After finalizing its controversial 'public charge' rule, which penalizes immigrants who obtain coverage through a government-sponsored health plan, the administration plans to bar immigrants from entering the country if they cannot demonstrate an ability to pay for their healthcare.
Beginning early next month, immigrants seeking visas will be denied entry into the U.S. if they cannot demonstrate their ability to pay for healthcare, under a proclamation issued Friday by President Donald Trump.
Immigrants will have to show that they will be covered by an approved form of health insurance within 30 days of entering the country. The list of approved plan types includes employer-sponsored insurance, short-term limited-duration insurance, and an unsubsidized plan through the Affordable Care Act's individual market, but it doesn't include subsidized ACA plans or Medicaid, according to the proclamation.
"Immigrants who enter this country should not further saddle our healthcare system, and subsequently American taxpayers, with higher costs," the proclamation states.
This isn't the first time the Trump administration has used health insurance as an immigration wedge. The government issued a final rule in August that expanded the definition of "public charge" to penalize immigrants who obtain insurance through a government-sponsored health plan.
Healthcare provider organizations—including the American Hospital Association, America's Essential Hospitals, and the American Academy of Pediatrics Council on Immigrant Child and Family Health—panned the public charge rule, arguing that it could frighten immigrant families into delaying needed healthcare. A lawsuit is expected.
Friday's proclamation applies to immigrants abroad who are applying for visas to come to the U.S., not to those who are already here. It doesn't apply to children, asylum seekers, or refugees. And the U.S. Secretary of State may make case-by-case exceptions.
The proclamation could affect families who are trying to bring their parents to the U.S., as Colleen Long reported for the Associated Press. That aligns with the Trump administration's stated intention of moving from a family-based immigration system to a so-called "merit-based" system.
About 69% of the U.S.-born population had private health insurance in 2017, while about 57% of immigrants had such coverage, according to the nonpartisan Migration Policy Institute. Meanwhile, about 36% of the U.S.-born population had public health insurance in 2017, and about 30% of immigrants had such coverage.
Since the ACA's implementation in 2014, the uninsured rate among the U.S.-born population fell from 12% in 2013 to 7% in 2017, and the uninsured rate among immigrants fell from 32% in 2013 to 20% in 2017, according to the institute.
Deciding whether to merge and managing a post-merger organization can be tricky, even when the acquisition is a good fit.
As mergers and acquisitions among healthcare providers continue at a frenzied pace in certain markets, some healthcare executives are prodding their peers to scrutinize their own M&A motivations more thoroughly.
The prospect of gaining an upper hand at the negotiating table across from insurers is a tantalizing reason to pursue scale. But getting bigger for the simple sake of protecting your business interests is a questionable rationale for mission-minded healthcare organizations, according to several senior strategy leaders who attended last week's HealthLeaders CEO Exchange gathering in Park City, Utah.
Instead, they say, health system executives have a responsibility to steer any consolidation in a way that serves the local market. That steering continues long after a deal is finalized, as C-suite leaders figure out how tightly to control each component of the post-merger system.
Toby Freier, MBA, FACHE, president of Allina Health's New Ulm Medical Center, a critical access hospital in New Ulm, Minnesota, says leaders need to consider carefully how they define success for any deal and whether that definition aligns with the community's best interests.
"It's hard to think that our communities have won over the last decade through consolidation, if our measures of success are the health outcomes and affordability of healthcare," Freier says.
That's not to suggest hospitals should abstain from M&A activity altogether. Sometimes leaders stall too long, Freier says.
"Hospitals, especially in rural communities, are waiting until financially they feel like they are out of options, rather than more proactively seeing what a system affiliation or partnership could do to extend and enhance care and services to their community or at a population health level," he says.
"When we approach it only from the economic side of it," he adds, "I think we miss what's the end game—the triple aim with better access and support to our community."
"As we looked at becoming part of some of the larger systems, they had a very spoke-and-hub model, where you get a little bit of care here and then everything gets shuffled off to somewhere else," she says. "Our philosophy is to provide as much care as we can locally—tap into innovative care models and use our technology, electronic health record, and our providers to maintain that care close to home and only transport patients when care cannot be safely provided at the site of service."
