Mergers and acquisitions in the healthcare industry surged in the second quarter of 2011, setting a pace to break all previous records in the sector as measured by dollars, according to Norwalk, CT-based Irving Levin Associates, Inc.
In the second quarter of 2011, a total of $73.5 billion was spent to finance 243 mergers and acquisitions in the healthcare industry, up 44% from the $51.1 billion spent in the first quarter of 2011, and up 61% from the $45.7 billion spent in the second quarter of 2010.
Medical devices ($33.1 billion), pharmaceuticals ($27.4 billion), biotechnology ($4.9 billion), and E-health ($639 million) accounted for $66.1 billion of the mergers and acquisitions in the second quarter.
Sanford Steever, editor of The Health Care M&A Report told HealthLeaders Media in an interview that the pace of mergers and acquisitions suggests that healthcare still remains a fragmented industry.
"In pharma and biotech in particular, there are a lot of drugs facing patent cliffs right now -- 2012 is going to be a horrendous year for some of the big drug companies," Steever says. "If they can't develop new blockbusters internally, they are going to try to buy them by acquiring biotechs. At the other end of the spectrum some have glommed on to the 'if-you-can't-beat-them-join-them' bandwagon and they're buying generic drug companies."
Steever says drug companies feel the need to diversify. "With medical devices, for them there is definitely a spurt in technological innovation.
Companies, particularly in orthopedics, are trying to get complementary technologies and hopefully get cheaper so the products can be cheaper because Medicare often contracts and says we are only going to pay so much for an implant and no more," he says.
The remaining $7.3 billion was accounted to mergers and acquisitions of providers, including hospitals ($3.5 billion), managed care ($1.6 billion, long-term care ($985 million), and physician practices ($416 million). Steever attributes a lot of the activity directly to healthcare reform.
"It's accelerating as hospitals are trying to build up their accountable care organizations."
"So," he said, "I am seeing far more deals involving hospitals acquiring physician groups to meet the needs of the ACOs. Hospitals definitely want to beef up their local and perhaps regional provider networks. They see strength in numbers and you can get efficiencies and economies of scale."
Managed care companies are also anticipating the effect of healthcare reform and attempting to diversify, Steever says. "That is one area that has been thrown into confusion by the implications of healthcare reform," he explained. "You are getting a couple of deals where managed care companies buy other managed care companies. I am seeing more instances of managed care companies diversifying their risk by buying into other sectors. Some are in sectors of technology like E-health, and others are in areas like retail outpatient workers' comp clinics. They're looking to buy services that don't rely necessarily on a managed care model."
Steever says the only thing that could slow down the pace of the mergers and acquisitions is if the federal government defaults. "That is driving people nuts on many fronts," he says. "We should have this settled in the next week or so, but stuff like that is exactly what tends to slow up activity. People aren't sure what their revenues are going to be."
It was the same scenario in 2010 as Congress wrangled with the healthcare reform bill. "The acquisition activity was impossible to predict. It was very slow," Steever says. "Once healthcare reform passed it really picked up. That is because people finally figured that we know we have what our revenues are going to look like. That means we can place a valuation on companies that want to buy or sell."
The average return on investment for a sample group of nonprofit healthcare organizations in fiscal year 2010 was 10.9%, a study shows.
The 2011 Commonfund Benchmarks Study Healthcare Organizations Report found that the 90 nonprofit healthcare organizations examined continued "a welcome follow-on" to the average 18.8% return posted in FY2009. The returns for FY2009 and FY2010 represent the best back-to-back annual performance in the nine years that the study has been conducted, and a dramatic shift from the investment returns of FY2008 that plummeted by an average of -21.2% in the recession-wracked year, the study showed.
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John Griswold, executive director at the Wilton, CT-based Commonfund Institute, said that two years of strong returns are a positive development for nonprofit healthcare organizations. But they barely moved trailing three-year returns into positive territory while leaving five-year returns in the 4% range.
