shusterman, a long-serving immigration attorney based in Los Angeles. "We've had the Conrad program since 1994 which allows each state to sponsor 30 foreign physicians each year to go to rural and urban medically underserved areas where they can't get Americans to practice."
"All in all it is a good program and over 1,000 physicians a year do get placed in these underserved areas," he says, "but like any program there are a bunch of flaws that we have being trying to correct for 20 years and this bill would correct most of them."
Shusterman says it's hard to predict if the bill will pass in the hyper-partisan Congress, where immigration is a divisive issue. The bill recently passed the Senate Judiciary Committee on a 13-5 vote and floor debate could begin this week.
"The Senate introduced over 300 amendments to the bill but I don't think any of them were concerning the physicians' part of the bill. That is relatively non-controversial," he says.
"What is controversial is it legalizes 11 million people that are undocumented. That's where the problem is as far as this passing. In the Senate I can almost guarantee it will get one pass by the end of the month. The big debate is will it get 60 votes or 70 votes. There are about five Republicans who are definitely on board and pretty much all the Democrats but if they can get 70 they figure that will have an influence on the House. If they can get about 30-40 Republicans in the House to sign on it's going to be a done deal, but that is the big 'if' now in the House of Representatives.'"
Shusterman provided a synopsis of the reforms proposed in the immigration bill.
Proposed Changes to the J Visas and Waivers:
The pending legislation would make the Conrad program a permanent part of the immigration law. J status for foreign-born physicians completing medical residencies/fellowships would be classified as a "dual intent" status, similar to H-1B and L-1s.
A physician could no longer be denied J status on the ground that he or she did not intend to return to his country of origin. Spouses and children of J-1 physicians would no longer be subject to the two-year home residency requirement.
The number of Conrad waivers available to a state could be raised in increments of five depending on the usage of waivers in various states during the previous year. In addition, the number of J waivers available to physicians working in academic medical centers outside of medically underserved areas could be raised by three per year under certain conditions.
Physicians who received J waivers would no longer be required to work in H-1B status, but could work in any immigration status for which employment is authorized. To prevent foreign-born physicians from being exploited, J waivers would not be granted unless the physician's employment contract contained the following clauses:
1. The amount of "on-call hours" per week and the compensation for such;
2. The amount of malpractice insurance provided to the physician and whether the employer will pay for this;
3. All work locations, and a statement that the employer will not add work locations without the approval of the state or federal agency requesting the waiver;
4. The contract may not contain a "non-compete" clause.
If a physician's J waiver were denied under the Conrad program because the state had used up all of its slots for the year, the physician could obtain a six-month work permit if he or she agreed to seek a J waiver from a state which has not used all of its J waivers. After that, the physician could extend his or her work permit from the time that the employer in the new state filed a Conrad waiver until the DHS either granted a change of status or denied the waiver application.
The proposed law also provides that when the U.S. Citizenship and Immigration Service determines that "extenuating circumstances" exist, the physician could change employers during the three-year required period of employment in an underserved area.
"This is important because some employers have taken unfair advantage of physicians who they have sponsored for J waivers," Shusterman says. "For example, some employers have failed to pay a physician at the prevailing wage or have insisted that a physician work outside of the designated medically-underserved area for 40 hours per week. If the physician does not claim 'extenuating circumstances,' he or she needs not only to complete the 3-year period in a medically underserved area, but also an extra year for each termination."
The proposed law would also do away with an impractical requirement that the physician begin working within 90 days of receiving the J waiver. Instead, the proposed law would require physicians to start working in 90 days only after the latter of the following three dates: 1) After the J waiver is approved; 2) After completion of graduate medical education or training; or 3) After receiving nonimmigrant status or an Employment Authorization Document.
Proposed Changes to H-1Bs and Green Cards
When a physician completes his or her residency/fellowship in cap-exempt H-1B status, and an employer has submitted a cap-subject H-1B petition on his behalf, his H-1B status would automatically be extended to Oct. 1st so that the physician does not become out-of-status or unemployable between July and October. However, if the physician's H-1B petition is rejected, denied or revoked, his or her status and employment authorization would terminate after 30 days, Shusterman said.
Physicians who qualify for National Interest Waivers by completing the five-year service requirement in a medically-underserved area or for the Veterans Administration would be granted green cards without regard to numerical limitations. This would occur whether a physician completed the five-year requirement before or after the enactment of the (Comprehensive Immigration Reform) bill.
The spouse and children of a physician would also be exempt from numerical caps whether the physician obtains a green card through an NIW or through Program Electronic Review Management, Shusterman said.
Per-country limitations would be eliminated for the employment-based green card categories, which would dramatically reduce the time that it now takes physicians born in India to qualify for green cards.
"All of these changes would make it considerably easier for internationally trained physicians to work and live in the United States, enhancing the overall number of physicians at a time when doctors are in short supply," Shusterman says.
By opting not to expand Medicaid, Texas is passing up an estimated $90 billion in federal funds over the coming decade, leaving its healthcare providers, especially hospitals, in a tough financial spot. Rural care facilities are especially vulnerable.
The Medicaid enrollment expansions that take effect on Jan. 1, 2014 under the Patient Protection and Affordable Care Act are expected to extend health insurance coverage to as many as 17 million Americans, depending upon who's doing the calculations and how many states eventually sign on.
For healthcare providers in most states, the expansion represents a windfall of billions of dollars. The federal government will pay for the entire cost of the expansion through 2016. After that, the cost will gradually shift toward the states, but the feds will still pay 90% of the cost after 2020.
The expansion offers coverage to people who earn as much as 138% of the federal poverty level, which is $15,400 for one person and $31,800 for a family of four.
Given that hospitals and healthcare are huge economic drivers, those new Medicaid dollars could prove to be as valuable for economic activity and job growth as they are for improving population health. The Medicaid money will also free up local property and sales taxes that would otherwise be used to prop up charity care.
Under such circumstances, expanding the Medicaid rolls would seem like a no brainer. After all, the need is already there. People are going to get sick and need medical care regardless of whether or not they are insured. That care is going to cost money. Medicaid expansion simply answers the question of who is going to pay for it.
