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January 2, 2012

ACO Proves Major Political Turning Point For Boston Hospital Chain

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Transforming a hospital system into a fully-functioning ACO is a huge project, and one which requires a big commitment.  It’s hardly surprising that going through the process would change how its leaders think about their business.  But the following is the first case I’ve heard of in which a hospital system made a major break with its peers over its ACO status.

Apparently,  for-profit Steward Health Care System has just resigned from the Massachusetts Hospital Association, bringing its 10 hospitals (and 11 percent of the MHA’s revenues) with it.  Steward, which was created by the acquisition of six-hospital Caritas Christi Health Care Chain a year ago by VCs, has since picked up four hospitals and done a host of doctor deals.

Not surprisingly, Steward seems to have bruised some competitors’ feelings along the path to ACO-hood, which probably has something to do with its MHA departure, but Steward isn’t copping to that of course.

At this point in its evolution, Steward’s leaders say, the MHA’s positions on politics don’t represent its needs anymore. Particularly when it comes to health reform, Steward’s leaders feel it now has a different take than other members of the MHA, which has to advocate for shared positions across almost 100 hospitals with varied approaches.

As for me, I’m not sure what those differences are; in fact, I’d think that a “real” ACO would be an inspiration for, and partner to, other hospitals on the path to health reform.  In fact, this raises some questions as to how the growing ACO trend will affect hospital relationships this year:

* Are IDNs that work hard at building a true ACO going to upset their peers so much that it will create a drag on their business overall?

* Most healthcare business models have some detractors and some fans, but is this one of the few that can actually divide the industry?

*  Are ACOs a direction every IDN can take, or are there resource constraints (such as the size of a local market or number of unaffiliated doctors) that will prevent some from building one? Will the coming rush create ACO “haves” and “have nots”?

What do you think, folks?  Have you seen anything happening in your markets that might answer these questions?

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November 14, 2011

Hospitals play unfair games with Medicare observation status

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Most hospital visitors don’t care a whole lot whether they’re classed as inpatients or outpatients  — unless it affects the size of their bill. But lately, many patients are getting hit with unexpected fees after spending days in a hospital, thanks to tricks hospitals are playing in an effort to lower their readmission rate numbers, a newly-filed lawsuit contends.

These days, hospitals are under intense pressure to lower readmission rates, as such rates figure into their ratings on various types of quality scales.  In some cases, of course, they have no direct control of this number, as readmissions often have far more to do with the care they receive from community physicians and their willingness to comply with discharge instructions.

But ever-resourceful administrators have found a loophole that allows them to rejigger the admissions numbers. Under Medicare rules, they’re allowed to keep patients on “observation status,” deliver care and let patients go without ever classing them as inpatients. All of which might be well and good, except that if patients are in a hospital for days, they rack up a big bill — one they’re expected to pay far more of if the visit is billed as outpatient care under Medicare Part B.

Even more delightful for these patients, the fact that they haven’t logged three or more “real” inpatient days means that Medicare won’t pay for follow-up in a skilled nursing facility after discharge. So seniors either do without, or end up having the state pay through Medicaid.

Nice way to look out for patients, guys. Being old and sick and scared isn’t bad enough; now seniors have to wonder if their hospital costs are paid for even with Medicare coverage in place.

With this kind of mumblety-peg becoming fairly common, a consumer group called Center for Medicare Advocacy has filed a lawsuit to call a halt to the fun. The group is asking CMS to simply end observation status as a billable category.

While I sympathize with hospitals to some degree, who are also hoping to dodge scrutiny from the RECs by avoiding inpatient claim reviews, setting up seniors for high costs by playing unfair games is bad for you, the industry and the patient. Cut it out.

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August 22, 2011

Another safety-net hospital on life support: Miami’s Jackson Memorial on its last legs?

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You know, no matter many how many times  you watch it happen, it’s always an ugly spectacle.

When a safety-net hospital goes under because, well, being a safety net costs a ton, the poor are left with less than nothing. Worse, along the way, the hospital often slips from being an inelegant but functional resource to a nasty, scary place you wouldn’t send your worst enemy.