"Continued strong performance will be needed to cover healthcare organizations' spending from endowment, investment management costs and inflation," Griswold said in a media release. "If we go back to the study for FY2007 before the losses of FY2008 trailing returns for three- and five-year periods were 9% and 11.1%, respectively. Returns at levels such as these are essential to support the missions of the nonprofit healthcare organizations over the long term."
The 90 nonprofit healthcare organizations represented $102.6 billion in investable assets and $42.3 billion in defined benefit plan assets. Investable assets include endowment/foundation funds, funded depreciation, working capital and other separately treated assets.
Griswold said that larger healthcare organizations with assets over $500 million reported average margins of 4.4% for FY2010 while those with assets under $251 million reported margins of 2.3%. "It appears that large hospitals and health systems have been able to reduce their operating expenses, increase operating efficiencies and capture greater economies of scale," Griswold said. "Healthcare reform -- specifically lower reimbursements -- pressures healthcare organizations to control costs, and will likely make them more reliant on support from their investable assets."
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Most healthcare organizations saw moderately lower returns on their investable assets in FY2010, when compared with other nonprofit sectors. The 175 independent and community foundations participating in the Commonfund Benchmarks Study Foundations Report posted an average return of 12.5% for FY2010.
The 69 charities participating in the Commonfund Benchmarks Study Operating Charities Report produced an average return of 11.6% for FY2010.
"Historically, healthcare organizations have higher allocations to fixed income securities than do foundations and operating charities, and in a good environment for equities that allocation likely served as a drag on relative return," Griswold said. Healthcare organizations' average 37% fixed income allocation in FY2010, compared to a 13% allocation among foundations and 20% among operating charities.
Domestic equities provided the best return in FY2010, with an average of 17.8%. Other asset class returns were international equities, 12.8%; alternative strategies, 9.9%; fixed income, 7.8%; and short-term securities/cash, 1.1%.
Within the larger alternative strategies category, the best returns came from distressed debt, 15.6%; commodities and managed futures, 15.4%; and energy and natural resources, 14.2%. Marketable alternative strategies including hedge funds, absolute return, market neutral, long/short, 130/30, event-driven and derivatives returned 7.4%, the study showed.
A Lakewood, WA oncologist and his wife face 20 counts of healthcare fraud and related charges for an alleged scheme to overbill Medicare and other government and private health plans by about $1.7 million for larger amounts of medicine than were delivered to patients, the Department of Justice said.
Alfred Hongleung Chan, 63, and Judy Yuan Chan, 62, face up to 20 years in prison if convicted of the charges, which include obstruction of justice and money laundering. The indictments were handed up earlier this year by a federal grand jury, and unsealed this week in U.S. District Court in Tacoma. Arraignment is scheduled for July 29.
The charges stem from a whistleblower False Claims Act suit by a former employee at the Chans' Lakewood clinic. The indictment and the civil suit allege that, beginning in 2006, Alfred Chan would make patient treatment notes on individual slips of paper which were given to his nurse. The notes specified the amount of drugs to be provided to a specific patient. After the nurse had provided the drugs to patients, the slips of paper were returned to Chan who shredded them. The doctor then made entries into a "Superbill" form, ostensibly recording the amount of medications the patients had received, DOJ said in a media release.
Evidence in the case, however, allegedly indicates that Alfred Chan recorded more medication administered than actually received by the patient, and claimed more time spent administering the medication than actually occurred.
Judy Chan then allegedly prepared the bills for Medicare and other government and private healthcare programs, using the inflated amounts, substantially increasing the amount of money owed to the Chans' clinic for medication.
The government alleges the scheme illegally boosted the clinic income by $1.7 million. Alfred Chan made false entries on patients' medical records so that they matched the billings. The records indicated that patients had received larger doses of various drugs than they had actually received, DOJ said.
The false statement, obstruction, and money laundering charges relate to steps allegedly taken by the Chans to hide their assets once they became aware of the government investigation. On a financial disclosure form required by the government, the couple didn't declare bank and brokerage accounts and properties owned by them. They allegedly transferred assets to shield them from the reach of law enforcement, DOJ said.
