ASSIGNMENT: You are the CEO of a hospital in
the cone of Hurricane Dorian! Tomorrow morning you have an 8AM Board of
Trustees Conference Call to brief Board members on your hospital’s Rapid
Response plan.
Starting with the sources below prepare your 15 minute
presentation!
____________________
We don’t know what we don’t know” The challenge to emergency
preparedness…..
“…the only way..to respond to a crisis ..is to ensure every
member of the staff feels as though they are part of a team.” (Hurricanes, Mass
Disasters, Wild Fires)
“Houston’s world-renowned health care infrastructure found
itself battered by Hurricane Harvey, struggling to treat storm victims while
becoming a victim itself.”
“Calling 911 (about Hurricane Harvey) didn’t work. Begging
for help on Facebook and Instagram failed, too. “I was like, ‘Siri’s smart
enough! Let me ask her!’ …
As he looked at the full beds and patients “packed and
stacked in the hallways,” he shifted into triage mode, asking himself “Who’s
dying first?” and who could he save.
It appears that Hurricane Irma evacuation shelter managers
may make people wait outside for hours? If so, just welcome them in and then do
the registration process inside.
Over the years I have collected some aphorisms, quotations
and “classics” perhaps worth sharing.
“I made a lot of mistakes in my time but didn’t waste any
time making them.” (attributed to Gustave Levy, Goldman Sachs)
“There are no secrets to success. It is the result of
preparation, hard work and learning from failure.” (Colin Powell)
“A person who never made a mistake never tried anything new.” (Albert Einstein)
The three umpires (attributed to many):
At a post-season symposium three umpires were discussing
“what’s a ball and what’s a strike?”
The rookie umpire said “There are balls and there are
strikes and I call them as they are.”
The mid-career umpire said “There are balls and there are
strikes and I call them as I seem them.”
The veteran umpire said “There are balls and there are strikes but they ain’t nothing til I call them.”
“Trust, but verify!” (Ronald Reagan)
“If Columbus had an advisory committee he would probably
still be at the dock.” (Arthur Goldberg)
“Meetings without an agenda are like a restaurant without a menu.” (Susan B. Wilson)
Dr. Jerome Groopman in “How Doctors Think” developed a
classification system for medical mistakes, observing a tendency to treat a
case based on past experience rather than looking at it based solely on the
evidence.
Vertical Line Failure – thinking inside the box
Confirmation Bias – confirming what you expect to find by
selectively accepting or ignoring information
Anchoring –the failure to consider multiple possibilities
but quickly and firmly latching on a single one
Availability –an unusual event that recently occurred which
has similarities to the current case causing MD to ignore important differences
Commission Bias – tendency toward action rather than
inaction due to “bravado”, desperation, or patient pressure
Relying on “Strict Logic” – answering a clinical question in
the absence of empirical data
Over-reliance on Clinical Algorithms – simply filling in the
blanks on the template
Haste – complicated problems cannot be solved quickly
Outcome Bias – thinking that the diagnosis that is wished
for has occurred• Limited Searching –stop searching for a diagnosis once “
This is not to criticize physicians who get most things right and in a very challenging, fast-moving environment occasionally make mistakes. The point is we all fall into comfortable patterns of thinking – our own default classification systems.
“If you’re stuck in a routine that’s limiting your creativity or you’re faced with a challenging business problem and need a fresh approach, you can think outside the box. Or even better, think like there is no box.”
When you’re not sure flip a coin because while the coin is in the air, you realize which one you’re hoping for.” (source unknown)
“There are known knowns. These are things we know that we know.
There are known unknowns. That is to say, there are things that we know we
don’t know. But there are also unknown unknowns. These are things we don’t know
we don’t know.” (Donald Rumsfeld)
“No battle plan survives contact with the enemy.” (Helmuth
von Moltke the Elder. He was the Chief of Staff of the Prussian army before
World War 1)
“Insanity: doing the same thing over and over again and
expecting different results.” (Einstein)
“Life is What Happens to You While You’re Busy Making Other Plans.” (John Lennon)
“Never, never, never give up.” (Winston Churchill)
“Don’t depend on anyone else to bring the coffee.” (me)
“The best things in life aren’t things?” (Art Buchwald)
…and the most important
“Character is how you act when no one is watching” (attributed to many)
Confidential September 11, 2001 LESSONS LEARNED memorandum
by hospital CEO Jonathan Metsch goes “viral” and becomes a New Jersey
gubernatorial campaign issue
PART 1: January 31, 2019. “If you’re shot, stabbed, hit
by a car, fall off a roof or suffer any other major injury in San Francisco,
you’ll be whisked to San Francisco General Hospital, the only trauma center in
the city “
PART 2: February 20, 2019. A new bill would outlaw the big,
surprise bills that Zuckerberg San Francisco General Hospital has sent to
hundreds of patients.
PART 3: April 18, 2019. “Zuckerberg San Francisco
General Hospital announced Tuesday it has overhauled its billing policies…
PART 4: August 20, 2019. Hospitals kept ER fees secret
ASSIGNMENT:
How do other states address financial sustainability for their “safety-net”
hospitals?
PART 1: January
31, 2019. “If you’re shot, stabbed, hit by a car, fall off …
“If you’re shot, stabbed, hit by a car, fall off a roof
or suffer any other major injury in San Francisco, you’ll be whisked to San
Francisco General Hospital, the only trauma center in the city. …But you may
leave with a very unpleasant side-effect: a shockingly high bill. …That’s
because S.F. General – whose patients are overwhelmingly poor and are on
Medicare or Medi-Cal, or have no insurance at all – lacks a good way to deal
with patients who are actually insured.” (A)
“Under a new state law, if you visit an in-network
facility – such as a hospital, lab or imaging center – you will only be responsible
for your in-network share of the cost, even if you’re seen by an out-of-network
provider…
The new law covers Californians with private health
insurance plans that are regulated by the state Department of Managed Health
Care, or DMHC, and the state Department of Insurance, which includes roughly 70
percent of the state’s private insurance market, according to the California
Health Care Foundation.
It does not cover some 5.7 million people whose
employer-sponsored insurance plans are regulated by the U.S. Department of
Labor…
The key point to remember is that you shouldn’t pay more
than your in-network copayment, coinsurance or deductible, as long as you
visited an in-network facility for non-emergency services.” (B)
“The trauma center has no contracts with private
insurance companies. If it did, there would be agreements with those insurers
on how much a particular drug or a particular procedure costs.
Instead, the hospital charges the highest rates approved by
the Board of Supervisors and the mayor, receives whatever amount the patient’s
insurance company decides to pay, and bills the patient for the rest.” (C)
On April 3, Nina Dang, 24, found herself in a position like
so many San Francisco bike riders – on the pavement with a broken arm.
A bystander saw her fall and called an ambulance. She was
semi-lucid for that ride, awake but unable to answer basic questions about
where she lived. Paramedics took her to the emergency room at Zuckerberg San
Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of
her brain and spine. She left with her arm in a splint, on pain medication, and
with a recommendation to follow up with an orthopedist.
A few months later, Dang got a bill for $24,074.50. Premera
Blue Cross, her health insurer, would only cover $3,830.79 of that – an amount
that it thought was fair for the services provided. That left Dang with
$20,243.71 to pay, which the hospital threatened to send to collections in
mid-December…
Most big hospital ERs negotiate prices for care with major
health insurance providers and are considered “in-network.”
Zuckerberg San Francisco General has not done that bargaining with private
plans, making them “out-of-network.” That leaves many insured
patients footing big bills.
The problem is especially acute for patients like Dang:
those who are brought to the hospital by ambulance, still recovering from a
trauma and with little ability to research or choose an in-network facility.
A spokesperson for the hospital confirmed that ZSFG does not
accept any private health insurance, describing this as a normal billing
practice. He said the hospital’s focus is on serving those with public health
coverage – even if that means offsetting those costs with high bills for the
privately insured.