However, as we have seen over the last three years, the politics of "Obamacare" are so toxic that at least 14 states have said they will not expand coverage. "If the discussion is purely about money, it's hard to just walk away," says Matt Salo, executive director of the National Association of Medicaid Directors. "But this is not just about money. This is very much about politics and ideology."
More than any other state, Texas has come to represent "not just 'no' but 'hell no'" opposition to Obamacare, even though the Lone Star State has the highest percentage of uninsured citizens in the United States. It has been estimated that as many as 1.7 million Texans could gain coverage with the expansion, which would also funnel about $90 billion in federal dollars into the state over the next decade.
Governor Rick Perry and other key Republican leaders, however, have led the opposition, with Perry calling the expansion plan "a misguided, and ultimately doomed, attempt to mask the shortcomings of Obamacare. It would benefit no one in our state to see their taxes skyrocket and our economy crushed as our budget crumbled under the weight of oppressive Medicaid costs."
Instead of another federal mandate, Perry has called for "the flexibility to care for our own in a manner that makes sense both effectively and financially."
The problem is that the Texas legislature, which meets once every two years, adjourned this spring without taking any action on an alternative to the federal expansion plan. They could call a special legislative session to address the expansion, or it could be done administratively through the Perry administration, but those options appear unlikely right now.
As a result, when Jan. 1, 2014 rolls up, "the poorest Texans will be left out," says Anne Dunkelberg, associate director of the nonprofit Center for Public Policy Priorities.
"If they live in a big city they might be able to get some help from their local hospital district and what group gets served depends on what city they live in. That is going to be funded by 100% local property tax dollars instead of 100% federal funds. And if they live in a more rural county they may have no options. There may be no public program that is going to help them."
Dunkelberg says various studies have estimated that Texas will lose about $6 billion [PDF] a year over the next decade and beyond in federal subsidies because it won't expand the Medicaid rolls. "The funds would have created hundreds of thousands of jobs, the estimates ranged from between 215,000 to 300,000 jobs a year," Dunkelberg says.
"The amounts of money that are potentially going through communities—urban and rural—are fairly staggering and potentially having a big boost in terms of economic development in some parts of the state and certainly offsetting large amounts of uncompensated care that is currently funded with local property tax dollars. We are leaving that money on the table."
Left holding the bag, of course, will be healthcare providers, especially hospitals. They get the worst of both ends. They don't reap the benefit of seeing more insured patients, and their reimbursements for Medicare and Medicaid are being cut through the federal budget process and sequestration mandates.
"It's a difficult financial model," says John Hawkins, senior vice president for government relations at the Texas Hospital Association. "Trying to balance those cuts without being able to expand coverage is going to be difficult going forward."
In all likelihood, dwindling funding could mean that some smaller or financially strained hospitals will close. "For rural hospitals that is probably more the reality. In other areas you will see hospitals limit services which can be equally as challenging for their communities," Hawkins says.
"You are going to have worse health outcomes, particularly in areas where facilities have to limit services. Folks will have to drive farther. Your workforce isn't going to be as productive because of lack of coverage. The bigger impact will be poorer health outcomes and less-productive state."
It's not just the usual public advocacy groups who are calling for expanding the Medicaid rolls. Leading business groups in Texas have called for some sort of action. Hawkins says there has been a "continued drum beat" for expanding the rolls from a wide swath of special interest groups that recognize what is at stake.
"Certainly folks are concerned about the level of uninsured. They are concerned about the cost of healthcare. They understand the cost shift to taxpayers and the private market. There is a lot of discussion about it, but the general political headwind in this state against Obamacare is difficult to overcome," he says.
Perhaps the best hope for states that are ideological entrenched against Obamacare lies with the so-called Arkansas Medicaid Model, which would use Medicaid expansion money to subsidize premiums for commercial plans purchased through health insurance exchanges. That proposal is still being vetted by the Centers for Medicare & Medicaid Services.
It's not clear if Texas would adopt a similar plan. Even if it did it's not clear if the state could expand its rolls by Jan. 1, 2014 deadline.
Hawkins remains optimistic that some sort of solution will be reached.
"Actually, in retrospect, we are pleased the debate got as far as it did where we were actually talking about alternatives because early on it looked like folks were being reticent even to have that discussion given the will of the leadership," he says. "But we did advance the discussion even to the point where if things in other states continue to move forward we may have a chance to revisit this administratively."
The volume of mergers and acquisitions in healthcare is "consistent with efforts to try to achieve economies of scale… and changes in demand and particularly to realign and enhance services," says a report from the American Hospital Association.
The American Hospital Association contends that "the overwhelming majority" of hospital consolidations are "pro-competitive," improve quality and access to healthcare at a lower cost for the communities they serve.
And despite the seemingly daily accounts of mergers and acquisitions in the hospital sector, an AHA-commissioned report from FTI Consulting found that only 551 community hospitals—about 10% of all community hospitals—were involved in consolidations from 2007-2012 with an average of one or two hospitals acquired in most transactions. The report (PDF) was published Monday.
"It's a very dynamic industry with a large range of pressures in efforts to really realign care in the best site, with the best quality and most efficient cost of care delivery," Meg Guerin-Calvert, senior managing director at FTI, told reporters at a press conference Monday.
"While it is diverse, the common theme I would point to is that many of the acquired hospitals are smaller and they are standalone[s], suggesting that this structural change is consistent with efforts to try to achieve economies of scale and scope to try to respond to excess capacity and changes in demand and particularly to realign and enhance services. It's also consistent with the fact that the vast majority of transactions that have occurred in the last six years really have not received very intense antitrust scrutiny and the vast majority have been approved."
Monday's report may have been the AHA's attempt to change the media narrative of late. The nation's hospitals have taken it on the chin in the last several weeks, starting with the mid-May disclosures by the Centers for Medicare & Medicaid Services that showed huge and seemingly inexplicable variations in what hospitals charge for the same inpatient procedures.
