The system based in Cortez, Colorado, ousted its CFO less than two weeks after giving the boot to its CEO, CNO, and chief of ambulatory services.
Anthony G. Sudduth, CPA, FACHE, FHFMA, took over Monday as interim CEO of Southwest Health System, based in Cortez, Colorado, after the organization fired a fourth C-Suite executive this month.
Sudduth's specialty in healthcare finance appears to be of particular importance to the system, since money woes were cited when three executives were booted from their jobs earlier this month.
CEO Kent Rogers, CNO Karen Pasquin, and chief ambulatory services officer Ken Boucher “were separated from the organization” on April 6, a system spokesperson told The Journal newspaper.
Ten days later, on Friday, CFO Angela Kobel was booted from her job as well, the organization announced Monday.
“In the absence of a CEO, it became apparent that Ms. Kobel was no longer able to fulfill the responsibilities of the position,” Southwest Board Chairman Paul Deshayes said in a news release, as The Journal reported.
The system has hired Community Hospital Corporation's consulting arm to assess the hospital's current operations and possible areas of improvement.
Precisely what executive action the governor could take remains unclear.
Atlanta-based Piedmont Healthcare and Blue Cross Blue Shield (BCBS) of Georgia have until the close of business Tuesday to resolve their contract dispute.
That ultimatum came Monday in a tweet from Gov. Nathan Deal, who warned "the state will be forced to initiate executive action" if the impasse continues.
Because the parties failed to reach an agreement by April 1, Piedmont physicians became out-of-network providers under the BCBS plans for about 650,000 state employees, retirees, and their families.
"We understand the disappointment of our consumers, as many of our own employees who receive care through Piedmont are also affected, and we are very disappointed by the disruption caused by Piedmont’s rejection of our offer," BCBS said in a statement.
Piedmont, however, accused BCBS of drafting written contracts that failed to match the verbal commitments the parties had reached before March 31. Physician compensation appears to be a key point of contention.
"What Anthem Blue Cross is offering our doctors does not even cover the annual rate of inflation, but they will tell you that we are asking for unfair rate increases," Piedmont said in a statement. "One only needs to look at the small community hospitals—across Georgia and the country—that are closing their doors to see why fair rates are important."
Precisely what executive action Deal could take if the Piedmont-Anthem contract remains unresolved past today's deadline is unclear. One possibility would be a "re-enrollment" period that would give state employees an opportunity to switch from BCBS to another insurer, as The Atlanta Journal-Constitution's Greg Bluestein reported.
But pulling the trigger on re-enrollment in the middle of a health plan year would be expensive, as Georgia State University health insurance expert Bill Custer told Georgia Health News.
Alternatively, Deal could direct officials to look into other means by which to promote competition among hospitals and insurers in the affected market.
The original lawsuit was filed by the Missouri Hospital Association regarding how DSH payments are calculated.
The Centers for Medicare and Medicaid Services (CMS) filed an appealFriday of a federal court decision that had blocked it from enforcing a final rule last year regarding disproportionate share hospital (DSH) payments.
The move challenges a win by the Missouri Hospital Association (MHA), which was granted summary judgment in February after filing the original lawsuit in March 2017.
The MHA argued that a frequently asked questions (FAQs) page and final rule prepared by CMS contradicted the Medicaid Act. District Court Judge Brian C. Wimes agreed and blocked CMS from enforcing either document.
Jane Drummond, MHA general counsel, told HealthLeaders Media in February that she expected the Missouri ruling would be appealed.
"We are one of three cases that have challenged the Final Rule and this is the first decision invalidating it, so they will most certainly appeal to preserve their position in those other two cases," Drummond said.
At issue is the formula used to calculate DSH payments. If the MHA ultimately prevails, hospitals would potentially be spared from hundreds of millions of dollars in recoupment.
A repeat whistleblower has secured three settlements, with payouts totaling more than $6 million for herself, from three different health systems that employed her for short periods of time.
Cecilia Guardiola stands to gain about $3.3 million from Banner Health for settling a whistleblower lawsuit she filed in 2013 over the Phoenix-based nonprofit's billing practices.
This marks the third time Guardiola has used False Claims Act litigation to pressure a health system into changing its practices and paying millions in settlement money, according to federal court records reviewed by HealthLeaders Media.