“It’s a pretty common thing,” said Brent Andrew,
the hospital spokesperson. “We’re the trauma center for the whole city.
Our mission is to serve people who are underserved because of their financial
needs. We have to be attuned to that population.”
But most medical billing experts say it is rare for major
emergency rooms to be out-of-network with all private health plans. (D)
“The largest public hospital in the city, Zuckerberg San
Francisco General cares for 20 percent of all San Franciscans, according to the
hospital’s website..
But contrary to the hospital’s position, only 1 percent of
ambulance rides nationwide drop patients at out-of-network emergency rooms,
according to a study by economist Christopher Garmon at the University of
Missouri Kansas City. The study also found that approximately 20 percent of
emergency department admissions nationwide resulted in a surprise medical bill.
Because of its size and top-tier emergency room, Zuckerberg San Francisco
General takes in one-third of ambulances in the city, meaning many of its
patients, some unconscious on arrival, are unaware of the hospital’s unusual
lack of support for their insurance…
“As a Level 1 trauma center, we must meet certain
requirements, 24/7/365, as delineated in the California Code of Regulations
(CCR) and by state and national credentialing agencies. The requirements are
substantial and, because they require such commitment of resources,
costly,” a statement from ZSFG released to Newsweek reads. “We
realize there are challenges, difficulties and inefficiencies in our national
system of healthcare insurance. We realize burdens are often placed on
individuals who are least able to afford them. And we are not in the position
of defending the inequities of this system, only working within our prevailing
system to the best of our abilities.” (E)
On its web site, ZSFG declares that “everyone is
welcome here” regardless of their financial situation or immigration status:
Everyone is welcome here, no matter your ability to pay,
lack of insurance, or immigration status. We’re much more than a medical
facility; we’re a health care community promoting good health for all San
Franciscans.
We’re part of a large group of neighborhood clinics and
healthcare providers, the San Francisco Health Network. In partnership, we
provide primary care for all ages, specialty care, dentistry, emergency and
trauma care, and acute care for the people of San Francisco…
“Our mission is to serve people who are underserved
because of their financial needs,” the spokesperson also stated. “We
have to be attuned to that population.” (F)
“More than half of U.S. adults “have been
surprised by a medical bill that they thought would have been covered by
insurance,” according to a new survey from research group NORC at the
University of Chicago…
The big picture: Drug prices have been in the crosshairs of
lawmakers, and health insurers have always been a punching bag. But hospitals
and doctors aren’t attracting any large-scale movement to rein in pricing and
billing tactics.
“There’s a huge amount of trust in the providers people
choose to go to,” said Caroline Pearson, senior fellow at NORC. “I
think we’ve got a long way to go until we have backlash against those
providers. But as insurance gets more complicated and out-of-pocket costs rise,
we’re going to see more and more surprise bills.”
The other side: Ashley Thompson, SVP of policy at the
American Hospital Association, said in a statement that “patients and
their families should be protected from…unexpected medical bills,” but
“insurers have the primary responsibility for making sure their networks
include adequate providers.”” (G)
“U.S. Sen. Bill Cassidy, R-La., said federal lawmakers
on both sides of the aisle are moving closer to an agreement on legislation to
prevent surprise medical bills, according to a Bloomberg Government report…
Republicans and Democrats have been working to address the
issue, and bipartisan legislation is predicted for early 2019, Mr. Cassidy told
Bloomberg Government…
There have been legislative efforts related to surprise
medical bills. In September, a bipartisan group of senators unveiled the
Protecting Patients from Surprise Medical Bills Act. Then on Oct. 11, Democrat
Sen. Maggie Hassan of New Hampshire introduced the No More Surprise Medical
Bills Act of 2018. The first draft bill focuses on preventing out-of-network
providers from charging patients more for emergency care than what they would
pay using insurance. The second bars healthcare providers from out-of-network
billing for emergency services, according to the report.
Meanwhile, Bloomberg Government notes, insurers and
hospitals are pointing the finger at each other over who is at fault for the
problem.
Mr. Cassidy told the publication there are “bad apples
with both groups” and anticipates both sides “are going to have to
give a little bit” when it comes to changes.” (H)
“Congress is considering bipartisan legislation to
limit balance billing. But some legal scholars say that patients should already
be protected against some of the highest, surprise charges under long-standing
conventions of contract law.
That’s because contract law rests on the centuries-old
concept of “mutual assent,” in which both sides agree to a price
before services are rendered, said Barak Richman, a law professor at Duke
University.
Thus, many states require, and consumers expect, written
estimates for a range of services before the work is done – whether by
mechanics and plumbers or lawyers and financial planners.
But patients rarely know upfront how much their medical care
will cost, and hospitals generally provide little or no information.
While consumers are obligated to pay something, the question
is how much? Hospitals generally bill out-of-network care at list prices, their
highest charges.
Without an explicit price upfront, contract law would
require medical providers to charge only “average or market prices,”
Richman said.
In several recent cases, for example in New York and Colorado,
courts have stepped in to mediate cases where a patient received a big balance
bill from an out-of-network provider. They ordered hospitals to accept amounts
far closer to what they agree to from in-network private insurers or Medicare.
“This is the amount they are legally entitled to
collect,” said Richman…
That complexity – and the cost of hiring an attorney – have
made legal challenges to medical bills on the basis of contract law relatively
scarce.
Also, “it’s not a well-settled area of the law,”
said Hall. “(I)
“Payer groups, including America’s Health Insurance
Plans, are joining forces with employers, consumers and other stakeholders in
support of a plan they say will tackle surprise billing.
The groups signed on to a set of guiding principles aimed at
protecting consumers from the practice. The guidelines are: inform patients
when care is out of network, support federal policy that protects consumers
while restraining costs and ensuring quality networks and pay out-of-network
doctors based on a federal standard.
Meanwhile, the American Hospital Association and the
Federation of American Hospitals released a joint statement saying hospitals
and health systems also support patient protections from surprise billing but
place blame on insurers, not providers…
AHIP said surprise billing happens because providers aren’t
participating in certain networks. “When doctors, hospitals or care
specialists choose not to participate in networks – or if they do not meet the
standards for inclusion in a network – they charge whatever rates they
like,” the group wrote.
In their statement, the hospital groups also backed consumer
protections, but pointed the finger at payers for the issue. “Inadequate
health plan provider networks that limit patient access to emergency care is
one of the root causes of surprise bills. Patients should be confident that
they can seek immediate lifesaving care at any hospital. The hospital community
wants to ensure that patients are protected from surprise gaps in coverage that
result in surprise bills, and we look forward to working with policymakers to
achieve this goal,” they wrote…
National leaders have been working on the issue too, but so
far a bipartisan effort has only resulted in drafted legislation. The bill
would require payers to reimburse out-of-network providers at 125% of the
average in-network rate while limiting patient liability to in-network
costs.” (J)
“For the past 15 months, I’ve asked Vox readers to
submit emergency room bills to our database. I’ve read lots of those medical
bills – 1,182 of them, to be exact.
My initial goal was to get a sense of how unpredictable and
costly ER billing is across the country. There are millions of emergency room
visits every year, making it one of the more frequent ways we interact with our
health care system – and a good window into the health costs squeezing
consumers today…
I’ve read emergency room bills from all 50 states and the
District of Columbia. I’ve looked at bills from big cities and from rural
areas, from patients who are babies and patients who are elderly. I’ve even
submitted one of my own emergency room bills for an unexpected visit this past
summer.
Some of the patients I read about come in for the reasons
you’d expect: a car accident, pains that could indicate appendicitis or a heart
attack, or because the ER was the only place open that night or weekend….
I’ll stop collecting emergency room bills on December 31.
But before I do that, I wanted to share the five key things I’ve learned in my
year-long stint as a medical bills collector.