"I'm not sure that's always the discussion when mergers and acquisitions take place," she adds.
Steven N. Little, CPA, former president and CEO of Agnesian HealthCare in Fond du Lac, Wisconsin, similarly says hospitals that don't dominate their markets may reach a fork in the road that forces them to choose, but that point isn't the same for everyone.
"There is no one secret formula that says you have to be of a certain size, in my opinion, or you're not going to survive. I think there's many, many factors," Little says.
The end goal should be to provide better care at a more affordable rate, he says.
"We have an obligation as nonprofit and for-profit healthcare providers to provide better health for the people we serve," he says. "And this country is at a point where we'd better figure it out soon as providers, or the Amazons and the Walmarts will figure it out for us."
Tension: Cost Efficiency vs. Local Control
Although numerous academic studies have shown mergers among healthcare providers tend to lead to higher costs, the American Hospital Association has pushed back against that conclusion, arguing that patients have benefited from consolidation because hospitals can operate more efficiently in larger systems.
Michael Ugwueke, MPH, DHA, FACHE, president and CEO of Methodist Le Bonheur Healthcare in Memphis, Tennessee, says the actual benefits of M&A activity vary from one market to the next.
"In most markets, operating still as a holding company makes it very hard to really take costs out, take advantage of synergies brought together by an acquisition or merger," Ugwueke says.
While leaders who take a holding-company approach to running a post-merger system may preserve some degree of local autonomy, thereby remaining responsive to local-market needs, those who take more of an operating-company approach can centralize control in a way that reduces administrative redundancy, thereby capitalizing on the merger's cost-saving potential. There are tradeoffs depending upon where a given system lands on the spectrum between those two extremes.
"I think the jury is still out ultimately on what benefits accrue to patients," Ugwueke says.
Chris Woleske, JD, president and CEO of Bellin Health in Green Bay, Wisconsin, says the bottom line in this conversation is that healthcare is too expensive.
"At the end of the day, we need to find a way to reduce the total cost of care, and I don't see big systems in a position to achieve that more effectively than independent organizations that are community-based and focused on achieving quality, affordability and improving health and well-being for the communities," Woleske says.
"That will be key, so that's what we're putting our energy and effort into."
Roberta Luskin-Hawk, MD, chief executive of St. Joseph Health, Humboldt County in Eureka, California, says the role local leaders play has shifted as large systems evolve to operating models and integrated delivery networks. While regional leaders have substantial authority, they need to collaborate with those who manage their local markets, she says.
"I believe that there is significant value in the development of a cohesive and aligned culture and operations across large systems, but we need to ensure that there is meaningful input from the local markets—as [our system CEO] Dr. Rod Hochman talks about, being 'big and small at the same time,' leveraging your size while keeping that intimate personal connection with your community and the people you serve," Luskin-Hawk says. "That's the balance that we are trying to achieve."
The HealthLeaders CEO Exchange annually gathers leading hospital and health system CEOs for a custom dialogue on only the critical issues facing the future of their organizations. The 2019 HealthLeaders CEO Exchange was held September 25–27 in Park City, Utah. For more information on this and future events, please email exchange@healthleadersmedia.com.
Editor's note: This story was updated Thursday with an additional comment from Roberta Luskin-Hawk, MD.
The combined nonprofit, which will be named Dartmouth-Hitchcock Health GraniteOne, will be better positioned to meet rising demand for integrated care throughout the region, resulting in a local option at a lower cost than out-of-state providers, the companies said in their announcement.
"Our goal has been, and continues to be, to provide access to the highest-quality care for the people of New Hampshire, right here at home," said Dartmouth-Hitchcock Health CEO and President Joanne M. Conroy, MD, in a statement. "Combining our systems will enable us to more effectively and efficiently use the existing capacity of our two systems, expand capacity where and when necessary, and enhance existing services across all the hospitals in our systems and in our communities, in order to meet growing patient demand, particularly in southern New Hampshire."
GraniteOne Health CEO Joseph Pepe, MD, similarly said the combined system will be better positioned to offer the right care at the right place and the right time.
"I’ve worked in health care in New Hampshire for 30 years and have seen firsthand, in business and in our communities, that we can achieve great things when we work together," Pepe said in the statement.