In an effort to reduce emergency department crowding, nine associations representing ED healthcare providers have signed a consensus statement that proposes standardized definitions for six common ED metrics.
Under the consensus statement, for example, an emergency department is defined as "a dedicated location serving an unscheduled patient population requesting emergency assessment," and triage time is defined as "the time that rapid or comprehensive triage is initiated by a registered nurse or institutionally credentialed provider."
AnnMarie Papa, RN, president of the Emergency Nurses Association, said that a standard set of metrics are needed to get everyone on the same page when looking for solutions to the nation's worsening ED crowding issue.
"Addressing it is one of ENA's top clinical priorities, but we can't solve a problem if we can't agree on how to quantify it," Papa said in a media release. "This consensus statement is a first and important step in reducing crowding and boarding in emergency rooms and helping us provide better and faster care to our patients."
Wait times in emergency departments are surging. The practice of boarding is a symptom of gridlock and prompts patients to leave the hospital without proper care.
ED transfer of care from pre-hospital providers' time;
ED triage time; and
ED treatment space time.
Robi Hellman, clinical practice manager, American Association of Critical-Care Nurses, said common metrics are needed because the sickest patients enter the nation's healthcare system through the ED. "Universally defined time stamps and intervals will ensure accurate patient hand-offsand consistency in health records," Hellman said.
The other organizations that signed onto the final statement are: the American Academy of Emergency Medicine; American Academy of Pediatrics; American College of Emergency Physicians; American Nurses Association; Association of periOperative Registered Nurses; Emergency Department Practice Management Association; and National Association of EMS Physicians.
A Toms River, NJ, man admitted to a federal judge this week that he posed as a physician and illegally treated hundreds of elderly patients and prescribed medicine as part of a Medicare fraud scheme.
Patrick Lynch, 54, pleaded guilty in U.S. District Court in Trenton to one count each of healthcare fraud and aggravated identity theft in connection with the scheme he orchestrated through Toms River-based Visiting Doctors of New Jersey. Federal prosecutors said Lynch conducted hundreds of visits with elderly, home-bound patients and billed them to Medicare.
"Patrick Lynch defrauded a government program designed to help Americans most in need of health support," U.S. Attorney Paul J. Fishman said in a media release. "To further his deception, he misused the identities of skilled professionals and put elderly patients at risk. Homebound individuals with pressing medical concerns should not have to worry that they are receiving substandard care from untrained hands."
Documents and statements connected with the investigation showed that Lynch created Visiting Doctors of New Jersey to provide care for elderly home-bound patients in the Monmouth and Ocean County areas. He hired licensed physicians and nurses to conduct patient visits but they quit when Lynch failed to pay them. So Lynch then posed as the medical professionals, using their names and government-issued ID numbers to write prescriptions and submit billings to Medicare, the Department of Justice said.
The healthcare fraud charge carries a maximum penalty of 10 years in prison and a fine of $250,000, or twice the gross gain or loss from the offense; the aggravated identity theft charge carries a mandatory sentence of two years in prison, to run consecutive to any sentence imposed on the healthcare fraud charge.
Sentencing is scheduled for Oct. 17. The amount that Lynch will be required to repay in restitution is still being determined, DOJ said.
"The threat to the public well being in this case is considerable," Michael B. Ward, Special Agent in Charge of the FBI's Newark field office, said in a media release. "Without sufficient training and lacking minimal credentials, Patrick Lynch attempted to profit by presenting himself as a licensed medical professional, conducting home healthcare visits with elderly patients, writing prescriptions, and falsely billing Medicare. His actions placed these unsuspecting patients at undeterminable risk."
An American Hospital Association survey of 820 hospitals across the nation found that almost all of them reported a drug shortage in the last six months, and nearly half of them reported 21 or more drug shortages.
That growing shortfall has prompted some patients to take less-effective drugs or delay treatment because of drug shortages, the survey showed.