1) The prices are high – even for things you can buy in a
drugstore
2) Going to an in-network hospital doesn’t mean you’ll be
seen by in-network doctors
3) You can be charged just for sitting in a waiting room
4) It is really hard for patients to advocate for themselves
in an emergency room setting
5) Congress wants to do something about the issue.. (K)
“Zuckerberg General’s emergency room fees are also
higher, on average, than ERs nationally, in the state of California, and in the
city of San Francisco. In the city, they’ve charged up to five times as much.
The fees are set by the San Francisco Board of Supervisors, which has voted for
steady increases, doubling the charge since 2010.
When asked about the fees, board members admitted that they
hadn’t kept a close eye on the prices and said they plan to hold hearings on
the issue.
“It turns out we should have been monitoring this much
more closely,” says Aaron Peskin, a supervisor who has previously voted in
favor of the hospital prices and who is now calling for the hearings…
The city of San Francisco manages Zuckerberg General and
sets the prices the hospital charges.
The task falls to the San Francisco Board of Supervisors, an
11-member board that oversees city policies and budgets. Every year or two,
they approve a lengthy document that lists hospital prices for everything from
an emergency room fee to a day in the obstetrics unit to a primary care exam.
The document describes the fees as “proper reasonable amounts.”
The current prices were approved at a board a meeting in
July 2017. A video recording of that meeting shows there was no debate or
discussion of the prices. Instead, the board of supervisors unanimously
approved the ZSFG charges in a voice vote that latest less than a minute…
But there is little record of public discussion or debate
over that increase. Meeting records for each vote on the hospital prices since
2010 show that the fees have always been approved unanimously.
“I cannot recall there ever being any discussion of
them,” says Peskin, a board member who has served on and off since 2001.
“I don’t think there has ever been a split vote, and that’s been true as
long as I’ve been on the board of supervisors. But that will probably change
now.”..
The San Francisco Board of Supervisors now plans to bring
greater scrutiny to the hospital’s billing practices in light of Vox’s
reporting.” (L)
“Zuckerberg San Francisco General Hospital is reducing
a bike crash patient’s $20,243 bill down to $200 – only after the case drew
national attention to the hospital’s surprising policy of being out-of-network
with all private health insurance…
The San Francisco Board of Supervisors, which oversees the
hospital, now plans to hold hearings on Zuckerberg General’s billing practices
as well.
“While we as a city should absolutely seek
reimbursement from private insurers, we should not be placing the burden of
exorbitant bills on patients – who deserve the highest quality care, not the
highest possible costs,” said Gordon Mar, the supervisor who chairs the
board’s government audit and oversight committee…
Zuckerberg San Francisco General Hospital has not commented
on whether it plans to change its policies, and go in-network with private
health insurance, although a spokesperson told Vox they are looking into how to
make sure other patients don’t end in a situation like Dang’s.
“We are focused on reducing the number of people who
could be in this predicament, through a variety of methods, including our own
practices, insurance payments, and policy solutions,” spokesperson Rachael
Kagan told Vox in an email.” (M)
“Momentum is building for action to prevent patients
from receiving massive unexpected medical bills, aided by President Trump, who
is vowing to take on the issue.
Calls for action against so-called surprise medical bills
have been growing, spurred by viral stories like one involving a teacher in
Texas last year who received a $108,951 bill from the hospital after his heart
attack. Even though the teacher had insurance, the hospital was not in his
insurance network.
Lawmakers in both parties say they want to take action to
protect people from those situations, marking a health care area outside of the
partisan standoff over ObamaCare, where Congress could advance bipartisan
legislation to help patients.
Trump gave a boost to efforts on Wednesday.
“[People] go in, they have a procedure and then all of
a sudden they can’t afford it, they had no idea it was so bad,” Trump said
at a roundtable with patients about the issue.
“We’re going to stop all of it, and it’s very important
to me,” he added.
But the effort still faces obstacles from powerful health
care industry groups – including hospitals, insurers and doctors. Those groups
are jockeying to ensure that they avoid a financial hit from whatever solution
lawmakers and the White House back.” (N)
“And the Republican chairman of the Senate health
committee told reporters recently he expects pushback from the industry – but
warned industry to act before Congress does. “The first place to deal with
it is for the hospitals and doctors and insurance companies to get together and
end the practice,” Sen. Lamar Alexander, R-Tenn., said. “And if they
don’t, Congress will do it for them.” The senator hasn’t, however, put
forward any specific legislation or scheduled hearings on the topic yet.”
(O)
“There are 141 million visits to the emergency room each
year, and nearly all of them.. have a charge for something called a facility
fee. This is the price of walking through the door and seeking service. It does
not include any care provided.
Emergency rooms argue that these fees are necessary to keep
their doors open, so they can be ready 24/7 to treat anything from a sore back
to a gunshot wound. But there is also wide variation in how much hospitals
charge for these fees, raising questions about how they are set and how closely
they are tethered to overhead costs.
Most hospitals do not make these fees public. Patients
typically learn what their emergency room facility fee is when they receive a
bill weeks later. The fees can be hundreds or thousands of dollars. That’s why
Vox has launched a year-long investigation into emergency room facility fees,
to better understand how much they cost and how they affect patients…
We found that the price of these fees rose 89 percent
between 2009 and 2015 – rising twice as fast as the price of outpatient health
care, and four times as fast as overall health care spending.” (P)
“Matt Gleason had skipped getting a flu shot for more
than a decade.
But after suffering a nasty bout of the virus last winter,
he decided to get vaccinated at his Charlotte, N.C., workplace in October.
“It was super easy and free,” said Gleason, 39, a sales operations
analyst.
That is, until Gleason fainted five minutes after getting
the shot. Though he came to quickly and had a history of fainting, his
colleague called 911. And when the paramedics sat him up, he began vomiting.
That symptom worried him enough to agree to go to the hospital in an ambulance.
He spent the next eight hours at a nearby hospital – mostly
in the emergency room waiting area. He had one consult with a doctor via
teleconference as he was getting an electrocardiogram. He was feeling much
better by the time he saw an in-person doctor, who ordered blood and urine
tests and a chest-X-ray.
All the tests to rule out a heart attack or other serious
condition were negative, and he was sent home at 10:30 p.m.
And then the bill came.
Total Bill: $4,692 for all the hospital care, including
$2,961 for the ER admission fee, $400 for an EKG, $348 for a chest X-ray, $83
for a urinalysis and nearly $1,000 for various blood tests. Gleason’s insurer,
Blue Cross and Blue Shield of North Carolina, negotiated discounts for the
in-network hospital and reduced those costs to $3,711. Gleason is responsible
for that entire amount because he had a $4,000 annual deductible. (The ambulance
company and the ER doctor billed Gleason separately for their services, each
about $1,300, but his out-of-pocket charge for each was $250 under his
insurance.)..
The biggest part of Gleason’s bill – $2,961 – was the
general ER fee. Atrium coded Gleason’s ER visit as a Level 5 – the
second-highest and second-most expensive – on a 6-point scale. It is one step
below the code for someone who has a gunshot wound or major injuries from a car
accident. Gleason was told by the hospital that his admission was a Level 5
because he received at least three medical tests.
Gleason argued he should have paid a lower-level ER fee,
considering his relatively mild symptoms and how he spent most of the eight
hours in the ER waiting area.