On Sunday, The New York Times ran a front page story comparing the significantly higher price of medical carein the United States when compared with other countries. And on Monday CMS released for the first time hospital pricing data for 30 types of hospital outpatient procedures.
The health insurance industry has long taken a dramatically different view of hospital consolidations and says several studies have shown that it drives down competition and increases the cost of care while not necessarily improving access.
"The evidence clearly demonstrates that increasing provider consolidation is leading to higher prices for medical services and higher health care costs for consumers and employers," Robert Zirkelbach, spokesman for America's Health Insurance Plans, said in an email exchange.
Melinda Hatton, AHA senior vice president and general counsel, told the media that the report was needed because "there has been a lot of misinformation about what is going on in the hospital field particularly around mergers and acquisitions. This really fills a gap."
"You hear a lot about consolidation but you don't ever really see the facts of consolidation and this sums it up in a compelling way," Hatton says. "For the last six years there have only been 20 mergers or acquisitions (in service areas) where they started with fewer than five hospitals. In every other area there were more than five hospitals and plenty of competition. We looked at the 20 hospitals… and there were real tangible benefits to having to hospitals that are relatively close together come together for the community. When you hear people talk about consolidation, you need to talk about the particular hospital transaction to determine how it benefits the community… even though the community may be losing some putative competition."
AHA Executive Vice President Rick Pollack says the movement toward hospital consolidation "is all a part of trying to transform the whole delivery system to make it more efficient and improve care to get access to capital to keep struggling entities open so they can provide access."
"Sometimes hospitals would go bankrupt if you didn't have these kinds of arrangements. Another reason they are occurring is because we need to reconfigure services to reduce overlap and duplication that is necessary to help rationalized the delivery system."
"We need to achieve economies of scale for purchasing. A big reason is people need to come together to access capital to be able to invest in new technology and upgrade facilities and buy electronic medical record systems. It's not really about pricing all the time at all."
For the second time in three months, Bronx-based Montefiore Medical Center has announced it will buy a financially troubled suburban hospital. This time it is Sound Shore Health System, which operates two hospitals in New York.
Financially troubled Sound Shore Health System was thrown a lifeline last week when Montefiore Medical Center petitioned a federal bankruptcy court for permission to buy the two-hospital system. Terms of the deal were not disclosed.
Sound Shore Health System includes the 252-bed Sound Shore Medical Center of New Rochelle, and the 196-bed Mount Vernon Hospital. Montefiore said in a media release that it plans to keep open both hospitals and a skilled nursing facility. Sound Shore filed for Chapter 11 protection last week, just hours before Montefiore petitioned the court.
"Providing ongoing jobs and supporting the local economy are important benefits of a vital healthcare system," Steven M. Safyer, MD, president/CEO of Montefiore Medical Center, said in a media release."We are making a long-term commitment to lower Westchester to support and improve the health of area residents as well as the health of the local economy."
John Spicer, president of Sound Shore, told WVOX in Westchester that Montefiore has agreed to invest "a minimum" of $60 million for renovations.
"(A) new patient care unit, a number of infrastructure improvements, meaning new boilers, new roofs. So they're committing a significant amount of resources to upgrade facilities—both at Mt. Vernon and Sound Shore," Spicer said. "We are going to go through a restructuring process and they're putting significant resources behind that, in the $60 million-plus range. So they're committing a lot of money."
Spicer told the radio station that Sound Shores physicians would warm to the plan as they learned the details. "The more they are finding out… and we've become a little more public with everything, the comfort level is increasing," Spicer said.
"Montefiore has said out loud that they are committed to the private practice of medicine and our voluntary attending physicians, Montefiore has a couple of mechanisms within their structure, meaning the Montefiore IPA – which is an Independent Practice Association – which helps doctors improve their rates with insurers. And I think more and more our physicians are very comfortable with the entire process."
With the promise that both hospitals would remain open, the deal appears to have the support of the heavily unionized workforce at Sound Shore. The combined new system will include about 8,500 unionized staff. "Patients in Mount Vernon and New Rochelle deserve access to hospitals where they live," said Jill Furillo, RN, executive director of the New York State Nurses Association, which represents nurses at Sound Shore.
"Montefiore has committed to keeping Mount Vernon and Sound Shore hospitals open for care. We look forward to working with Montefiore, patients, and community leaders to preserve and expand healthcare access in our communities."
Adam Powell, a healthcare economist, says he thinks the deal will be approved by a federal bankruptcy judge because the acquisition is a good fit.
"Montefiore Medical Center has a large unionized staff, and may have the competencies necessary to manage the many unionized employees at the former Sound Shore Health System. Secondly, Montefiore may have been willing to take this risk it is rumored to have received the hospitals for a fractional of the value of their physical assets," says Powell, president of the Boston-based consulting firm Payer+Provider Syndicate.
"The push towards value-based care may have also played a role. While the hospitals are not exactly overlapping, they are potential substitutes for people with access to a car. In the long-run, the combined health system may be able to push patients towards lower cost facilities within it to reduce costs. Some types of shared overhead may also be reducible in the long-run."
The deal marks the second time in three months that Bronx-based Montefiore has picked up a suburban hospital at bargain basement prices. In March Montefiore finalized its $15.3 million acquisition of Westchester Square Medical Center, a community hospital in the Bronx that had operated under bankruptcy court protection for nearly seven years.
Earlier this year nearby Westchester Medical Center announced that it had ended six months of negotiations to acquire Sound Shore, claiming in a media release at the time that "Sound Shore appears to have a dramatically different view than WMC about how to best balance resources between investment in improving the Sound Shore/Mount Vernon facilities and the obligations that the Sound Shore System has accumulated over the years."
Spicer assured WVOX that this time the deal with Montefiore would go through. "This deal is done," he said. "It's a merger of the two facilities but when the dust clears, we are a part of Montefiore. We will be part of the Montefiore Medical Center Health System and frankly, they're the lead character here."