"The number of drugs in short supply is increasing at an alarming rate and hospitals are working diligently to reduce the impact to the patients they care for," AHA President and CEO Rich Umbdenstock said in a statement Tuesday that came with the survey's release. "Clinicians need more notice about drug shortages so they have time to act to ensure that patient care is not disrupted."
Earlier this year Premier Inc., a hospital purchasing alliance, reported that the near-crisis shortage of drugs had reached a 10-year high. The lack of chemotherapy, sedation, and pain relief medications endangers patient safety and costs hospitals more than $200 million annually for higher priced substitutes, a Premier survey found.
The AHA survey found that in the last six months:
Hospitals report that they have delayed treatment (82%) and more than half were not always able to provide the patient with the recommended treatment
Patients got a less-effective drug (69%)
Hospitals experienced drug shortages across all treatment categories
Most hospitals rarely or never receive advance notification of drug shortages (77%) or are informed about the cause of the shortage (67%)
The vast majority of all hospitals reported increased drug costs as a result of drug shortages
Most hospitals are purchasing more expensive alternative drugs from other sources
The AHA made public the results of its survey at a Capitol Hill press conference that also endorsed bipartisan legislation to address the drug shortages. U.S. Reps. Tom Rooney (R-FL) and Diana DeGette (D-CO) are cosponsors of the "Preserving Access to Life-Saving Medications Act," which they said will improve patient safety by reducing shortages of life-saving drugs.
The bill would expand existing law to combat drug shortages by:
Requiring manufacturers of all prescription drugs, including biologics, to notify the FDA of any discontinuance or interruption in the production of a drug at least six months in advance;
Requiring manufacturers to notify the FDA as soon as possible in the event of an unplanned discontinuance or interruption;
Instructing FDA to publish these notifications and any drug shortage on its website, and work to distribute this information to appropriate healthcare providers and patient organizations; and,
Directing a GAO study to examine the possible causes of drug shortages, including manufacturing problems, breakdown in supply chains and delivery systems, and restrictive regulatory requirements.
The AHA, American Society of Clinical Oncology, American Society of Health-System Pharmacists, and Institute for Safe Medication Practices have endorsed the bill.
A former chief financial officer who pleaded guilty to bilking about $200,000 from hospitals in Ohio and Connecticut was sentenced Monday to a maximum 33 months in a federal prison, three years of supervised release, and ordered to pay restitution, the Department of Justice said.
William Roe, 55, had been the CFO at St. Rita's Hospital in Lima, OH, from 2006-2009, and the CFO of Danbury Hospital in Danbury CT from 2009-2010.
From 2008-2010, Roe used a company he'd created called Cycle Software Solutions to defraud both St. Rita's Hospital and Danbury Hospital by billing them for $75,000 and $95,000, respectively, for nonexistent software and services. Roe also billed Danbury Hospital for another $25,000, but that payment was stopped, DOJ said.
On Jan. 4 Roe pleaded guilty to one count of wire fraud.
On Monday, U.S. District Judge Vanessa L. Bryant ordered Roe to pay restitution of $75,000 to St. Rita's Hospital, and $141,166 to Danbury Hospital. The Danbury Hospital restitution figure includes an additional $46,166 that Roe improperly received, DOJ said.
Roe was arrested on Aug. 17, 2010, and had worked as an adult day care aide for Goodwill Industries after he was released on bond.
That bond was revoked in March when Roe violated the terms of his release and used the Internet. Prosecutors said Roe sent his probation officer an email using his wife's email account, and under his wife's name.
In a six-page, single-spaced letter filed with the court, Roe asked Bryant for leniency, and said he came before her "a broken man." He blamed his downfall on a convergence of problems at work, personal family substance abuse and other domestic issues, financial strains, and an extra-marital affair.
"I have been financially devastated by my crime. I have ruined my reputation in an industry that I loved and was good at," Roe said in his letter. "I ask that you be lenient with me and let me return to society as soon as possible. I want to be a productive member of society. I want to see my grandchildren grow up. I know I have a financial penalty as well and want to begin repaying that as soon as possible. I would never consider doing anything remotely like this again."