The three known payouts were agreed upon in 2012, 2016, and 2018, as outlined below:
2012: Christus Spohn (Texas)
Guardiola worked about 16 months as director of case management for nonprofit Christus Spohn Health System in Texas, according to court records. She resigned in 2007 and filed a lawsuit in 2008. It was settled in 2012.
Christus agreed to pay the federal government more than $5.1 million, according to the settlement agreement. The terms called for Guardiola to receive more than $1 million of that amount.
Christus also agreed to pay more than $145,000 to cover Guardiola's legal fees.
2016: Renown Health (Nevada)
Guardiola worked about 19 months as director of clinical documentation then director of clinical compliance for Renown Health in Nevada, according to court records. She resigned in January 2012 and filed a lawsuit within five months. It was settled in 2016.
Renown agreed to pay the federal government $9.5 million, according to the settlement agreement. The terms called for Guardiola to receive $1.7 million, as the Associated Press reported.
The litigation was still active as of early 2018.
2018: Banner Health (Arizona)
Guardiola worked less than three months as corporate director of clinical documentation for Banner Health in Arizona, according to court records. She resigned in December 2012 and filed a lawsuit in 2013. It was settled this week.
Banner agreed to pay the federal government more than $18.3 million, according to the settlement agreement. The terms called for Guardiola to receive $3.3 million of that amount.
Banner also agreed to pay more than $144,000 to cover Guardiola's legal fees.
Her attorneys
In all three of these lawsuits, Guardiola has been represented by Houston-based attorney Mitch Kreindler of Kreindler & Associates. Kreindler partnered up with Reno-based co-counsel for the Renown case and Phoenix-based co-counsel for the Banner case.
Kreindler told HealthLeaders Media that his client is "basically unemployable" in the healthcare industry these days due to her whistleblower status. Her message to hospital and healthcare executives is pretty clear, he said.
"I think she would say it's possible to be very successful in healthcare while acting with integrity in a manner that safeguards public dollars," Kreindler said. "The two issues are not inconsistent, and if you act with integrity, you can be very successful in the field."
Guardiola, a registered nurse, graduated from Michigan State University's Detroit College of Law in 2002 before returning to the healthcare field, according to court documents.
She worked as a clinic nurse for MD Anderson in Houston then as director of case management for Providence Memorial Hospital in El Paso, Texas, before taking her job with Christus.
Maryland and New Jersey passed laws designed to help stabilize their health insurance markets.
As the federal government continues to denounce the Affordable Care Act (ACA) and neutralize some of its requirements, certain states are responding with countermeasures of their own.
New Jersey lawmakers sent a bill Thursday to Gov. Phil Murphy that would reinstate a state-level individual mandateto require most insurers to have health insurance or pay a penalty, as the Asbury Park Press reported. A separate state bill would establish a reinsurance plan funded partly with federal dollars.
"It's a two-pronged attack to get at premium costs,” New Jersey Health Care Quality Institute President and CEO Linda Schwimmer told the Press.
Other states are considering similar policies to stabilize their insurance markets.
Maryland Gov. Larry Hogan, a Republican, recently signed the Maryland Health Care Access Act of 2018, which reinstates a fee insurers used to pay through the ACA, as The Frederick News-Post reported. The fee is expected to funnel about $300 million into the Maryland Health Benefit Exchange Fund.
“Increasing rates have been a problem now for close to a decade and are a direct result of massive changes to our health care laws made in Washington. And the problems have only increased due to the lack of action in Washington,” Hogan said, as the News-Post reported. “The stakes here were tremendous, but we faced this crisis together, and we addressed it head-on.”
The bill also requires that a study be conducted to recommend further stabilizing measures Maryland may implement over the coming year.
Andy Slavitt, who served as acting administrator of the Centers for Medicare and Medicaid Services (CMS) under former President Barack Obama, said New Jersey and Maryland are leading the way to shore up the ACA despite efforts to undermine Obama's signature healthcare law.
"What states do today, the country will do beginning 2021," Slavitt wrote Thursday in a tweet.
But others are less convinced that state efforts will be able to solve the ACA riddle, as Sam Baker wrotelast month for Axios. Baker cited several reasons, including the fact that state-level individual mandates aren't significantly more popular than the federal-level mandate was.
A clinical documentation specialist worked only three months before resigning and accusing the health system of fraudulent billing practices.
Phoenix-based nonprofit Banner Health hired Cecilia Guardiola, a registered nurse, as corporate director of clinical documentation in fall 2012.