I was truly sorry to read that Jackson Memorial Hospital of Miami — a sprawling, 1,550-bed campus which still houses outstanding programs like the Bascom Palmer Eye Institute and the Ryder Trauma Center — seems to be moving rapidly from quick to dead.

The giant public entity, which serves as the primary teaching hospital for the University of Miami Miller School of Medicine, has faced plenty of controversy of its time, including accusations that some of its poor clientele were allowed to die for lack of followup care. That, of course, is an extremely serious matter.

But for most of its life, Jackson did at least offer the roughly 650,000 uninsured of Miami-Dade county an alternative to going into hock in the pricey EDs run by its competitors. It went through a colorful string of outspoken leaders, none of which seemed to share the same vision for the place, faced lawsuits and immigration issues and politics galore, but continued to stay afloat.

Those days, it seems, are over. According to a recent Miami Herald article, the Jackson Health System lost $337 million over two years, despite taking in $350 million a year from sales and property tax revenue alone.

This week, the system announced that it was hiring new leaders to step into the top administrative roles at JHS.  But in a system where its own employees refuse to get their care on site, I get the feeling that “changing deck chairs on the Titanic” covers things. What a shame.

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November 19, 2010

Meaningful Use: What is it good for? A lot of smoke and mirrors

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EHR Adoption Framework_AD

Image by andyde via Flickr

Meaningful Use?  Whoa! Good God y’all! What is it good for?  Very, very little. Sing it again…

OK, maybe it’s the greatest idea in the history of health IT, or maybe it’s a good idea gone terribly, terribly wrong (my theory), but it it’s not going to move hospitals along any faster than they are already toward smart, sophisticated IT use that saves lives.  There are efforts out there that do stand a chance of improving IT use (take your pick from dozens, which I’ll get to in another post), but has anyone provided clinical, social science or other data suggesting that going to MU first was the best way to spend all of this time and money?

After my months-long absence from the blog that I love (<grin>) I’m freshly charged up with looks to me like another major distraction from improving quality.

Here’s my logic: check me  out here and see if you agree. The harder the government comes down on hospitals, the more dust will get swept under the rug.  And when that “dust” is inefficient processes that stand a chance of killing people,we’re not talking any kind of joke here.

Want an idea of why I’m so skeptical?  Here’s a few (why not a  couple of bonuses):

*  Just got off the phone this week with a children’s hospital CEO, who’s found that 20 percent or less of his colleagues are ready for meaningful use.   And check out an Information Week article below, which reports that just 40 percent of hospitals  meet 5 MU criteria. Wow.

*  Why has it suddenly become a priority, in recent years, to automate processes at the bedside before the processes themselves have been perfected?  When Your Editor attended a conference this week on healthcare IT topics, the bedside came up a lot, but not much talk on whether we’ll be running into a GIGO problem.

* Medical groups and hospitals are under great pressure to form Accountable Care Organizations, a new entity for which there are some precedents (decades of capitation) but no clear-cut model.  With doctors and hospitals struggling to create the most basic levels of partnerships, is now a good time to pressure them to form their work habits around their IT investments? Yeah, yeah, they’re suppposed to fund and find EMRs and HIEs that meet their needs but really, how often will that happen?

If you’re a big MU fan, well, I’m sorry if I offended you.  But I’d much rather you flame the heck out of me here so we can have a nice dialogue on the subject. This is important stuff, people.

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August 13, 2010

Oops, he did it again; Rick Scott's history repeats itself

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For those who have followed the rise and fall of Rick Scott, former CEO of hospital chain Columbia/HCA, you may find the following to be  amusing.

If you’re  a Scott fan, you may see the allegations below as a setup. But if you thought the Columbia/HCA scandal was his misdoing, however, you may wonder how the man keeps this stuff up.

Not long ago, Scott bought a lot of media attention by running an anti-health reform organization, “Conservatives for Patients Rights,”  spending $5 million of his personal fortune to promote his message.  Now, it seems, he’s hoping to parley his renewed high profile into a role as governor of Florida.