In a media release announcing the deal last week, South Shore said the "transaction will not impact the day-to-day operation and our nationally recognized doctors, nurses and staff will continue to serve our patients and provide quality, uninterrupted healthcare. This transition will not change SSHS's status as a not-for-profit hospital system and we will continue to treat all patients regardless of their ability to pay. In the long term, we believe that this acquisition will ultimately strengthen SSHS, leading to growth and enabling us to better serve the southern Westchester communities."
Montefiore operates nine clinics in Westchester and provides specialty care in cardiology, neurology and women's health, such as obstetrics and gynecology, fertility and reproductive medicine, fetal medicine and reproductive genetics. The transaction is subject to regulatory approval and could be completed by the end of the year, Montefiore said.
Advocate Health Care (IL) Finalizes Sherman Health Acquisition
Advocate Health Care on Sunday finalized its acquisition of Elgin-based Sherman Health Systems, which will now be known as Advocate Sherman Hospital.
Based in Bolingbrook, Advocate is the largest health system in Illinois.
Sherman's six other facilities in the Fox Valley will also take the Advocate name. Full integration of the two systems is expected to take about two years, Advocate said in a media release.
During its search for a buyer Sherman met with more than a dozen potential partners and began the due diligence process with Advocate in October, 2012. The deal was approved by state regulators in May.
"From the inception of our partnership discussions, our respect for the Sherman team and their accomplishments and capabilities has only increased," Jim Skogsbergh, Advocate's president/CEO said in a media release. "We share numerous core values; including a commitment to health outcomes and patient safety and a commitment to the communities we are privileged to serve."
Advocate operates 10 acute care hospitals, Illinois' largest integrated children's network, five Level I trauma centers, two Level II trauma centers, the state's largest home healthcare company and more than affiliated 6,000 physicians. Sherman will add seven sites, including a skilled nursing and inpatient rehabilitation facility, approximately 2,200 associates and 600 physicians to the Advocate system.
Advocate said it will not assume liability for Sherman's outstanding debt.
The federal agency's findings, other data, and practical experience suggest that hospitals should brace for a pronounced increase in ED use in 2014 when the ranks of the insured are expected to expand, says a board member of the American College of Emergency Physicians.
Andrew I. Bern, MD, FACEP (Photo Credit: ACEP)
One in five adults visited the emergency room at least once in 2011 and 7% reported two or more visits for the year, the Centers for Disease Control and Prevention reports.
The CDC's 36th annual Health, United States, 2012 report also found that in the decade from 2001 to 2011 both children and adults on Medicaid were more likely than the uninsured and people with private insurance to have at least one emergency room visit in the past year.
Andrew I. Bern, MD, an emergency physician in Florida and a board member with the American College of Emergency Physicians, says much of the CDC report "absolutely validates" what his organization has long been saying.
"The data is debunking the myth that only the uninsured go to the ED," Bern says. "We’ve been saying that for a while but it has not been carried well by the media."
Bern says the CDC data, other reports, and practical experience suggest that hospitals should brace for a pronounced increase in ED use in 2014 when the ranks of the insured are expected to expand by about 30 million people under the Patient Protection and Affordable Care Act.
"If you look at the Massachusetts, which is the basis for the Affordable Care Act, they found their volume of ED visits increased about 9% a year. When Canada instituted similar sorts of coverage their visits went up as well," Bern says. "Wherever this has been attempted to provide universal coverage or near-universal coverage utilization increases unless you provide an infrastructure alternative, such as increasing the primary care physician access."
Bern says it’s becoming apparent that sufficient ED alternatives will not be in place in many parts of the U.S. in 2014 when the ranks of the insured expand.
"You have alternative sites of care being developed but there is not good information on what impact that will have," he says. "Those alternative sites of care include the retail clinics run by nurse practitioners, urgent care centers, and free-standing emergency departments that are popping up in different states. These may ultimately provide different sites of care when people are looking for care urgently but there is no consistent basis. If a patient wants to be sure that they are not going to be turned away the only sure bet they have is the emergency physicians who are under federal law to treat everybody regardless of their ability to pay."
The CDC report also noted that:
In 2009–2010, cold symptoms were the most common reason for emergency room visits by children (27%) and injuries were the most common reason for visits by adults (14%.)
Between 2000 and 2010, 35% of emergency room visits included an x-ray, and the use of CT or MRI scans increased from 5% to 17% of visits.
In 2009–2010, 81% of ED visits were discharged for follow-up care, 16% ended with the patient being admitted to the hospital, 2% ended with the patient leaving without completing the visit, and less than 1% ended in the patient’s death.
In 2009–2010, 59% of ED visits (excluding hospital admissions) included at least one drug prescribed at discharge.
During 2001-2011, the percentage of persons with at least one ED visit in the past year was stable at 20-22%, and the percentage of persons reporting two or more visits was stable at 7-8%.
Bern says the CDC findings are consistent with a RAND Corporation study commissioned by the Emergency Physician Action Fund which shows that emergency physicians are key decision makers for nearly half of all hospital admissions.
RAND found that hospital admissions from the ED increased 17% over seven years, accounting for nearly all the growth in hospital admissions between 2003 and 2009, offset by a 10% drop in admissions from primary care physicians and clinical referrals. Nearly all of the increase was from "non-elective" admissions from the ED—a rate 3.8 times the rate of population growth.
Hospital inpatient care is a key driver of healthcare costs, accounting for 31% of the nation's healthcare expenses. Because of that, the role emergency physicians play in deciding who to admit to the hospital is critical to hospital cost savings, since the average cost of an inpatient stay ($9,200) is roughly 10 times the average cost of a comprehensive emergency visit ($922), RAND said.
"When you look at the overall $2.7 trillion healthcare system and that 31% of that expense is in the hospital and we are integrally involved in 50% of those admissions decisions it points to the value of the emergency physicians in the entire system," he says.
"The things we are proposing in terms of costs savings and integration are important points and our role in the entire healthcare context is one that is very very important to the bulk of that."
A program at the University of Alabama helps students prepare for the rigors of medical school—and careers as primary care physicians.
Mark Christensen, MD, knew he wanted a career in medicine ever since he served as an emergency medical technician with the volunteer fire department while still in high school at his tiny hometown of Toney in northern Alabama.