Within three months, however, Guardiola resigned over concerns that Banner seemed to be billing Medicare improperly. When she told administrators that she found inflated numbers and falsified documents, her bosses were allegedly unwilling to change.
"It became clear to her very quickly that the interest was on enhancing revenue and not on guaranteeing compliance or integrity," Guardiola's attorney Mitch Kreindler told HealthLeaders Media.
Guardiola filed a federal whistleblower lawsuit under the False Claims Act in 2013, detailing her allegations. That lawsuit was settled this week, with Banner agreeing to pay more than $18 million, the Department of Justice (DOJ) announced Thursday afternoon.
Twelve of Banner's hospitals in Arizona and Colorado had been accused of taking patients who could have been treated in an outpatient setting and admitting them instead for costlier inpatient care, then submitting false claims to Medicare.
"Hospitals that bill Medicare for more expensive services than are necessary will be held accountable," said Christian J. Schrank, special agent in charge for the Department of Health and Human Services (HHS) Office of Inspector General (OIG), in the DOJ's written announcement. "Medical decisions should be made based on patients' conditions and needs, not on providers' profits."
The organization has until April 20 to pay the federal government $18.3 million, plus 2.25% interest calculated from last May, according to the settlement agreement, which was filed in federal court this week. The government will then pay Guardiola 18% of that amount, about $3.3 million.
The health system must also pay more than $144,000 in Guardiola's legal fees.
Banner spokesperson Becky Armendariz released a statement saying the organization is "fully committed" to complying with regulations and the law while providing high-quality patient care.
"Although the rules that dictate when a hospital can accommodate a physician's request to admit a Medicare patient are complex and evolving, our policy has always been to make those decisions in accordance with government guidelines," Armendariz said in an email.
"The settlement does not involve any finding of wrongdoing on Banner's part, and we are pleased to resolve this matter to avoid the disruption and expense of ongoing litigation," Armendariz added.
Guardiola's complaint had accused Banner of knowingly defrauding the government in three ways: by falsifying Medicare bills to avoid denials, by billing short-term outpatient services as though they were inpatient services, and by inflating the number of hours spent observing patients.
The complaint lists hundreds of specific transactions that Guardiola alleged were billed inappropriately.
"In many of these situations, defendants billed the services as inpatient even though the patient was admitted to and discharged from the hospital on the same calendar day," the complaint states. "As a result of their conduct, the defendants reaped substantial and illicit profits at taxpayer expense."
Banner's spokesperson declined to comment on the specific allegations Guardiola and her attorneys raised.
Kreindler said his client, who was not available for an interview Thursday, has had a tough time finding work because she challenged Banner's practices.
"Being a whistleblower is a little bit like being a homeless shelter," he said. "Everybody thinks we should have them, but nobody wants to be near them."
Editor's note: This story has been updated to include additional information.
Researchers say the key is in a facility-specific model, rather than a one-size-fits-all approach.
A team of medical researchers trying to predict which hospital patients face the highest risk of contracting Clostridium difficile (C. diff) reviewed more than a quarter-million electronic health records (EHR) with a simple hypothesis.
Perhaps the key to understanding C. diff risk factors is context, they suggested. So the team of researchers from the University of Michigan, Massachusetts General Hospital, and the Massachusetts Institute of Technology (MIT) devised a project to test whether risk factors vary from one facility to the next.
Jenna Wiens, PhD, a senior author on the paper and an assistant professor of computer science and engineering at the University of Michigan in Ann Arbor, said the project threw out some of the overly generalized assumptions that inhibited past efforts to predict which patients would face the highest C. diff risk.
“When data are simply pooled into a one-size-fits-all model, institutional differences in patient populations, hospital layouts, testing and treatment protocols, or even in the way staff interact with the EHR can lead to differences in the underlying data distributions and ultimately to poor performance of such a model,” Wiens told the university’s Michigan Health Lab publication.
“To mitigate these issues, we take a hospital-specific approach, training a model tailored to each institution,” she added.
Wiens and her colleagues used big data techniques to analyze EHR entries from more than 190,000 adult admissions to the University of Michigan Hospitals (UM) and more than 65,000 adult admissions to Massachusetts General Hospital (MGH), according to the abstract.
“We extracted patient demographics, admission details, patient history, and daily hospitalization details, resulting in 4,836 features from patients at UM and 1,837 from patients at MGH,” the researchers wrote.