The American Hospital Association, the American College of
Emergency Physicians and other health groups devised criteria in 2000 to bring
some uniformity to emergency room billing. The different levels reflect the
varying amount of resources (equipment and supplies) the hospital uses for the particular
ER level. Level 1 represents the lowest level of ER facility fees, while ER
Level 6, or critical care, is the highest. Many hospitals have adopted the
voluntary guidelines…
Blue Cross and Blue Shield of North Carolina said in a
statement that the hospital “appears to have billed Gleason
appropriately.” It noted the hospital reduced its costs by about $980
because of the insurer’s negotiated rates. But the insurer said it has no way
to reduce the general ER admission fee…
Gleason, in fighting his bill, actually got the hospital to
send him its entire “chargemaster” price list for every code – a
250-page, double-sided document on paper. He was charged several hundred
dollars more than the listed price for his Level 5 ER visit…
Resolution: After Gleason appealed, Atrium Health reviewed
the bill but didn’t make any changes. “I understand you may be frustrated
with the cost of your visit; however, based on these findings, we are not able
to make any adjustments to your account,” Josh Crawford, nurse manager for
the hospital’s emergency department, wrote to Gleason on Nov. 15.” (Q)
Zuckerberg hospital puts balance billing on hold
Mayor London Breed and Supervisor Aaron Peskin Announce Halt
to Balance Billing at Zuckerberg San Francisco General Hospital Until Plan to
Improve Long-Term Billing Practices is Implemented
Friday, February 01, 2019
“Department of Public Health and ZSFG will develop a
comprehensive plan for improvements within 90 days to address the issue of
patients being billed the balance of their bills when their private insurers
refuse to cover their bills
San Francisco, CA -Today Mayor London N. Breed, Supervisor
Aaron Peskin, the Department of Public Health and Zuckerberg San Francisco
General Hospital and Trauma Center (ZSFG) announced immediate steps to improve
billing practices at ZSFG for patients who have gotten stuck in the middle of
disputes between the hospital and their insurance provider, including a
temporary halt to the practice of balance billing.
The San Francisco Department of Public Health (DPH) operates
ZSFG as part of the San Francisco Health Network, the City’s public health care
system. As San Francisco’s public hospital, the vast majority of ZSFG patients
have Medi-Cal, Medicare or are uninsured. About 6 percent of patients have
commercial insurance (including HMO or PPO plans) and come to ZSFG through
trauma and emergency services. For those patients, their insurance is billed
for services, and the insurance company decides what to pay. When an insurance
company does not pay in full, PPO patients can be billed for the balance, a
practice known as “balance billing.”
“Although ‘balance billing’ affects a very small number
of ZSFG patients, the stress and hardship they experience when it happens is
very real,” said Mayor Breed. “We need to look hard at our current
billing practices, and until we come up with a plan that works for patients, we
will not continue the practice of balance billing. In an emergency, people’s
focus should be on getting help quickly, not on what hospital they should go
to. Private insurance companies also need to be held accountable to actually
pay for the healthcare for anyone they cover.”
“The City is taking the right step by stopping the
practice of balance billing at SF General, because there’s nothing ‘balanced’
about it,” said Supervisor Peskin. “It’s extra billing for services
that patients don’t have a choice about receiving, further delaying their
ability to move on and heal. This immediate halt also covers the previous
patients who’ve been stuck with crippling bills, including those being sent to
collections. Healing delayed is healing denied, so I’m looking forward to
working with the Department of Public Health on a new path forward.”
Greg Wagner, Acting Director of Health, and Dr. Susan Ehrlich,
CEO of ZSFG, outlined a set of immediate actions and elements of a
comprehensive plan for improvement that will be developed within 90 days. This
includes making changes to billing practices, financial assistance and patient
communications. In addition, DPH and ZSFG are exploring policy solutions in
coordination with local and state elected officials.
“The billing practices at Zuckerberg San Francisco
General Hospital and Trauma Center for privately insured patients who receive
trauma and emergency services are not working for some of our patients,”
Wagner said. “Keeping the patients’ experience as the focal point, we will
explore ways to protect patients from financial hardship, increase
participation in financial assistance programs and where possible, recover
costs for services from insurers to avoid lost revenues to the City.”
“While hospital billing in the United States is very
complicated, patients should not be caught in the middle of disputes between
hospitals and insurance companies,” Ehrlich said. “At ZSFG, our
mission is to provide high quality health care and trauma services with
compassion and respect to everyone in San Francisco. We are working to ensure
that our billing practices better align with that mission. We are sensitive to
people’s circumstances and our patients come from all over the economic
spectrum. We cannot solve the problems of the entire health care system, but we
can do better to serve San Franciscans, who consistently have supported ZSFG
and the rest of the City’s excellent public health programs and services.”
DPH and ZSFG have continued to address the problem of
insurance payment shortfalls. DPH sued insurers for underpayment and reached
settlements, reducing the number of privately insured patients who might be
affected by a dispute. DPH’s patient financial services department works with
individuals year-round to help them with billing issues, including financial
assistance and appeals to insurance plans.
Immediate Changes
Temporarily halt all balance billing of patients
Effective immediately until a better plan is determined
Make financial assistance easier to get
Proactively begin the process of assessing a patient’s
eligibility for assistance, rather than waiting for them to apply
Improve patient communications
Proactively reach out to patients who are receiving large
bills to explain the situation, remove the element of surprise, and offer to
help
Create a Frequently Asked Questions document to clear up
many of the routine questions about billing and financial assistance
Publicize the patient financial services hotline, (415)
206-8448, so that people know where to go for help
Increase communication with patients and provide information
about financial assistance opportunities
Additional elements of a comprehensive plan to be developed
within 90 days
Make financial assistance easier to get
Adjust charity care and sliding scale policies to expand the
number of people who are eligible
Revise ZSFG catastrophic high medical expense program to
support more patients who are faced with high, unexpected bills for
catastrophic events
Streamline the process of applying for assistance
Protect patients’ financial health
Establish an out-of-pocket maximum for patient payments to
ZSFG
Pursue agreements with private insurance companies
Work with state partners to explore additional efforts to
improve insurance payments
Ensure ZSFG prices and practices are fair
Undertake a study of hospital charges regionally, comparing
trauma centers, academic medical centers, San Francisco and Bay Area hospitals
Research billing and financial assistance practices of
California public hospitals to identify opportunities for improvement
Conduct financial analysis of impact on the City of proposed
changes (R)
PART 2: February
20, 2019. A new bill would outlaw the big, surprise bills that Zuckerberg San
Francisco General Hospital has sent to hundreds of patients.
California lawmakers will introduce legislation Monday to
end surprise emergency room bills like those that left one patient with a
$20,000 treatment bill after a minor bike crash – a move they say was inspired
by Vox’s reporting on the issue.
The new bill, introduced by Assemblyman David Chiu and Sen.
Scott Wiener, would bar California hospitals from pursuing charges beyond a
patient’s regular co-payment or deductible. The ban would apply even if a
hospital was out-of-network with a patient’s health insurance.
“These practices are outrageous,” says Chiu, who
represents part of San Francisco in the state assembly. “No one who is
going through the trauma of emergency room care should be subsequently
victimized by outrageous hospital bills.”..
California actually has some of the country’s strongest
protections against surprise medical bills – but the state’s laws never
anticipated a hospital with billing practices like Zuckerberg San Francisco
General.
In 2016, California passed a law that protected patients
from surprise bills from out-of-network doctors they didn’t choose.
This might happen if, for example, a patient went to an
in-network hospital and then received a bill from an out-of-network
anesthesiologist or radiologist they never even met.
That law covered patients receiving scheduled care like
surgery or delivering a baby. Separately, a decade-old California Supreme Court
ruling provided similar protections for emergency room patients.
Neither the court ruling nor the 2016 law anticipated a
situation like Zuckerberg San Francisco General, where the entire hospital is
“out of network” with all private health insurance.”..
“This new legislation would tackle that rarer situation
where a hospital is not in network, and then sends the patient a bill for
whatever balance their insurer won’t pay.
There are two key parts to the proposal. First, the bill
would prohibit hospitals from pursuing any balance that the patient owed beyond
their regular co-payment or contributions to the health plan’s deductible.
Second, the bill would regulate the prices that the hospital
could charge for its care, limiting the fees to 150 percent of the Medicare
price or the average contracted rate in the area, whichever is greater.
“Patients would no longer receive exorbitant, surprise
bills,” says Chiu. “The discussion between insurers and hospitals
would become far more predictable.” ” (A)
“”At the heart of what we are trying to do is to
ensure that if you or are a loved one are in the ER, the only thing you should
be thinking about is how to get better and not about the bill for that
care,” said Chiu.