"I always thought it would be interesting to go the extra step and become a physician," Christensen says. "I enjoyed going into people's houses and taking care of them there and going all the way up to the hospital doors. But I wanted to see that other side of the doors as well and continue that care from inside the hospital throughout their stay."
Now a third-year resident in family practice at the University of Alabama School of Medicine, Christensen plans to return to rural Alabama when he finishes his residency in 2014. In large part, Christensen credits the University of Alabama's Rural Medical Scholars Program with helping him realize his dream of becoming a doctor. Christensen completed the scholars program during his senior year at the University of Alabama at Birmingham and it helped to prepare him for the rigors of medical school.
"They were able to help me because with the rural background and that kind of education I was at a disadvantage compared to some of the students going to bigger schools where they're doing calculus in the 8th grade it seems like," Christensen says. "We just didn't have those resources growing up and I didn't even know what I needed to know. This program definitely helps with that. They saw the potential in me and it turns out, I guess they were right."
Christensen says the tutoring and counseling he received from the program proved to be invaluable. "Coming into college was a rude awakening about how much you needed to study. I had no preparation for that coming in. They really helped you," he says.
"It takes a lot of things to get into med school, MCATs and GPA. A lot of people getting into the program have low MCATs. My MCATS were fine. I probably could have gotten in the regular way, but they help make you a better overall applicant. They understand you have a true desire to do this and they advocate for you to get in."
On Thursday, dozens of recent college graduates and college seniors from across rural Alabama will be interviewed and 24 of them will be selected to become Rural Health Scholars for the coming year. They will spend the time prepping for medical school and shadowing rural providers.
Susan Guin, RN, the associate director the Rural Scholars Program and a nurse practitioner, has been with the program for 17 years. She says interviewers try to find that mix of medical school candidates who can combine solid academics with the relationship-building and communication skills needed to thrive in rural environments.
"The common theme is that they come from a rural area so our selection criteria require that you have spent at least eight years of your life in a rural community. We try to select the student who has the desire to go back for the community and has a sense of family and home and wanting to be involved and immersed in the local community," Guin says.
"We are not necessarily looking for a GPA of 4.0 and an MCAT of 30. That is a great student and a smart person but there are also smart people who may have a 3.3 or 3.4 GPA, but they still do well and can sit down and carry on a conversation. They understand local culture and how to communicate with different people. There is value beyond the typical standardized testing idea."
While the rural scholars are not required to sign any sort of contract, Guin says there is "more of a handshake agreement" that they will commit to rural medicine when they graduate from medical school. The program appears to be working.
"[Within] general regular medical school admissions you are looking at maybe 10% of med students [who] end up going into family medicine/primary care. For us, we've got at least 60%—70% ending up in primary care, which would include family medicine and internal medicine and pediatrics and 90% that are staying in Alabama as practicing physicians. Some are cardiologist and radiologists, but they are still coming through our program and staying in the state. So we are not training physicians and seeing them go to another state. Those numbers alone are way outside the box for the norm."
The Rural Scholars program has proven so successful that it has morphed into a Rural Health Leaders Pipeline with six distinct programs that involve about 150 students of various ages at any given time, and even identifies and recruits 10th graders who've shown an interest in pursuing careers in healthcare.
"We work with them for the nine-month school year, at least having monthly meetings with them. College students, medicals students, and residents interact with the 10th graders to be mentors for students who might be interested in some sort of health profession," Guin says.
A separate program for 25 eleventh graders includes a five-week summer program with courses in chemistry, creating writing, and visits to hospitals and physicians offices. There is also a Rural Minorities Health Scholars program that provides first-year college students with preparatory classes in biology and shadowing healthcare providers.
Although he is committed to practicing in rural Alabama, Christensen says he understands the challenges that come with living in the country.
"It's hard because as we go through medical school we accumulate so much debt. The bill I just got the other day was $187,000. I can defer that because I am in residency for another year, but after that I have to start paying $187,000," he says.
"I don't know what $187,000 is! The most we had in the bank account growing up was $26,000 a year combined. In a rural area, you feel like you want to make up what you are in debt for and then some and so rural areas might not make as much money or you might go into a specialty and they are usually in bigger cities."
"Also as you go through medicine, you decide education is important and you look back at think, 'I was in a rural area and I didn't get a good education and I want my kids to have a better education so I am going to go to a large city where they will get a better education, better cultural opportunities and all that.' So it is hard balancing all of that."
Even with those challenges, Christensen says he's excited about his career path. "The more rural you are, the more skills are in need for all aspects of family medicine, which includes taking care of a kid on the pediatrics floor and then walking over to the ICU to take care of an adult in critical condition and bring them back to life and then you go to your office and treat a family," he says.
"I love that you can practice to your maximum ability. And as long as you are good and passionate about those areas, you will do fine. I put myself against any of those specialists any day."
Gary D. Newsome (Photo credit: Health Management Associates)
In the latest twist for Health Management Associates, the for-profit hospital operator's CEO, Gary D. Newsome, announces he will retire in July. Last week HMA moved to block a takeover bid by filing a shareholders' rights plan.
Just days after launching a shareholders' rights plan to protect Health Management Associates Inc. from a perceived takeover, CEO and President Gary D. Newsome announced Tuesday afternoon that he will retire in July to pursue missionary work in South America.
"I am proud of our accomplishments over the past five years as we've transformed Health Management into a vibrant, innovative company that is well-positioned and on a clear path to great success," Newsome said in prepared remarks.
Newsome has been named by The Church of Jesus Christ of Latter-day Saints to serve as the president of its Uruguay-Montevideo Mission in South America, the HMA release said.
"My family and my faith have always been the most important parts of my life and it is a rare privilege to serve in Uruguay, a place that has remained in my heart since I served my first mission there more than 35 years ago," Newsome said. "I am sincerely grateful for the support I've received from the Health Management Board of Directors, management team, and our associates and physicians."
Newsome's announcement is the latest twist in an eventful week for the Naples, FL-based for-profit hospital chain.