However, David B. Fein, the U.S. Attorney for Connecticut, said in the government's sentencing memo that Roe created a convincing façade to mask his criminal conduct. "To be sure, at least one person has described Roe as a 'very generous man who would do anything for anyone,' and Roe himself states that his conduct was 'totally out of character' for him. But it is precisely this facade of a good and generous character that allowed Roe to get away with his criminal actions for two years," Fein said.
The prosecutor noted that Roe had complained that he was underpaid, even though he owned two houses and earned more than $500,000 in 2009 at the height of the scam.
"Plainly Roe's moral compass was askew, and his conduct in stealing money not for need, but for what can only be interpreted as sport is deserving of a sentence at or near the top of the agreed-upon guidelines range," Fein wrote in the memo.
Bryant apparently agreed, and sentenced Roe to the maximum 33-month prison term under the guidelines.
Physician alignment and incentive challenges could prove to be a major hurdle for healthcare providers who want to take part in accountable care organizations.
Richard C. Johnston, MD, an internist with Dallas-based Medical Clinic of North Texas, says hospitals will find ACOs to be a tough sell for skeptical physicians. "The main stumbling block in physician integration is alignment of incentives. That, and who controls the dollars. Who does CMS write the check to?" Johnston tells HealthLeaders Media.
"Since most of the savings in the ACO comes out of limiting hospitalizations and ER visits and readmissions, there is a natural conflict there. If hospitals start to have their reimbursement cuts and if their admissions fall it is going to be difficult to sustain their infrastructure. So, who gets the money and distributes it," he says. "If the hospital is getting the money I would think they would probably try to protect their profitability first and the physicians would be left out there."
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A recent survey of 882 hospital administrators and physicians by recruiters AMN Healthcare found that 42% said physician alignment was the most serious obstacle to forming an ACO, followed by a lack of capital (38%), a lack of integrated IT (31%) and a lack of evidence-based treatment protocol data (25%).
David A. Spahlinger, MD, a senior associate dean for clinical affairs at the University of Michigan Medical School, says he's not surprised that physician alignment is becoming a sticking point.
"Yes there are some capital investments you have to make for IT and there are staffing issues, but in the end it's really the alignment of the parts in how we are going to care for patients," he says.
For most healthcare professionals Spahlinger says it's a matter of perspective.
"Physician alignment for health systems is 'how can we make sure the medical staff is on the same page and working together to accomplish system goals?' Every hospital administrator struggles with that," he says. "The physicians say 'Well that is the hospital's goal not our goal. What's in it for us?' That is a major problem in most organizations, and even in the so-called integrated organizations. It's not an easy goal to align everyone in an organization around system goals."
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The challenge of aligning disparate groups around a set of unified goals is challenging for any organization, Spahlinger says, and healthcare is no exception.
"With the way they have it laid out in the proposed rules, there are significant hurdles before you see the savings, and it is not clear how much savings you'll get back versus the investment you make," he says. "In order to really accomplish these goals you have to have everybody working on the same page."
Johnston says ACOs should be "driven" by primary care physicians. "And then the primary care group needs to establish relationships with specialists and hospitals and try to get everybody working together to deliver better faster cheaper care," he says. "That is the goal. It is easy to say, but man!"
Medical Group Management Association and its credentialing and standard-setting body American College of Medical Practice Executives on Monday said it has named a Wisconsin primary care physician as its new president/CEO.
Susan Turney, MD, an internist, will take over in early October, succeeding William F. Jessee, MD, who retires in September after 12 years at the associations. Turney, a fellow in ACMPE, was picked by the boards of directors after a year-long national search.
She will oversee the strategy and operations of MGMA, ACMPE, and their affiliated organizations. With 22,500 members, MGMA is the largest national professional association representing medical practice managers and executives.