The problem is, there’s the teeny little  issue of what’s going on at the company he runs today.  Just two weeks before the Florida primary,  his urgent care company Solantic has been accused a string of improper practices, including Medicare fraud and misuse of physician licenses.

None of the Medicare fraud allegations have been proven, and a series of physician suits against the company have been quietly settled, but these problems have cast a cloud over Scott’s gubernatorial bid nonetheless. And in reality, they should probably raise deeper questions as to Scott’s personal culpability — though to date the state hasn’t gotten involved.

The rise and fall of the Columbia empire

As many readers will know, Scott was kicked out of office CEO of Columbia/HCA hospital chain, an organization he’d helped to build with the backing of Texas billionaire and GW Bush financier Richard Rainwater. (Rainwater’s wife Darla was the one who fired him.)

Looked at one way, Scott and lieutenant David Vandewater (now CEO of Ardent Health) did a spectacular job. With  hustle, muscle and an eye for undervalued properties, they built Columbia up from two dinky hospitals in El Paso to the world’s largest health care organization. At its peak, Columbia/HCA had $20 billion in annual revenues, and more than 340 hospitals, 130 surgery centers and 550 home health locations in 38 states and two foreign countries.

The  problem is that the whole sprawling empire seems to have been rife with billing fraud.

It’s important to note that throughout the Columbia/HCA mess, Scott was never charged with a crime or deposed. Still, the meltdown happened on his watch, and after his departure the company paid out a stunning $1.7 billion fine to the feds.

By the way, Solantic CEO Karen Bowling headed up advertising at Columbia Healthcare Corporation, the company Scott built and merged with HCA. By no means do I want to suggest that she did anything wrong, either, but it is a bit curious that someone goes from marketing to a complex healthcare administration role.  (Not sure what that means — just putting it out there.)

The Solantic chapter

Anyway, regardless of who actually pulled the trigger on the Medicare and Medicaid shenanigans at Columbia/HCA, what’s up this time around? If nothing else, I don’t buy Scott’s “bad things just happen around me” line, do you?

As with Columbia/HCA, Solantic been accused of systematic, deliberate Medicare  billing fraud, a charge which was also leveled at him as leaders  of the Columbia/HCA empire.  For example, Solantic has purportedly  been in the habit of billing Medicare 100 percent of scheduled fees for unsupervised nurse practitioner visits, when rules require that it bill 85 percent.

Solantic is also accused of adding its doctors’ names to state filings and billing forms, seemingly in an effort to falsify how much physician coverage if had in place.

For example, former Solantic physician Dr. Randy Prokes, who worked there from 2004 to  2009, says he found his name on billing forms and medical records at company clinics he’d never visited and for patients he’d never treated, according to The Florida Independent.

Another plaintiff, Dr. P. Mark Glencross, filed a lawsuit in 2008 asserting that Solantic used his name to license six clinics without his knowledge.  Glencross began work  at Solantic in 2003 as chief medical officer, but left in 2004 after he allegedly discovered the misuse of his name and medical license, the Independent reports.  Solantic settled with Glencross this year, under a confidentiality agreement which keeps Glencross from chatting up the press any further.

No “Governor Scott”?

What makes all of this explosive, of course, isn’t the allegations themselves. As readers know, many healthcare organizations make it through accusations  that forms weren’t filled out properly or that Medicare was billed incorrectly.

But given Scott’s fight for the Republican gubernatorial nomination — he’s (yuck) the Tea Party’s candidate — the Solantic accusations are nasty, corrosive and who knows, might even derail his bid.  His primary opponent, State Attorney General Bill McCollum, has pulled ahead  in the polls since the allegations went public.

McCollum has been pounding on Scott to voluntarily disclose the video of the deposition he gave in the case filed against him by Dr. Glencross (one of the two MDs claiming Solantic misused their licenses and names).  Scott, to date, has refused to do so.