On Friday, just before the long Memorial Day weekend, HMA dropped a filing with the Securities and Exchange Commission stating that its board of directors adopted the shareholders' rights plan to thwart a perceived takeover bid by hedge fund manager Glenview Capital Management, LLC.
Glenview owns 14.56% interest in HMA common stock and in a 13D filing with the SEC on May 6 Glenview said that it "may engage in communications with relevant parties regarding the company and ways to enhance shareholder value, including, but not limited to, the Company's management, members of the board of directors, shareholders or other investors, potential strategic partners, financial advisers and other industry participants."
Pointing to the Glenview filing, HMA in its 8-K filing with the SEC said "the rights agreement is intended to protect the Company and its stockholders from efforts to obtain control of the Company that the Board of Directors determines are not in the best interests of the Company and its stockholders, and to enable all stockholders to realize the long-term value of their investment in the Company."
HMA said that affiliates of Glenview also had filed notice under the Hart-Scott-Rodino Antitrust Improvement Acts on May 22, which "indicates that these affiliates presently intend to acquire, collectively, up to approximately $2.2 billion of the Corporation's outstanding common stock."
HMA's filing, in turn, prompted Glenview on Tuesday to issue a "statement of clarification regarding its holdings" in HMA.
"We feel the 8-K issued by HMA in conjunction with the Board's decision to enact a shareholder rights plan, commonly referred to as a poison pill, may cause confusion regarding our intentions and may lead to undue volatility in the stock price…," the Glenview statement read.
Glenview said its filings with the SEC were intended to comply with provisions of Hart-Scott-Rodino "in order to be in a position to acquire even one additional share of HMA." Further, Glenview said "such an investment size is both beyond our present intention and beyond our present resources available for any single position. Such a filing was required to facilitate even a modest increase in our present holdings. In plain English, we have no present intention or future plan to buy either $2.2 billion of stock or 75% of HMA."
HMA spokeswoman MaryAnn Hodge said Tuesday that Glenview's clarification "will not change (HMA's) shareholders' rights plan. The Board continues to believe that adopting the rights plan at this time is prudent and in the best interest of the company and its stockholders."
Brian Tanquilut, a senior analyst for healthcare services at Jefferies & Company, Inc., says fears that Glenview is mounting a takeover are overblown:
"Glenview is a savvy healthcare investor. It's just a deep value picking strategy and I wouldn't read too much into that," Tanquilut says. "They made a decision to invest in HMA given that HMA is the cheapest hospital stock today. I don't think people thought Glenview was going to try to take over HMA. That's not their M.O. They are a hedge fund, not a private equity shop. They have never been an activist shareholder. People who know Glenview and what they are doing never ever thought it was a takeover strategy, but it was an opportunistic play. It just so happens that because of the size of their investment they had to file and HMA read into it 'Holy cow! They filed for up to $2.2 billion worth of stock and we are a $2.7 billion company.' But for HMA it's the right thing to do on their part, which is to protect their shareholder base."
HMA made no mention of the shareholders rights plan in its announcement of Newsome's retirement, which takes effect July 31.
HMA operates 71 general acute care hospitals in small- to mid-sized markets in 15 states with approximately 11,500 licensed beds, more than 42,000 employees and a medical staff of 10,000 physicians.
Health Management Associates has adopted a shareholders' rights plan to protect the hospital operator and its stockholders from efforts by Glenview Capital Management to obtain control of the company.
Health Management Associates, Inc. has launched a shareholders' rights plan that the investor-owned hospital chain says is needed to block a potential takeover.
In a Securities and Exchange Commission filing Friday Naples-based HMA said the board of directors adopted the rights plan to thwart efforts by Glenview Capital Management LLC to gain control.
"The rights agreement is intended to protect the Company and its stockholders from efforts to obtain control of the Company that the Board of Directors determines are not in the best interests of the Company and its stockholders, and to enable all stockholders to realize the long-term value of their investment in the Company," HMA said in the filing.
Glenview owns 14.56% interest in HMA common stock but filed a 13D filing with the SEC on May 6 suggesting that it would increase its ownership stake and "may engage in communications with relevant parties regarding the company and ways to enhance shareholder value, including, but not limited to, the Company's management, members of the board of directors, shareholders or other investors, potential strategic partners, financial advisers and other industry participants."
HMA noted in its filing on Friday that a Hart-Scott-Rodino Antitrust Improvement Acts was also filed on May 22 by affiliates of Glenview which "indicates that these affiliates presently intend to acquire, collectively, up to approximately $2.2 billion of the Corporation's outstanding common stock."
"In light of Glenview's Schedule 13D filing, as well as its filing under the HSR Act, the Board of Directors determined to implement the Rights Plan," HMA said in its filing. "The Board of Directors believes that the Rights Plan will help promote the fair and equal treatment of all stockholders of the Corporation (not just Glenview) and ensures that the Board of Directors remains in the best position to discharge its fiduciary duties to the Corporation and its stockholders. The Rights Plan adopted by the Board of Directors, which has a short one-year term and a 15% threshold, reflects the Board of Directors' effort to balance these concerns with best corporate governance practices."
HMA operates 71 general acute care hospitals in small- to mid-sized markets in 15 states with approximately 11,500 licensed beds, more than 42,000 employees and a medical staff of 10,000 physicians.
HMA was the subject on an unflattering report on 60 Minutes last December alleging that the company pressured physicians to admit patients regardless of their medical needs in order to boost profits. Producers for 60 Minutes "talked to more than 100 current and former employees." HMA denied the allegations.
A merger between two Michigan healthcare providers has been called off because of stark cultural differences between them, observers say. Those differences include the patient populations they each serve and the organizations' physician compensation models.
Detroit's Henry Ford Health System and Beaumont Health System announced this week that they would let expire a deadline for merger talks that would have created a $6.4 billion integrated system. In the end, observers say, it came down to a clash of cultures that could not be overcome by the advantages gained from a merger of equals.
Seven months after telling a room full of journalists that Beaumont was "the absolute ideal partner for us" Henry Ford CEO Nancy Schlichting sent a note to employees saying the deal was off. "This decision was made because it became apparent that two very different perspectives had emerged for the new organization between Henry Ford and Beaumont," Schlichting wrote.