The merger includes Catholic Medical Center in Manchester, so the combination is proceeding without objection from the the Bishop of Manchester.
The organizations said they will preserve their local identities, traditions, community commitments, current names, and local leadership. They are no preparing to submit their plans to the Federal Trade Commission and New Hampshire Attorney General's Office, which recently blocked an effort by Boston-based Partners HealthCare's flagship Massachusetts General Hospital to acquire facilities in the Granite State.
The FAA granted UPS full certification to fly unmanned drones beyond the operator's line of site.
Unmanned aircraft may soon begin making more deliveries to hospitals across the country, after the Federal Aviation Administration granted full certification to a UPS subsidiary to operate a drone airline.
The certification—which permits UPS to fly an unlimited number of drones, day and night, beyond the operator's line of site—comes six months after the company's historic drone delivery at WakeMed Health & Hospitals in Raleigh, North Carolina.
With the FAA's green light, UPS plans to scale up its operations first to meet healthcare needs then to serve other industries, according to the company's announcement.
"This is a big step forward in safely integrating unmanned aircraft systems into our airspace, expanding access to healthcare in North Carolina and building on the success of the national UAS Integration Pilot Program to maintain American leadership in unmanned aviation," said U.S. Secretary of Transportation Elaine L. Chao in a statement.
The subsidiary, UPS Flight Forward, secured full Part 135 Standard certification.
"This is history in the making, and we aren't done yet," said UPS CEO David Abney in the statement.
"We will soon announce other steps to build out our infrastructure, expand services for healthcare customers and put drones to new uses in the future," Abney added.
The company said it plans to expand its drone delivery services to new hospitals and other medical campuses and also build a centralized operations control center.
The health system plans to provide more convenient care in co-branded retail clinics, as health systems have done in other markets.
Novant Health, based in Winston-Salem, North Carolina, agreed to hand the keys for nine of its pharmacies over to Walgreens, as part of a deal the 15-hospital system hopes will improve healthcare access in the Tar Heel State.
The arrangement calls for retail clinics, co-branded as "Novant Health Express at Walgreens," to be opened in three of the pharmacy chain's North Carolina locations early next year, with more sites to be added over the coming two years, according to the companies' announcement Tuesday.
The clinics will be staffed by Novant Health's advanced practice clinicians and open seven days per week.
The strategic partnership aims to make healthcare more convenient, affordable, and accessible, said Pam Oliver, MD, executive vice president and president of Novant Health Physician Network.
"Our new clinics at Walgreens will allow patients to avoid the emergency room by expanding access to quality care for minor illnesses and injuries, and create a new avenue for Novant Health to support and care for our patients with chronic conditions," Oliver said in a statement.
Novant Health, which operates in South Carolina, Virginia, and Georgia as well, will continue to operate specialty pharmacies.
"Our customers have come to rely on their local Walgreens to provide accessible and convenient health care options," said Chet Robson, DO, the pharmacy chain's acting chief medical officer, in the statement. "Our collaboration with Novant Health is a great example of how we're integrating care and bringing a simplified health care experience to North Carolina residents."
The first three "Novant Health Express at Walgreens" sites are expected to open in Charlotte, Winston-Salem, and Leland.
The administration is implementing a provision of the ACA to allow 'health-contingent' wellness programs in the individual market.
Insurers selling individual market health plans in certain states may soon be allowed to encourage healthier behaviors among plan members by offering discounted premiums and other incentives to those who participate in wellness programs.
The federal government will give 10 states a chance to participate in a demonstration project that will allow the so-called "health-contingent" programs in participating states' individual markets, as the Centers for Medicare & Medicaid Services announced Monday with an informational bulletin.
CMS Administrator Seema Verma said the change will support the Trump administration's efforts to give states more leeway and to empower members of the public to make their own healthcare decisions.
"Allowing states to implement these wellness programs in their individual markets offers the opportunity to not only improve the health of their residents but also to help reduce healthcare spending," Verma said in a statement.
This demonstration project is the only context in which the Affordable Care Act allows individual market health plans to offer health-contingent wellness programs, according to the CMS announcement. If Health and Human Services, Labor, and Treasury officials determine the demonstration project is effective, they may expand it to more states after three years, according to the bulletin.