At this point, with so much questionable behavior at issue, one has to ask:  Would you want Rick Scott to run your healthcare organization, much less your state?    Seriously folks, would you?

P.S.  I can’t vouch for the accuracy of the content, but you might want a look at this post, which purports to offer a detailed map of Scott’s relationships over the last decade or so.  Intense stuff.

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August 6, 2010

Proposition 8: A warning to hospitals

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Sadly, it seems that unless the Supreme Court kills California’s anti-gay-marriage Proposition 8 dead, and that creates a domino effect nationally, hospitals will be slow to treat gay and lesbian families with dignity and provide similar levels of support.  

As far too many sad incidents illustrate, hospitals have treated gay couples as though their relationship gave them no rights — even when they’d signed a stack of legal papers which should have closed the matter.

One recent example is the case of Janice Langbehn, who was barred from seeing her dying partner Lisa Pond because the two weren’t married.  According to Langbehn, who sued Miami’s Jackson Memorial Hospital over the incident, the staff refused to even take a medical history on Pond from her, despite the fact that Pond was unconscious. 

The incident, which happened in February 2007, drew national attention. But it still took Jackson until April of this year to institute an official policy naming same-sex partners as “family” for vistation purposes.

Now, Jackson Memorial may be an outlier —  other hospitals have already clarified their policies to offer equal protection and access to all families — but it’s also a county facility.  Apparently, governmentally-sanctioned discrimination was just fine with the city fathers and mothers until just this year.

That kind of foot-dragging has to stop. Regardless of how you feel about gay marriage, there’s a lot of momentum behind the movement, and it’s not likely to go away.  So even if you’re unmoved by appeals to fairness or the suffering of gay spouses, try legal reality on for size. 

Hey, hospitals are terrified of blowing HIPAA rules, and only a couple hundred violations have been cited since its inception. (Criminal convictions? Counted easily on your fingers.)  Don’t you think gays and lesbians are going to see to it that you get some very serious heat if  you treat them like second-class citizens?  That’s a more serious threat than a possible Britney Spears leak.

Hospital leaders, it’s time to begin training your staff that discriminatory treatment of gays and lesbians won’t be tolerated, any more than they’d be permitted to kick Latino dads out of their wives’ rooms or refuse to take medical histories from Asians.  Their politics, feelings and preferences are fine, but they have to stay at home (or go elsewhere with them to a different institution).  This is going to be a really tough one, sadly, so be prepared for some blowback. But go ahead anyway.

P.S.  For a little treat, I give you “Summer of Loving,” a sweet and memorable tune comparing the battle over Proposition 8 to Loving v Virginia, the case in which the Supremes struck down laws against interracial marriage.

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July 15, 2010

Video/satire: The real health plan business model

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The following song, by brilliant social and political satirist Roy Zimmerman, offers his view of health plans’ real business model. His take?  As far as health plans are concerned, sick patients would (literally) be better off dead:

Dear Number 1036924053887
Have you considered suicide?
It’s a healthcare plan you haven’t tried.
Enclosed please find a tab of cynanide…for your perusal
You’re getting to an age where your potential need for medical
Attention even intervention isn’t hypothetical
So, do it quick!
And solve this nation’s healthcare crisis
By not getting sick.

To hear more incredibly elegant rhymes (hey, there’s a reason Tom Lehrer likes this guy) here’s the full song:

Now, I’ll confess that I simply get a massive kick out of Mr. Zimmerman, whether in health parodist mode or not, but I think you’ll  be amused by this one too.  Maybe you’ll be inspired to lampoon some bad actors too.  Street theater, anyone?

BONUS: While we’re having a bit of fun, here’s blast from the clinical world:  Emergency Depatment rap!  Seems there’s quite a trend going on here — maybe a dozen ED hip-hop videos cropped up on YouTube when I recently checked — but this group, from the University of Alabama’s Birmingham hospital, seems to be the Grandmaster Flash and Melle Mel of the bunch.

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June 25, 2010

Time to demand charity program disclosures

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Here’s a quick thought for the day:  What if the federal government made non-profit hospitals meet specific standards for publicizing their charity/free care programs?