He said that the bill is a response “in regard to what
we learned is happening at [ZSFGH] – but also across California – this is the
situation of patients who get a surprise bill after visiting an emergency
room.”..
Rachael Kagan, a spokesperson for the San Francisco Public
Health Department, which manages the hospital, said in a statement on Friday
that the department can’t comment on the proposed legislation but that “we
absolutely agree that there is a role for policy changes to improve patients’
experience with billing,” including “local state and federal
efforts.”
She added that the hospital and department are working in
the meantime on making improvements. One proposal so far suggests capping
out-of-pocket payments made by insured patients receiving emergency services,
as was previously reported by the San Francisco Examiner.” (B)
Joint Surprise Billing Letter to Congress and Committee
Leadership (C)
Dear Congressional and Committee Leadership:
On behalf of our member hospitals, health systems and other
health care organizations, we are fully committed to protecting patients from
“surprise bills” that result from unexpected gaps in coverage or
medical emergencies. We appreciate your leadership on this issue and look
forward to continuing to work with you on a federal legislative solution.
Surprise bills can cause patients stress and financial
burden at a time of particular vulnerability: when they are in need of medical
care. Patients are at risk of incurring such bills during emergencies, as well
as when they schedule care at an in-network facility without knowing the
network status of all of the providers who may be involved in their care. We
must work together to protect patients from surprise bills.
As you debate a legislative solution, we believe it is
critical to:
Define “surprise bills.” Surprise bills may occur
when a patient receives care from an out-of-network provider or when their
health plan fails to pay for covered services. The three most typical scenarios
are when: (1) a patient accesses emergency services outside of their insurance
network, including from providers while they are away from home; (2) a patient
receives care from an out-of-network physician providing services in an
in-network hospital; or (3) a health plan denies coverage for emergency
services saying they were unnecessary.
Protect the patient financially. Patients should have
certainty regarding their cost-sharing obligations, which should be based on an
in-network amount. Providers should not balance bill, meaning they should not
send a patient a bill beyond their cost-sharing obligations.
Ensure patient access to emergency care. Patients should be
assured of access to and coverage of emergency care. This requires that health
plans adhere to the “prudent layperson standard” and not deny payment
for emergency care that, in retrospect, the health plan determined was not an
emergency.
Preserve the role of private negotiation. Health plans and
providers should retain the ability to negotiate appropriate payment rates. The
government should not establish a fixed payment amount or reimbursement
methodology for out-of-network services, which could create unintended
consequences for patients by disrupting incentives for health plans to create
comprehensive networks.
Remove the patient from health plan/provider negotiations.
Patients should not be placed in the middle of negotiations between insurers
and providers. Health plans must work directly with providers on reimbursement,
and the patient should not be responsible for transmitting any payment between
the plan and the provider.
Educate patients about their health care coverage. We urge
you to include an educational component to help patients understand the scope
of their health care coverage and how to access their benefits. All
stakeholders – health plans, employers, providers and others – should undertake
efforts to improve patients’ health care literacy and support them in
navigating the health care system and their coverage.
Ensure patients have access to comprehensive provider
networks and accurate network information. Patients should have access to a
comprehensive network of providers, including in-network physicians and
specialists at in-network facilities. Health plans should provide
easily-understandable information about their provider network, including
accurate listings for hospital-based physicians, so that patients can make
informed health care decisions. Federal and state regulators should ensure both
the adequacy of health plan provider networks and the accuracy of provider
directories.
Support state laws that work. Any public policy should take
into account the interaction between federal and state laws. Many states have
undertaken efforts to protect patients from surprise billing. Any federal
solution should provide a default to state laws that meet the federal minimum
for consumer protections.
We look forward to opportunities to discuss these solutions
and work together to achieve them.
, a move that comes three months after a Vox story drew
national attention to the hospital’s abnormal and aggressive billing tactics.
The hospital has for years made the rare decision to be out
of network with all private health insurance plans. This created an acute
problem for patients like like Nina Dang, 24, who made an unexpected trip to
the hospital’s emergency room, the largest in San Francisco. An ambulance took
Dang to the trauma center after a bike accident last April. She is insured by a
Blue Cross plan, but she didn’t know that the ER does not accept insurance. She
received a bill for $20,243.
After the Vox story ran, the hospital reduced Dang’s bill to
$200, the copay listed on her insurance card.
Now, Zuckerberg San Francisco General Hospital (ZSFG) is
essentially making the same change for all future patients: Its new billing
policies will no longer charge those with private coverage “any more than
they would have paid out of pocket for the same care at in-network facilities,
based on their insurance coverage.”
This will put an end to the hospital’s use of a
controversial practice call “balance billing,” when a hospital sends
a patient a bill for the balance that an insurer won’t pay.
ZSFG will also create a new out-of-pocket maximum on what
patients could end up owing for their treatment. The maximum is tethered to a
patient’s income and ranges from zero dollars for the lowest earners to a
$4,800 maximum for those with the highest incomes (1,000 percent of the poverty
line, or $251,400 for a family of four).” (A)
“The changes are aimed at shielding patients from large
bills by removing them from payment disputes between the hospital and the insurance
company, said Rachael Kagan, director of communications with the department.
“We don’t have a large number of privately insured
patients at Zuckerberg San Francisco General Hospital, but some of those who
have been in that situation in the past have had a terrible experience and we
want to rectify that,” said Ms. Kagan.
“We don’t want that to happen in the future. We know
that it’s very stressful to get a large bill and we consider our responsibility
to the patients to care for them in all ways. They will have gotten excellent
medical care from us, and we want to protect their financial well-being
also,” she added.
The hospital estimated that up to 1,700 of its 104,000
patients a year may have received a balance bill…
Zuckerberg hospital will also set a maximum out-of-pocket
cost for patients at all income levels, with any insurance status, and this
maximum will be income-based. No one will be charged more than 5 percent of
their income…
Additionally, the hospital will make its patient financial
assistance programs easier to qualify for so more people will get financial
assistance. This involves increasing the threshold to qualify for the
hospital’s charity care program. The threshold to qualify will increase from
350 percent of the federal poverty level to 500 percent of the federal poverty
level.
The hospital is also adjusting the “sliding scale”
financial assistance program for San Francisco residents. Previously,
Zuckerberg hospital assessed eligibility for the program based on income and
assets but will now only take income into account…
Overall, she said she’s pleased the hospital is taking these
steps to better align its billing with its values and mission.” (B)
“We may get called the “enemy of the people,”
but the press can make a real difference in forcing the powers that be into
changing some of their most horrific and unfair practices. Consider Zuckerberg
San Francisco General Hospital, which has been hounded by pesky reporters
covering their “aggressive billing tactics” with privately insured patients.
In the wake a January Vox report showing a fully insured
woman was charged $20,000 for a broken arm and a San Francisco Chronicle exposé
detailing a $92,000 appendectomy, the city’s only trauma center (named for a
billionaire worth $70 billion, give or take) has announced a significant change
to its billing policy. The Chronicle reports that Zuckerberg General is
reversing the policy, and establishing “out-of-pocket” maximum that
should not exceed $4,800 for patients with copays. Vox got a copy of the
announcement which claims the practice was “was halted on February 1, 2019
and will not resume.”
The practice is called “balance billing,” an
Orwellian term that indicates some sort of fairness and balance in a system
that bills fully insured patients tens of thousands of dollars for routine
injury treatments. Zuckerberg General, which primarily serves Medicare,
Medi-Cal, and uninsured patients, had employed an unusual system where fully
insured patients’ insurance companies could just choose how much they wanted to
cover or not cover, effectively ignoring whatever copay amount they had
communicated to the patient.” (C)
“A doctor assured DeAnn Allen the trace of blood in her
urine after a car crash was just a little bruising, but she wouldn’t have
guessed it by the size of her bill.