States that wish to participate must show that their programs won't result in any decrease in coverage or increase in cost to the federal government's ACA exchange subsidies, according to the CMS announcement.
States must also make sure that their wellness programs don't discriminate based on a person's health status, the agency said—which is why states must make sure reasonable alternatives are available to those who can't meet the wellness program's standards, due to a preexisting or other medical condition.
Participating states must submit performance data to the federal government for the review process.
Although wellness programs are common among employer-sponsored health plans, academic studies have found them to be largely ineffective in impacting healthcare usage or costs.
A study published earlier this year by the Journal of the American Medical Association reviewed records for nearly 33,000 employees at a large company and found employees at worksites with a wellness program reported significantly higher rates of certain health behaviors but no significant effects on clinical measures, healthcare spending, or utilization.
"Although limited by incomplete data on some outcomes, these findings may temper expectations about the financial return on investment that wellness programs can deliver in the short term," the researchers, Zirui Song, MD, PhD, and Katherine Baicker, PhD, wrote.
The possible arrangement comes as Cleveland Clinic continues to pursue an ambitious growth strategy.
Mercy Medical Center, which operates a 476-bed Catholic hospital in Canton, Ohio, might be on its way to full membership in the Cleveland Clinic health system.
The Sisters of Charity Health System, which owns the hospital, signed a non-binding letter of intent Friday to explore a possible deal in which the hospital would retain its Catholic identity through sponsorship by the Sisters of Charity of St. Augustine, according to announcements from the two healthsystems.
Cleveland Clinic currently operates 11 regional hospitals across five Ohio counties. This would be its first in Stark County, though it already offers some services in the area. It comes as the prominent academic institution pursues an ambitious growth strategy not only in Ohio but also in Florida, Nevada, and select international locales.
The letter initiates a due diligence process to hammer out the details.
Sister Judith Ann Karam, CSA, congregational leader of the Sisters of Charity of St. Augustine, said in a statement that Mercy Medical Center has been "a treasured ministry" for the organization since its founding 111 years ago.
"Our goal is to position Mercy so its caregivers, physicians and volunteers can continue to provide safe, high-quality Catholic health care to Stark County and beyond for generations to come," Karam said. "In our rapidly evolving health care environment, hospitals have a greater opportunity to successfully serve individuals, families and communities by working in clinically integrated systems of care. And, Cleveland Clinic is Ohio's most comprehensive health care network."
Sisters of Charity Health System President and CEO Thomas J. Strauss, who is also interim CEO of the hospital, said in the statement that joining Cleveland Clinic will improve Mercy Medical Center's ability to serve the local community, with an expanded range of clinical services, growth opportunity, and long-term sustainability.
Cleveland Clinic President and CEO Tom Mihaljevic, MD, said his organization is committed to protect the delivery of Catholic healthcare in Stark County, where Mercy Medical Center operates.
"Our mission is to do what is best for our patients, and to maintain a commitment to safety, quality and exceptional outcomes at every one of our hospitals," Mihaljevic said.
Mercy Medical Center employs 620 medical staffers and a total of about 2,500 people.
From consolidation and competition to consumerism and clinical excellence, leaders outlined their approaches to the biggest threats and opportunities facing their enterprises today.
PARK CITY, Utah — Three dozen senior healthcare strategy leaders gathered here this week, as part of the HealthLeaders CEO Exchange program, to discuss some of the critical choices they and their peers must make in an industry that's constantly changing.
During a series of roundtable discussions that began Thursday and will continue Friday, the executives outlined their approaches to the biggest threats and opportunities facing their enterprises today, from consolidation and competition to consumerism and clinical excellence.
Here are three highlights from Thursday's discussions:
1. Meet Patient Expectations or Your Competitors Will
Health systems use a wide variety of tactics to improve patient access, such as extending their hours of operation, opening clinics in more convenient locations, and offering telehealth options to meet low-acuity care needs without requiring an in-person visit.
But health systems shouldn't unilaterally define access for their local markets. That's because access means meeting patients where they are, and you can't fully know where patient populations stand without asking them, says Joe Hodges, MHA, regional president of SSM Health Oklahoma.