As we all now, hospitals have to put their EMTALA notice front and center in the emergency department entry area.  I don’t know if the feds set a specific size for the notice, but in my experience as a patient, it’s usually a pretty big sign.

When it comes to charity care, on the other hand, there’s few if any standards for informing the public of their options. And far too often, hospitals don’t get the job done.

While some hospitals offer charity care notices on every bill they send out, post signs alerting patients to the option, tag every electronic transaction with a charity-care reminder — hell, they write it in the sky — others make rather perfunctory efforts.  Either they’re hiding something, or more likely, they just aren’t sure how to get the point across.

So, let’s make things simple. Let’s set a federal standard for displaying information on charity programs, something along the lines of EMTALA public display rules.
That way, financial managers won’t be forced to think like marketing communications types, and every hospital will be forced to follow the same rules.

Seems to me that would even the playing field; hospitals wouldn’t be rewarded for dodging their responsibilities, but instead, could compete on how well they performed.

So, why do I think this would be wildly unpopular? Am I right?

June 17, 2010

Video: How public reactions rip hospital buyouts apart

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   In theory, selling a hospital should be a fairly routine matter, at least if no unusual legal issues are involved. Often, the acquisition solves some serious problems by bringing in much-need capital.

But just as often, things get extremely messy. Communities like things the way they are, and go nuts.  Nurses strike. Regulatory issues mire down transactions for years and political debates get very ugly. In fact, after 20 years of watching hospitals get acquired, I can’t tell you how many times I’ve seen such deals go down in flames.

Just how bad can it get?  Well, consider this video , a slickly-produced political statement challenging the sale of Houston’s Memorial Hospital Southwest to a county entity. The deal involved fell apart late last year, but the way it went down is worth a look.

When Harris County announced plans to buy Memorial Hermann,  at least 200 doctors vowed to walk off the job if the facility changed hands. Their grievances were many, but the CEO’s position really cheesed them off. From the text accompanying the video:

 [CEO Dan Wolterman says] that Memorial Hermann has exceeded profit expectations for nine straight years, but the system still laid off many of the system’s top people this year. Now they want to dump Memorial Hermann Southwest and are asking for a $165 million taxpayer bailout from the Harris County Hospital District, whose history of Medicare/Medicaid fraud should be a source of concern for all taxpayers. Can we really trust these two greedy executives?

And then they get to what seems to have been the real issue. “They want to get rid of urban hospitals and build palaces in the suburbs. And they want us to pay for it!” the announcer warns sternly. So this particular battle had a “haves vs. have-nots” feel.”

OK, I’m going to get cruel here. I’m not convinced that doctors were really worried about saving an urban hospital.  They don’t make much money there and their patients are often indigent. But sometimes power struggles don’t need any real  justification.

The bottom line is that this kind of protest plays out in some community every day — and can get even hotter if a for-profit company rolls into town and starts shopping.

In fact, during Columbia Hospital Corp.’s acquisition spree in the early 90s, I attended a closed-door meeting on a proposed buyout in south Miami. One doctor said that he’d better drop his pants now because of, uh, what would happen next. Bear that in mind as you’re shopping, investors. And watch this video once or twice.

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June 15, 2010

News nuggets: Provocative news briefs from around the Web

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Here’s the first of my occasional posts sharing news briefs of interest (directly or indirectly) to the hospital world.

For future issues, please free to pass along interesting items if you see fit.  Just  drop me an note and I’ll take a look.


This Week’s Updates and Info

Aussie hospital proposes use of Tasers to subdue violent patients
http://bit.ly/czSxqw

Great McKinsey case study w/ chart:  Tracks how need for heart surgeons fell in the UK
http://bit.ly/aas21P

2009 Health Insurance CEO Compensation Study
http://bit.ly/9tleD3

The Pitfalls of Accountable Care Organizations
http://bit.ly/9giVya

AMA: One in five claims processed inaccurately by health plans
http://yhoo.it/dt6IAM

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