That urine test and visit with the doctor cost Allen, who
was visiting Las Vegas, more than $1,800.
“If you care about your care, and have a choice, we
urge you to go somewhere else!” Allen wrote in a review on Facebook for Elite
Medical Center, Las Vegas’ newest emergency hospital situated just west of the
Strip.
Just like any full-service emergency room, Elite Medical
Center treats a range of urgent medical problems, from headaches to heart
attacks. But unlike the other ERs in Southern Nevada, you’ll generally pay more
for your care.
That’s because the facility doesn’t contract with any
insurer. So if you break a bone or your child has an earache and you go there,
you’ll be paying for out-of-network care.
Elite is licensed as a hospital by the state, but experts
say it is operating similarly to freestanding emergency rooms that have become
common recently in other states. It is the only unaccredited hospital in Clark
County that provides emergency care but doesn’t contract with insurers…
There’s no license for a freestanding ER in Nevada, though
hospitals are allowed to open satellite emergency rooms that provide care at
other locations.
Elite Medical Center pursued a different path by getting the
state to license it as a hospital. That means the facility has the capacity to
keep patients for 48 hours.
State law doesn’t mandate these facilities be accredited by
the federal Centers for Medicare or Medicaid Services or accept any insurance,
private or public.” (D)
PART 4: August 18,
20129. Hospitals kept ER fees secret.
Zuckerberg San Francisco General and the University of
California San Francisco are two of the city’s busiest hospitals, about 4 miles
apart. But if you have private insurance and visit Zuckerberg General, you
could end up paying a lot more for the same treatment.
For an especially serious visit, Zuckerberg General charges
a facility fee of $11,176, 46 percent more than UCSF, which charges an average
of $7,635.
The hospital is also out-of-network with all private
insurance, leaving patients responsible for the fee and the cost of treatment.
UC San Francisco, meanwhile, accepts insurance from most big providers. Insurers
generally negotiate lower prices for patients, and many plans cover ER visits
in part or in full…
When asked about the fees, board members admitted that they
hadn’t kept a close eye on the prices and said they plan to hold hearings on
the issue.
“It turns out we should have been monitoring this much more
closely,” says Aaron Peskin, a supervisor who has previously voted in favor of
the hospital prices and who is now calling for the hearings.
These charges, known as “facility fees,” are the price that
patients pay for walking in the door of an emergency room and seeking service.
Nationally, these fees are kept secret. Patients only learn their emergency
room’s facility fee when they receive a bill after the visit…
We found that privately insured patients seen at Zuckerberg
General end up with significantly bigger bills than those seen at other nearby
emergency rooms. For example, the hospital charged a $5,369 facility fee for a
patient who presents with a “severe” emergency…
The city of San Francisco manages Zuckerberg General and
sets the prices the hospital charges.
The task falls to the San Francisco Board of Supervisors, an
11-member board that oversees city policies and budgets. Every year or two,
they approve a lengthy document that lists hospital prices for everything from
an emergency room fee to a day in the obstetrics unit to a primary care exam.
The document describes the fees as “proper reasonable amounts.”
The current prices were approved at a board a meeting in
July 2017. A video recording of that meeting shows there was no debate or
discussion of the prices. Instead, the board of supervisors unanimously
approved the ZSFG charges in a voice vote that latest less than a minute…
The fees at Zuckerberg General have nearly doubled over the
past decade. In 2010, the emergency room fees at the hospital ranged from $287
to $6,118, depending on the severity of the visit. Now the prices range from
$525 to $11,958.
But there is little record of public discussion or debate
over that increase. Meeting records for each vote on the hospital prices since
2010 show that the fees have always been approved unanimously.
“I cannot recall there ever being any discussion of them,”
says Peskin, a board member who has served on and off since 2001. “I don’t
think there has ever been a split vote, and that’s been true as long as I’ve
been on the board of supervisors. But that will probably change now.” (A)
“California lawmakers will introduce legislation Monday to
end surprise emergency room bills like those that left one patient with a
$20,000 treatment bill after a minor bike crash — a move they say was inspired
by Vox’s reporting on the issue.
The new bill, introduced by state Assembly member David Chiu
and state Sen. Scott Wiener, would bar California hospitals from pursuing
charges beyond a patient’s regular co-payment or deductible. The ban would
apply even if a hospital was out-of-network with a patient’s health insurance.
“These practices are outrageous,” says Chiu, who represents
part of San Francisco in the Assembly. “No one who is going through the trauma
of emergency room care should be subsequently victimized by outrageous hospital
bills.”..
Zuckerberg San Francisco General Hospital has, in light of
reporting from both Vox and the San Francisco Chronicle, promised to revise its
billing policies to be more patient-friendly. The hospital is reportedly
considering a cap on charges for privately insured patients.
But Chiu thinks that even more action is needed: a statewide
law that would outlaw this kind of behavior…
This new legislation would tackle that rarer situation where
a hospital is not in network, and then sends the patient a bill for whatever
balance their insurer won’t pay.
There are two key parts to the proposal. First, the bill
would prohibit hospitals from pursuing any balance that the patient owed beyond
their regular co-payment or contributions to the health plan’s deductible.
Second, the bill would regulate the prices that the hospital
could charge for its care, limiting the fees to 150 percent of the Medicare
price or the average contracted rate in the area, whichever is greater.
“Patients would no longer receive exorbitant, surprise
bills,” Chiu said. “The discussion between insurers and hospitals would become
far more predictable.”
Chiu said the hospital and insurance industries are aware of
the effort but haven’t yet seen the full text of the legislation, which will be
introduced on Monday.” (B)
“Lawmakers in both the U.S. Senate and House have introduced
bills to end surprise billing. But passing federal legislation promises to be
an uphill battle because two influential lobbying groups — health insurers and
health providers — have been unable to agree on a solution.
Frustrated by waiting for federal lawmakers to act, states
have been trying to solve this issue. As of December 2018, 25 states offered
some protection against surprise billing, and the protections in nine of those
states were considered “comprehensive,” according to the Commonwealth Fund.
California, New York, Florida, Illinois and Connecticut are among the nine.
New state laws also have been adopted since, including in
Nevada, which will limit how much out-of-network providers, including
hospitals, can charge patients for emergency care, starting next year.
In California, a 2009 state Supreme Court ruling protects
some patients against surprise billing for emergency care, and a state law that
took effect in 2017 protects some who receive non-emergency care.
But millions remain vulnerable, largely because California’s
protections don’t cover all insurance plans. The California Supreme Court
ruling applies to people with plans regulated by the state Department of
Managed Health Care. That leaves out the roughly 1 million Californians with
plans regulated by the state Department of Insurance and the nearly 6 million
people with federally regulated plans, most of whom have employer-sponsored
insurance.
The state law governing non-emergency care also doesn’t
apply to the millions of residents with health plans regulated by the federal
government…
The California Hospital Association opposes the measure,
which would limit the amount hospitals could charge insurance plans to a
certain rate for each service, varying by region…
“We fully support the
provision of the bill that protects patients. It is the rate-setting piece that
is our concern,” she said.
Skewered by media reports, the hospital announced in April
that it would no longer balance-bill privately insured patients.” (C)
“Legislation to prohibit California hospitals from sticking
patients with huge emergency room bills that their insurers won’t cover has
cleared a crucial hurdle in the state Capitol.
Lawmakers in the Assembly voted 48-9 on Thursday to approve
AB1611, which would prohibit hospitals from “balance billing” patients if their
insurance won’t cover the full cost for care.
Assemblyman David Chiu and state Sen. Scott Wiener, both
Democrats from San Francisco, co-wrote the legislation. The bill now moves to
the Senate.
They wrote the bill in response to Chronicle stories about
patients who had undergone treatment at San Francisco General Hospital, often
for minor injuries, and been billed tens of thousands of dollars even though
they had insurance.