"Whether it's on your phone, whether it's in your laptop, whether it's in an office, whether it's Sunday at 4 o'clock in the afternoon, it's really how the patient defines what that access is, and we should be there to achieve that goal for those patients," Hodges says. "If we're not, I feel like someone else is going to fill that gap for us."
2. Vetting Virtual Care Tools? Test Them Internally First
Just about every major health system has adopted a virtual care solution in one form or another, but not all of those solutions have lived up to their potential. Several participants in this week's CEO Exchange event say their virtual care options have gone woefully underutilized.
One great way to prepare your organization for a successful virtual care rollout is to begin with your own team, says Chris Woleske, JD, president and CEO of Bellin Health, based in Green Bay, Wisconsin. That's why her organization put an initiative in place to adopt tech tools internally before offering them to the public, Woleske says.
"When we rolled out e-visits and video visits, we did it first within our own employee base and tested it with them because, if they like it, they're going to tell their patients about it, and they're going to encourage their family members to use it," she says. "Creating that internal set of ambassadors has been successful."
3. Don't Let Innovation Disrupt Your Relationships
While the latest bits of technology might promise to alleviate your biggest headaches, they cannot eliminate your primary leadership responsibilities.
"You need to get back to the core basics instead of always looking for the next bell or whistle," says Charlotte Ipsan, DNP, RNC, NNP-BC, FACHE, chief administrative officer for Norton Women's & Children's Hospital in Louisville, Kentucky.
"Physicians, nurses, therapists, and support all want to know: can they trust their leader? You need to speak to the mission, vision and values, and where you're going and be sure that they have a voice at the table," Ipsan says.
The HealthLeaders CEO Exchange annually gathers leading hospital and health system CEOs for a custom dialogue on only the critical issues facing the future of their organizations. For more information, please email exchange@healthleadersmedia.com.
The retail giant has 'bold ambitions to partner' with providers as it aims to make care more affordable and accessible.
There's more than a fresh coat of paint at a newly remodeled Walmart supercenter in Dallas, Georgia, where the company aims to deliver a better shopping experience not only for electronics and home goods but for healthcare services as well.
The retail giant opened its first Walmart Health prototype this month, partnering with local providers to offer an array of services, including primary care, lab work, x-rays, EKGs, vision and hearing care, counseling, and more right there at the store, accessible through a separate entrance.
It's precisely the type of retail invasion that's been making incumbent hospitals, health systems, and medical groups nervous. And the disruptive influence could spread to other markets, as the company aims to perfect a scalable model.
"This is kind of an Amazon play," says Ken Kaufman, MBA, managing director and chair of consulting firm Kaufman Hall.
In the same way that Amazon established its market dominance in the online retail space for books and more, Walmart might cement its footing in outpatient healthcare delivery by underpricing the competition, Kaufman says.
The company said it aims to price Walmart Health services at 30%–50% below what patients have been paying elsewhere, partly by eliminating middlemen and using Walmart's market size to negotiate, as Business Insider reported.
That's feasible because Walmart is the biggest corporation in the country, by revenue, Kaufman says.
"They can really do whatever they want for as long as they want," he says. "If this doesn't work and the whole venture is losing money, then they'll have to decide how much pain to take."
The possible strategy, as modeled by Amazon, seems to be pretty clear, Kaufman says.
"You just hang on until you have created the No. 1 market share in that particular area, that particular vertical. Then you expand your business out from there," he says.
"It's worked extraordinarily well for Amazon in numerous different areas," he adds. "I think that's what Walmart's going to try here."
If successful, Walmart's moves will translate into market share, will likely rearrange the way referral systems work within those markets, and could lower the cost of care, Kaufman says.
Meeting Consumer Expectations
Walmart Senior Vice President Sean Slovenski, who also serves as president of health and wellness, said the company plans to use the prototype to learn best practices that it can then roll out to the other communities it serves. A second location is already slated to open early next year in nearby Calhoun, Georgia, he said.
The retailer's expansion in brick-and-mortar healthcare delivery stems from its ambition to improve affordability and accessible for patients, whether they have insurance or not, Slovenski said.