They used machine learning to identify two models, one for each facility. Although the two models bore some similarity in which factors predicted higher C. diff risk, many of the top-ranked factors differed between the two facilities.
The study states that it appears to have predicted earlier and more accurately which high-risk patients should be targeted for infection prevention.
Vincent Young, MD, PhD, a study coauthor and a professor in the University of Michigan Department of Internal Medicine, told the institution’s publication that this research could make it easier to mitigate the dangerous hospital-acquired infection.
“The ability to identify patients at greatest risk could allow us to focus expensive and potentially limited prevention methods on those who would gain the greatest potential benefit,” Young said.
The CEO, CNO, and chief of ambulatory services were dismissed from their posts immediately.
Three members of the senior leadership team at Southwest Health System in Cortez, Colorado, were fired Friday morning for unspecified reasons, The Journal reported.
A system spokesperson told the local paper that CEO Kent Rogers, CNO Karen Pasquin, and chief ambulatory services officer Ken Boucher “were separated from the organization.”
Current directors of surgical services and medical staff will fill in for Pasquin and Boucher, while Southwest looks for an interim CEO to handle Rogers’ duties.
The spokesperson said the decision was made as part of a “change in leadership direction,” the Journal reported.
Local radio station KSJD reported Monday that financial reasons, including troubles with Medicaid reimbursement and lackluster growth, prompted the removals.
The Associated Press reported last fall that Southwest Memorial Hospital was among hospitals across Colorado that were owed millionsof dollars by the state’s Medicaid program.
After attempts to repeal the Obama administration's signature healthcare law faltered, the Trump administration set an agenda for the Affordable Care Act's implementation next year.
In signing a major tax reform bill into law late last year, President Donald Trump claimed to have "essentially repealed Obamacare" by neutralizing the legislation's individual mandate penalty.
But the Affordable Care Act (ACA) is still on the books—and gaining in popularity—despite the repeal-and-replace rhetoric Trump and fellow Republicans have voiced for years.
The administration acknowledged that fact on Monday when it unveiled a final rule for ACA implementation in 2019.
“Too many Americans are facing skyrocketing premiums that they can’t afford and every year consumers are faced with the threat of fewer choices," Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma said in a statementblaming the ACA for rising insurance premiums and declining choices. "This rule gives states new tools to stabilize their health insurance markets and empower citizens to find coverage that fits their families’ needs and budgets."
A draft version of the final rule, which is scheduled for publication in the Federal Register on April 17, is available online.
"Over time, issuer exits and increasing insurance premiums have threatened the stability of the individual and small group Exchanges in many geographic areas," the proposal's executive summary states, adding that the final rule will focus on enhancing the role states play in ACA programs, increasing flexibility, "reducing unnecessary regulatory burden on stakeholders, empowering consumers, and improving affordability."
Verma's summary of the final rule notes that this increase in flexibility will give states more leeway in defining essential health benefit (EHB) benchmarks.
The push for added flexibility comes as the administration has sought also to ease restrictions on short-term, limited-duration insurance and association health plans, which are exempt from some of the ACA’s requirements.
Andy Slavitt, who served under former President Barack Obama as CMS administrator, said in a tweet that the rule lowers protections for people with preexisting conditions, increases the cost of coverage, and increases barriers to enrollment.
"It’s an effort to create a very different vision that looks like 2007," he added.
Ambulatory healthcare and hospitals saw biggest March gains in within the sector.
The latest employment numbers released by the federal government indicate that healthcare remains among the major industry sectors driving jobs growth.
More than 22,000 healthcare jobs were added in March, keeping roughly in line with the average number of healthcare jobs added for each of the past 12 months, according to data released Friday by the Bureau of Labor Statistics (BLS).
Within healthcare, the largest gains were among ambulatory healthcare services (16,000 jobs) and hospitals (10,000 jobs). Nursing and residential care facilities, meanwhile, lost nearly 4,000 jobs in March.
These overall numbers are not surprising. Healthcare occupations were projected to grow by 18%, or 2.4 million jobs, from 2016 to 2026, according to BLS analysis. The strength of the healthcare sector is attributed largely to the aging U.S. population, which drives demand for services.
But this rising demand coincides also with rising healthcare spending, which is projected to grow by 5.5% each year through 2026, outpacing American spending in other sectors.