“After a trip to the
emergency room, the only thing you should be focused on is getting better,”
Chiu said. “Not a bill for tens of thousands of dollars.”
San Francisco General had billed patients for the difference
between the cost of their treatment and what their insurance companies were
willing to pay. The hospital announced in April that it would end the practice,
meaning patients won’t be billed beyond what their insurance requires.
AB1611 would prohibit hospitals from billing patients for
any cost beyond their insurance deductible and co-payment. It also spells out
rules for how hospitals and insurers resolve cost disputes.” (D)
“Zuckerberg is
notorious for being not necessarily the worst but one of the worst places to go
in terms of prices for emergency care,” Anderson continued. “The prices are outrageously
high. They are notorious for it. And everybody knows about them.”
The maddening element about hospital billing is that the
costs charged to patients are only abstractly related to the costs incurred by
the hospital.
“They do not need to justify their charges. They have full
discretion,” explains Ge Bai, a Johns Hopkins professor of both accounting and
health management and policy. “There are no regulatory forces to limit their
ability to set a high charge. The charge is coming purely from the hospital and
subject to no external forces.”
Patients — especially uninsured patients — “become prey of
this charging game.”…
The No. 1 reason that hospitals aggressively bill their most
vulnerable patients? That, too, is relatively easy to grasp. It’s the same
reason people from around the world phone you up and demand your Social
Security Number: A very small percentage of folks give them everything they
want.
Hospitals “don’t get most of the money — in most cases,”
says Anderson. “It’s simply preferable for them to charge $3,300 and get it
from some people rather than charge $200 and get it from nearly everybody.” (E)
“Hospitals focused their opposition on a provision of the
bill that would have limited charges for out-of-network emergency services.
The proposal would have required hospitals to work directly
with health plans on billing, leaving the patients responsible only for their
in-network copayments, coinsurance and deductibles. (Photo: Shutterstock)
Citing fierce pushback from hospitals, California lawmakers
sidelined a bill Wednesday that would have protected some patients from
surprise medical bills by limiting how much hospitals could charge them for
emergency care.” (F)
The attempt by two San Francisco politicians to stop
hospitals around California from sticking patients who receive emergency care
with outrageous bills is on life support.
“Assemblyman David Chiu on Tuesday said he is holding back
his bill that was inspired by news of San Francisco General Hospital’s unfair
billing practices after intense lobbying from hospital CEOs around the state
urging his colleagues to kill it.
The bill was supposed to be heard in the Senate’s health
committee Tuesday, but Chiu said its passage would have required amendments
making the bill worthless, and he wasn’t willing to move ahead with them.
Instead, he’s turning the bill into a two-year piece of
legislation, meaning it can be taken up again in January. But that means the
earliest Gov. Gavin Newsom can sign it is September, 2020. And that means the 7
million Californians who have private insurance and yet are still at risk of
big emergency care bills won’t see any relief for more than a year — if at all.
“It’s disappointing this couldn’t get done this year,” Chiu
said. “But this doesn’t mean we’re done. It ain’t over.”” (G)
“Citing fierce pushback from hospitals, California lawmakers
sidelined a bill Wednesday that would have protected some patients from
surprise medical bills by limiting how much hospitals could charge them for
emergency care.
The legislation, which contributed to the intense national
conversation about surprise medical billing, was scheduled to be debated
Wednesday in the state Senate Health Committee.
Instead, the bill’s author pulled it from consideration,
vowing to bring it back next year.
“We are going after a practice that has generated billions
of dollars for hospitals, so this is high-level,” said Assemblyman David Chiu
(D-San Francisco). “This certainly does not mean we’re done.”
Chiu said he and his team would keep working on amendments
to the bill that address the concerns of hospitals while maintaining
protections for patients.
Hospitals focused their opposition on a provision of the
bill that would have limited what they can charge insurers for out-of-network
emergency services, criticizing it as an unnecessary form of rate setting.” (H)
“San Francisco’s health network has
finalized its first contract with a private health insurer, Canopy Health Canopy
— meaning Zuckerberg San Francisco General Hospital, long perceived as the
hospital of last resort, is now in the business of wooing expectant mothers to
choose to deliver at its Family Birth Center…
Department of Public Health staff
said the signing of this contract was not a reaction to billing controversies
at ZSFGH that erupted earlier this year, when it was revealed that even insured
patients were being hit with crippling debts through the practice of “balance
billing.” Because the hospital was out-of-network for private insurance
companies, there was often a great divergence between what ZSFGH billed the
insurance and what the insurance company would deign to pay — leaving
individuals responsible for the “balance.”
This situation, however, did
highlight the hospital’s unhealthy and precarious “payer mix.” With few
privately insured patients, ZSFGH ministers mostly to Medi-Cal recipients or
the marginally insured. Deals like the one initiated July 15 with Canopy would
begin to change that mix, however.
“It is good for the hospital to
diversify its revenue with different payors,” notes Department of Public Health
spokeswoman Rachael Kagan. “We have been working to accomplish private
contracting for some time now.”
Inundating the hospital with
better-paying privately insured patients at the expense of publicly insured
patients would be cause for concern. But this doesn’t figure to happen at the
Family Birthing Center, one of the few departments at ZSFGH that isn’t overloaded
beyond capacity.
Kagan says the Department of Public
Health hopes 60 privately insured Canopy patients deliver at ZSFGH. Hospital
staff have been told to expect up to 80. This would represent a small bump in
the total number of deliveries at the hospital, which is about 1,200 a year.
Just how many privately insured
mothers opt to deliver at ZSFGH will depend on how effectively the hospital
sells itself as the “good and safe place to have a baby” — and how effectively
it can dispel the perception that anyone who could afford to go elsewhere would
do so.
Hospitals competing for patients —
especially expectant mothers — often play up amenities more closely resembling
a luxury resort than a medical center: private rooms, steak dinners, sumptuous
views.
It remains to be seen if ZSFGH will
go this route. What it does have to offer, however, is a 24-hour/seven-day
on-call midwife — which no other city hospital does. ZSFGH also claims the
lowest C-section rate in all San Francisco.
Kagan declined to reveal whether the
city is in negotiation with other private insurers, which could alter ZSFGH’s
payer mix even more. The Canopy deal required three years to close. So it would
be surprising if others aren’t in the works, if not imminent.
“Our hope is that down the road we
can expand access to more of our services to Canopy Health and other
commercially insured patients,” wrote Roland Pickens, the director of the
city’s Health Network, in the inter-office memo announcing this deal. “ (I)
“California hospitals want you to
know that they’re fully on board with the idea that emergency room patients
shouldn’t be hit with thousands of dollars in surprise billings because the ER
isn’t in their insurance plan’s network.
You should also know, however, that
the hospitals just killed a measure in Sacramento that would have accomplished
that goal, and that the reason they did so was to protect their own revenues….
Chiu’s legislation had two major
pieces. It prohibited hospitals from charging out-of-network ER patients more
than they would charge an in-network patient for the same services. It also
established a standard for what a hospital could charge a non-network insurer.
In other words, the bill limited what patients would pay hospitals out of
pocket but set rules on what insurers would pay the hospitals too.
Originally, the bill set 150% of
Medicare reimbursement as a payment benchmark. The sponsors eventually amended
that to whatever rate is “reasonable and customary,” defined as the average
in-network contracted rate in a hospital’s geographic region. Hospitals could
appeal for higher reimbursements through the state Department of Health Care
Services.
The state’s hospitals went to the
mattresses over the payment provision, cursing it as “government rate setting”
that they would never accept. Hospital executives inundated legislators with
warnings that rate-setting would force their institutions to shut down…
The proponents were aware that they
were poking a stick into a tiger’s cage. “We’re going after a practice that has
generated billions of dollars in profits for hospitals, Chiu told me, “and
hospital CEOs around the state waged very aggressive lobbying to protect those
profits.”” (J)
“Twelve Connecticut hospitals charge
patients a trauma activation fee when they arrive by ambulance with a serious
injury.