"For the past year, a team of healthcare experts and visionaries inside and outside of Walmart have been working hard to bring this concept to life in Georgia, and the journey we've been on is just the beginning as we aim to bring quality, accessible healthcare to our customers," Slovenski said.
Walmart's undertaking includes key principles of the emerging healthcare marketplace:
Price transparency: An average primary care office visit for an adult patient will cost $40, a dental exam will cost $25, and a 45-minute counseling session will cost $45, according to a pricing list for the Dallas, Georgia, location. The goal is to charge 30%–50% less than other providers, as Slovenski told Business Insider.
Community health: The facility will offer education and enrollment assistance for health insurance programs, plus fitness and nutritional resources. This could be a big differentiator for the retailer, since Walmart's grocery aisles give it an edge over Amazon, as CNBC's Tim Mullaney reported last month—though Amazon has been investing in a grocery strategy of its own. Industry players and policymakers alike have acknowledged the role access to healthy food plays in social determinants of health.
To pull this off, Walmart knows it will need strong partnerships with local providers and wellness organizations alike.
"Helping families save money so they can live better is at the heart of Walmart's business," Slovenski said, "and we have bold ambitions to partner with great providers and find solutions to deliver quality health services at low, transparent pricing to our customers in a way that is convenient for them, making 'live better' the norm."
Don't mistake this prototype as some shot in the dark. This is "not a dabble" but a "serious" strategy, as Slovenski told Forbes. And the company's follow-up announcement Tuesday that it is investing in health-related educational opportunities for its associates adds to the reasons to believe Walmart intends to have its healthcare priorities taken seriously.
Serving Rural Populations
Christopher Cornue, MSHSA, FACHE, a Chicago-based strategic adviser who used to work for Navicent Health in Macon, Georgia, says Walmart is moving into relatively rural areas that have high percentages of Medicaid and uninsured populations.
In a state that didn't expand Medicaid under the Affordable Care Act, that might set Walmart Health apart from the strategies undertaken by CVS Health or Walgreens, Cornue says.
"They are not necessarily going to be going after the same type of patient that maybe some of the other retail boxes would be," he says.
Each of the two Georgia communities in which Walmart is opening its health centers has fewer than 17,000 residents. Rural providers in those communities and surrounding areas may not be fully prepared to respond to the disruption, Kaufman says.
Cornue says another business model is emerging, whether the most viable version comes from Walmart, Amazon-backed Haven, the newly merged CVS-Aetna enterprise, or elsewhere. So incumbent health systems should be thinking through the possible implications for their own operations, he says.
But keep in mind, Kaufman says, that Walmart doesn't have to expand into your market for a Walmart-style model to disrupt your relationships with your patient populations: "You should see this as the introduction of a very competitive business model, where Walmart just happens to be the first practitioner."
As the retail giant looks to step deeper into the healthcare provider space, it's offering a path for employees to earn degrees in the growing field.
After opening a health center prototype earlier this month in search of a scalable model, Walmart has announced a new way for its employees to train for the types of healthcare jobs the company hopes to add.
All of the retailer's 1.5 million associates in the U.S. are eligible to apply for degree-granting health-related programs through Walmart's education benefit program, Live Better U, effective Tuesday, the company said.
That includes seven bachelor's degree programs and two career diplomas, all priced at $1 per day.
"Walmart aims to be the market leader in providing retail workers a path to careers in growing fields like healthcare," the company's senior vice president of associate experience, Drew Holler, said in a statement.
"We don't know of any other retailer in America that has a program that allows its associates the opportunity to achieve a degree in healthcare that can translate into a higher-paying job within the company or in the broader field," Holler added.
While the move could help Walmart reshape its workforce to meet the future needs of its rising strategic focus on healthcare services, it may also serve a more-immediate purpose. The company, which includes Sam's Club stores, operates more than 5,000 retail pharmacies, 3,000 vision centers, and 400 hearing centers.
The available training includes programs for pharmacy technicians and opticians, health science, health and wellness, healthcare management, and more. The participating universities include Purdue University Global, Southern New Hampshire University, Wilmington University, the University of Florida, Brandman University, and Bellevue University, according to a fact sheet.
The dozens of other education programs available through the Live Better U platform include options for associates seeking a high school diploma and language skills as well.