Turney has been CEO and executive vice president of the Wisconsin Medical Society since 2004. She founded and chaired the Wisconsin Statewide Health Information Network to promote patient-centered healthcare, and advance the use of information technology to improve healthcare quality and efficiency. She also co-founded the Wisconsin Health Information Organization. Along with her clinical practice, Turney was medical director for patient financial services at Marshfield (WI) Clinic.
Turney was the 2005-06 MGMA board chair and has served in other board positions. She has served on the National Quality Forum, and fulfilled many other appointments from the Wisconsin governor and the secretary of the U.S. Health and Human Services.
She holds a medical degree and a master's of science degree in administrative medicine from the University of Wisconsin School of Medicine and Public Health. She served her internal medicine residency at Marshfield Clinic/St. Joseph's Hospital.
The Great Recession offers few silver linings, but the economic downturn has played a huge part in alleviating the shortage of nurses in this country.
Simply put, nurses haven’t been able to afford to retire.
If your nurse retention strategy is built around the recession, however, you may be in trouble. A 2011 survey from healthcare recruiters at AMN Healthcare found that one-quarter of the 1,002 registered nurses surveyed say they will look for a new place to work as the economy recovers – up sharply from the 15% who said they’d look for a new job in a 2010 survey.
The 2011 Survey of Registered Nurses: Job Satisfaction and Career Plans, also found that while nurse career satisfaction was high at 74%, actual satisfaction with the role RNs now hold was at 58%, down from 66% in the 2010 survey. Most alarmingly, the survey found that 32% of nurses plan to take steps in the next one to three years that would take them out of nursing, up from the 26% who said they would take those steps in the 2010 survey.
And, regardless of what the economy is doing, the simple fact is that nurses are getting older. The American Association of Colleges of Nursing cites studies that show that the average age of RNs in the United States is expected to reach 44.5 years by 2012. Nursing can be stressful, both mentally and physically, with new demands and expectations piled on almost daily.
Marcia Donlon, RN, vice president medical center/CNO at Holy Family Memorial in Manitowoc, WI, says she is not surprised by the findings.
“When it hits you in the face all at once it is like what are we going to do. All of a sudden there is going to be a huge exodus,” she says. “It just makes sense if you’ve been in nursing for any length of time and you look around the room and you see a lot of people in the same age group.”
As the role of the nurse changes to incorporate more knowledge of information technology, there is a learning curve associated with age, Donlon adds. Also, long hours and long shifts can be a turn-off for older nurses.
"The younger nurses really like [longer shifts]. They don’t get as tired. But a lot of the older nurses will tell you they can’t do them. Another thing is the number of morbidly obese patients. Nurses get hurt because you are trying to lift and turn and care for people who are over 400-500 pounds,” Donlon says.
These are significant demands that have to be overcome, but Donlon says hospital executives – and the nurses themselves – who are willing to compromise, may be able to minimize the exodus.
“It’s really a shift in our thinking about what the possibilities are,” Donlon says. “Why would I want one of my most valuable experienced nurses to retire at 60 when he or she is most valued by patients and colleagues.”
Hospital leaders can start the process by asking nurses a simple question: What is it going to take to keep you here?
“Nurses who want to work 4 hour shifts? Bring them on. Maybe I want to go to Florida for the winter but I will work all summer, so give me my three months off. Maybe I don’t want to cut down, I just want to shift things,” Donlon says. “Here’s another thing, working from home. There is resistance to that. How do I know what you are going to be doing at home? We have to get over that.”
Nurses have to be willing to explore new roles, too, and not necessarily let their past job experiences dictate their future job potential. “We as nurses trap ourselves, sometimes saying ‘I’ve worked on Med/Surg for 20 years what else can I do?’ But there are so many things we can do,” Donlon says.
Remember, however, that things like flexible schedules, shifting duties, mentoring programs, and team-care projects – no matter how well designed -- are only stop-gap measures. They cannot change the inalterable fact that America’s nursing workforce is graying along with the people for whom they provide care. At some point, they’re going to clock-off, no matter what’s going on in the economy.