At Beaumont, CEO and President Gene Michalski said in prepared remarks that "we have benefitted greatly from our merger discussions and have great respect for our colleagues at Henry Ford. However, we found through our discussions that we are not aligned on how to achieve our vision for a model health system due to differences in our structures and business models."
Beyond those public statements, neither side was talking, which left the field free for speculation.
Signs that the deal was faltering surfaced last week when physician leaders at Beaumont reportedly asked the system's board to reconsider the merger.
Marianne Udow-Phillips, director of the University of Michigan's Center for Healthcare Research & Transformation, says she was not surprised that the talks fell apart.
"I was more surprised in the first place when they said they wanted to do it," Udow-Phillips says. "The cultures are so different between these two organizations. Mergers and acquisitions are hard to do generally and in this particular case when you layer on top of it two organizations that have fundamentally different backgrounds and structures, that makes it even harder. I was surprised it was on track for as long as it was."
For starters, Udow-Phillips notes, the two health centers served different patient populations and used different physician compensation models.
"Henry Ford Health System is a very integrated academic health center where the physicians are predominantly salaried. The main campus is in the inner city of Detroit. They serve a population that is predominantly Medicaid and uninsured," Udow-Phillips said.
"In contrast Beaumont Health System," she said, "while it has some staff physicians, the leadership is predominantly led by independent physicians and private practice physicians. Their traditional home is in the wealthy suburbs. Their Medicaid population is very small."
"The physician cultures are quite different. Henry Ford has been an owner of the Health Alliance plan and is very familiar with capitated systems and salaries and structures for physicians and Beaumont is a much more fee-for-service oriented environment.
Allan Baumgarten, an independent health policy analyst and author of the Michigan Health Market Review, acknowledged the vast operational and cultural differences between the two systems, but said he was still surprised that the merger talks flopped.
"I thought these were two organizations that had concluded that they needed to combine forces to be more competitive in what has become a more dynamic and competitive regional market and I thought they had enunciated goals of improving quality and achieving efficiencies and reductions in costs that they thought they could achieve together better than separately," he said.
"Having said that, merging two organizations of that size and with different cultures and structures is obviously very difficult and at a certain point there were enough sticking points that they said they were better off walking away from the table than going any further."
Udow-Phillips believes that the merger talks were initiated last year more as a response to the Patient Protection and Affordable Care Act and other cost-containment and market share pressures brought forward by healthcare reform. Baumgarten says Vanguard Health System Inc.'s $1.2 billion acquisition of Detroit Medical Center in 2010 "stirred things up and was a major driver of Henry Ford and Beaumont to look for a marriage partner literally."
"Since Vanguard acquired the Detroit Medical Center, they have been pumping nearly $1 billion in capital into improving the buildings and the practices and challenging Beaumont on its own turf," he says. "Vanguard has now completed a major clinical center about two miles from the main Beaumont hospital at Royal Oak. Vanguard clearly has a strategy of trying to pick up more patients with better insurance than the inner city patients they have been seeing mostly up to now. They've been doing that by building new facilities and trying to acquire certain specific practices and had some success with that."
Neither Beaumont nor Henry Ford gave any suggestion in their brief statements to the media that they would pursue mergers or other alliances with other providers.
"We haven't seen the first quarter numbers yet, but for the end of the year the Beaumont finances improved significantly so there wasn't the same kind of financial pressure on them as there was when they first started the discussions I am not sure their path is going to be toward a merger," Udow-Phillips says.
"Henry Ford has already in their history done some mergers with other organizations. I am not sure which ones now they would approach. Henry Ford because their patient base is much more heavily based with public programs, they would benefit financially by finding a partner that would balance that out a little bit but I don't know how realistic that is going to be at this stage."
Baumgarten says Beaumont has already rejected advances from Vanguard "and I don't think that is likely to change."
"There are other possibilities," he says. "The University of Michigan Health System at Ann Arbor is about 50 miles from Beaumont and that is a very prestigious academic medical center which has been trying to extend its reach into different parts of the state through some acquisitions but mostly through different kinds of partnerships."
Baumgarten says some sort of alliance between Beaumont and Oakwood Healthcare System might also garner consideration. "Oakwood serves the west side of the Metro area where Beaumont is on the northeast side. There are geographically compatible," he said.
"Or maybe we'll see a partner relationship where Mayo Clinic or Cleveland Clinic is sharing certain lines of expertise of medical management or other administrative expertise with if not Beaumont than one of the other systems in the area."
Baumgarten says Henry Ford's improving balance sheet means the system could keep merger plans on the back burner for a while.
"Henry Ford has remade itself in the last couple of years with some success. Their profitability is much improved over where it was five years ago. It is mostly because of two things: one was the opening of the new West Bloomfield Hospital, which is a prosperous suburb of Detroit; and second was they closed what had been a money-losing (Henry Ford Macomb Hospital-Warren). Their medical group is in good shape. They have their own Health Alliance plan, which about 18 months ago acquired a Medicaid HMO in Detroit, which is strengthening their position. Henry Ford is thinking they're in pretty good shape."
If there is a lesson to be learned from the failure of the merger, Udow-Phillips says that key players in both systems have to be on board. "It is more than just two leaders wanted to come together, and I know the boards wanted to come together. But you saw in the physicians at Beaumont last week came out publicly in opposition to the merger so for any hospital the cautionary tale is to make sure that your physicians are aligned."
"The other message I would take from this is Beaumont and Henry Ford are two very strong institutions with a lot of history and strength in their markets. What you see more in mergers with hospitals is a very weak hospital merging with a strong hospital."
Baumgarten says the breakdown "is just a reminder of how difficult it is to engineer a merger of this scope."
West Virginia pediatric cardiologist Larry Rhodes, MD, speaks passionately about his work at three community outreach clinics. "It is always easy to hide under the guise of 'this is for patient care,' but the best days of the month for me are when I am in my truck driving to one of these clinics."
Larry Rhodes, MD, interim chair of the West Virginia University Department of Pediatrics is a subspecialist who enthusiastically takes his expertise into the field at outreach clinics across the Mountain State.
As director of the WVU Institute for Community and Rural Health, Rhodes has also played a key role in a program that has enabled 400 medical students to complete 2,700 weeks of rural healthcare training in 2012.
For his advocacy of rural health issues and efforts to improve access, Rhodes this month was named the 2013 Rural Health Practitioner of the Year by the National Rural Health Association.
Rhodes spoke this week with HealthLeaders Media about the challenges and rewards of taking his subspecialty skills to the people.
HLM: Talk about your work with outreach clinics.
Rhodes: I do three outreach clinics a month. I'm in Morgantown in the northern part of the state. I go to Parkersburg, which is about two hours away twice a month. And I do a clinic in Beckley, which is about a three-hour drive once a month. Each of our cardiologists do at least one outreach clinic a month. We have almost all areas of the state covered.
There are a couple of reasons why we do it. One is there are a number of children born in these rural communities who have congenital heart disease and we in Morgantown are the only center in the state that does surgery for kids with congenital heart disease. We have two doctors going to Beckley on Friday and we have 40 patients scheduled. We will keep that many patients from having to drive up here for a follow up.
West Virginia is almost all rural. The biggest town in the state in Charleston and it's only got 54,000 people. It's a big deal for some families to drive two or three hours and some of the patients are even five hours away. When I go to Beckley I will see patients that maybe have driven an hour and a half to get to the clinic.
I am primarily a pediatrician, but we do the same thing for adults with subspecialty problems. We have a doctor who does an outreach rheumatology clinic in the coal country in the southern part of the state. We have an ophthalmologist and a neurologist who go there too.
HLM: Why are there so few subspecialists venturing to these outreach clinics?
Rhodes: It's kind of an ivory tower mentality that 'I am here and they will come here.' Frequently when we think about rural healthcare, we think about primary care physicians, who are the cornerstone to the whole thing and who are very important.
But sometimes the patients with acute special healthcare needs are not lost in the shuffle, but we don't think enough about them at times. We just assume they will come back to the tertiary care center for follow up. I have patients who will cancel a clinic visit because they can't find the $50 to put gas in the car.
Or they may find that they can get a ride to an outreach clinic with a neighbor who is willing to drive them a half hour but they are not willing to drive two and a half or three hours and wait for the appointment and drive back.
HLM: Is sending subspecialists into the field a good use of limited resources?
Rhodes: That's true to a degree. You may need to bring the patients into the tertiary care center for the testing and expertise. But the patients I see in these outreach clinics I may be able to see three times before they need to come to Morgantown.
Once every one or two years I may have to bring a patient here, but I can see that patient every six months in their community. I can think of patients I haven't had to bring to Morgantown in five years. I can go and see the patient as a subspecialist. The family medicine guy is good at taking care of the patient in between.
But they get a little uncomfortable if they are watching the kid with the artificial heart valve. They may have the experience of 20 adults with that problem but what do you say to a 12 year old who has an artificial heart value in terms of his physical activities? There are certain things we can take to the community that are not necessarily things that they need to come to the tertiary care hospital for.
HLM: Are you urging other subspecialists to do outreach work?
Rhodes: I think so, very much. I personally prefer going to the communities because I love it. I love going out and seeing the patients in their home communities. I pride myself in knowing where almost every patient of mine is from. If I have not been to where they are from I will drive there sometime to find out.
There are always resources issues. If you only have one neurologist in your practice it is a little harder to say 'go do a clinic once a week somewhere else.' But it is a great public service. It helps the patients. It helps with compliance. It is very rewarding. I am old enough to realize that what I used to think I was doing for the patient I am really doing for myself.
It is always easy to hide under the guise of 'this is for patient care,' but I can tell you the best days of the month for me are when I am in my truck driving to one of these clinics.
HLM: Does clinical outreach make you a better physician?
Rhodes: Yes. It forces you to do things sometimes without all the technology. [Like] when I go to a clinic where I don't have an echo machine or some of the advantages I have here. If I am seeing a patient here and I am a little confused, I can send them for a test. Frequently I can't do that in outreach clinics. I can arrange a test and have it done the next week, but I can't just send them out of the office and tell them to 'go get this test and I will see you.'
We have taken residents and med students with us to the clinics and they love it. It's like practicing medicine the way you were taught to practice—using your physical exam abilities, using simple tests like an EKG or an X-ray. It gives you a rapport with your patients.
HLM: How does the outreach experience help you better understand better patients' perspectives?
Rhodes: Look at a map of West Virginia and you see there are interstates going through the state and you say there can't be anyone who lives more than three hours from here. I have a slide that I use when I talk to medical students about rural health.
I can show you the interstates and I will ask 'how long will that take you to drive?' and a lot of them will say 'it's three hours.' Well it turns out it's five hours, because it takes almost an hour and a half to get to the interstate.
You can't see that on the Google map, but when you drive out to these places and you realize where these people are coming from, you are not angry when they miss an appointment or when they come 25- or 30-minutes late.
I never refuse to see a person who is late and I won't let anyone in my division refuse to see somebody who is late because I have been there. I know where they are coming from. It may not be snowing in Morgantown, but an hour from here they may have a foot of snow.
You get mad because a family doesn't get a prescription filled and then you realize that the closest drug store to them is 45 minutes away and it closed at 8 p.m. and they didn't get back from the hospital until 9 p.m. There are things like that that you don't think of if you don't go out and do this type of stuff. It is that type of stuff that makes you appreciate what they are going through.
HLM: Is clinical outreach a good prescription for doctor burnout?
Rhodes: It is a great cure for burnout. The person who was my boss who is still in our division is 73 years old and he still works and he is the one who started the outreach clinics for pediatric cardiology.
He is not burned out and we will do a clinic together on Friday when I go to Beckley. I have another practitioner in our group who is 71 and another who is 65. They are all cardiologists and none of them are burned out. I have said a number of times; they will drag me out of this building feet first. I will not retire. I will work until I can't walk. And part of it is the passion for doing this.