These fees, ranging in the thousands
of dollars, are unregulated. And 11 of the 12 Connecticut trauma centers won’t
reveal publicly how much they charge…
(Only designated trauma centers are
permitted to charge trauma activation fees, which can add thousands of dollars
to hospital bills.)
A trauma fee is charged when a trauma
team is called to attend to a patient with significant or life-threatening
injuries who is brought to the hospital by emergency medical services. Only
designated trauma centers can use the billing code 068x to charge a trauma
activation fee.
These fees are set by the hospitals
and can range based on the level of response a patient requires. They help
hospitals recoup the costs of having highly trained doctors and specialized
nurses on call to respond to tragedies at a moment’s notice. Insurance
sometimes covers the fees so not all patients may notice them buried in their
hospital bill — if they have health insurance…
Connecticut has four hospitals
designated as level I trauma centers, 7 that are level II and one level III.
These levels refer to the resources available in the trauma center and the
amount of patients admitted yearly — but its unclear if they have any
correlation with the amount charged for trauma fees.” (K)
ASSIGNMENT:
Identify other health care conflicts in the news then identify Best Practices
of Boards of Trustees.
New PART 2 after old PART 1.
PART 1. September 28, 2018. HOW ACADEMIC MEDICAL CENTERS
ADDRESS CONFLICTS-OF-INTEREST.
ASSIGNMENT: Profile the University of Maryland Medical
System COI challenge.
DISCLOSURE. I am a member and Interim Chairman of the IRB*
at Stevens Institute of Technology.
“There are many varieties of conflicts of interest, and they
appear in different settings and across all disciplines. While conflicts of
interest apply to a “wide range of behaviors and circumstances,” they all
involve the use of a person’s authority for personal and/or financial gain.
Conflicts of interest may involve individuals as well as institutions.
Furthermore, individuals, in certain circumstances, may have conflicts
occurring on both an individual and an institutional level, as may be seen
among members of an Institutional Review Board (IRB).
Conflicts of interest are broadly divided into two
categories: intangible, i.e., those involving academic activities and
scholarship; and tangible, i.e., those involving financial relationships.” (A)
“In an article in the May 2014 issue of Compliance Today,
Bill Sacks, Vice President and co-founder of HCCS, a HealthStream company,
describes how new NIH regulations are forcing academic medical centers (AMCs)
to examine and update their conflict-of-interest policies. He lists the 15 best
practices for management of conflicts of interest that have been proposed by
the Pew Charitable Trust and discusses how some of these recommendations are
enjoying wide acceptance, as others are being met by serious objections. The Pew
“Best Practice” recommendations are summarized below.
1. No gifts or meals should be accepted from industry sales
representatives…
2. Faculty must disclose all conflicts of interest. All
academic medical centers must have a process in place to manage conflict of
interest (COI) disclosures.
3. Industry-funded speaking should not be allowed…
4. Industry-funding of continuing medical education (CME)
should be severely limited or prohibited…
5. Faculty, students, and trainees should not attend
industry-supported promotional or educational events…
6. Limit or prohibit pharmaceutical sales representative
access in academic medical centers…
7. Limit medical device representative presence in academic
medical centers to what is necessary…
8. Conflict-of-interest education should be required for all
clinical staff and students
9. Conflict-of-interest policies should apply to everyone
with a relationship to the academic medical center—paid, volunteering,
affiliated, etc…
10. Industry-supported clinical fellowships should be
available for scientific training only…
11. Ghostwriting and honorary authorship are strictly
prohibited…
12. …Consulting arrangements must require written contracts
with clear deliverables, to ensure that inappropriate payments are not
involved…
13. Consulting relationships for marketing purposes are
prohibited.
14. Pharmaceutical samples can be accepted and used only
when they don’t become marketing tools.
15. Members of pharmacy and therapeutics committee cannot
vote on formulary or treatment changes involving a company or product in which
they have a financial interest… (B)
“Open Payments gives the public more information about the
financial relationships between physicians and teaching hospitals and
applicable manufacturers and GPOs. Specifically, the program:
Encourages transparency about these financial ties
Provides information on the nature and extent of the
relationships
Helps to identify relationships that can both lead to the
development of beneficial new technologies and wasteful healthcare spending
Helps to prevent inappropriate influence on research,
education and clinical decision making. (C)
“Community Catalyst offers this Policy Guide to Academic
Medical Centers and Medical Schools to assist leaders, faculty, staff and medical
students in successfully adopting and improving policies to address conflicts
of interest and interactions with the pharmaceutical and device industries.
Policies such as these and their effective implementation are of critical
importance to the integrity of medical education and patient care…
Toolkit on Transparency and Disclosure. Toolkit on Relations
with Sales Representatives. Toolkit on Promotional Speaking. Toolkit on
Continuing Medical Education. Toolkit on Ghostwriting and Name-Lending. Toolkit
on Samples. Toolkit on Pharmaceutical and Therapeutics Committees. Toolkit on
COI Policy Implementation. Conflict of Interest Curriculum Toolkit (D)
“Papers in medical journals go through rigorous peer review
and meticulous data analysis.
Yet many of these articles are missing a key piece of
information: the financial ties of the authors.
Nearly two-thirds of the 100 physicians who rake in the most
money from 10 device manufacturers failed to disclose a conflict of interest in
their academic writing in 2016, according to a study published Wednesday in
JAMA Surgery.
The omission can have real-life impact for patients when
their doctors rely on such research to make medical decisions, potentially
without knowing the authors’ potential conflicts of interest…
They did this by sampling 10 large surgical and medical
device manufacturers. This list includes Medtronic, Stryker Corp., Intuitive
Surgical, Covidien, Edwards Lifesciences Corp., Ethicon, Olympus Corp., W.L.
Gore & Associates, LifeCell Corp. and Baxter Healthcare.
The researchers also pinpointed the 10 physicians who
received the highest compensation from each company. They then searched for
articles published by these physicians between Jan. 1 and Dec. 31, 2016, and
reviewed the full text of each article for COI disclosure.
According to their findings, those 10 companies paid more
than $12 million in 2015 to the 100 doctors included in the study. The median
payment to these physicians was $95,993.” (E)
“Memorial Sloan Kettering Cancer Center launched a conflict
of interest task force in the wake of the resignation of its chief medical
officer, Dr. José Baselga, who failed to disclose connections to medical
industry…
The Manhattan-based cancer center said the task force will
assess its internal policies and processes for reporting and managing outside
activities and industry-supported clinical trials.
The task force was announced by President and Chief
Executive Officer Dr. Craig Thompson. It will be chaired by Debra Berns, MSK’s
Senior Vice President and Chief Risk Officer.
Among its objectives, the task force will: Review MSK’s
policies, procedures, and training on conflicts of interest; Identify best
practices in COI, including monetary and commitment limits; Assess new or
improved processes to support timely and thorough disclosure; Identify medical
societies and journals with whom to partner in improving public disclosure at
meetings and in publications. (F)
“One of the world’s top breast cancer doctors failed to
disclose millions of dollars in payments from drug and health care companies in
recent years, omitting his financial ties from dozens of research articles in
prestigious publications like The New England Journal of Medicine and the
Lancet.
The researcher, Dr. José Baselga, a towering figure in the cancer
world, is the chief medical officer at Memorial Sloan Kettering Cancer Center
in New York. He has held board memberships or advisory roles with Roche and
Bristol-Myers Squibb, among other corporations; has had a stake in start-ups
testing cancer therapies; and played a key role in the development of
breakthrough drugs that have revolutionized treatments for breast cancer.
According to an analysis by ProPublica and The New York
Times, Baselga did not follow financial disclosure rules set by the American
Association for Cancer Research when he was president of the group. He also
left out payments he received from companies connected to cancer research in
his articles published in the group’s journal, Cancer Discovery. At the same
time, he has been one of the journal’s two editors in chief.
At a conference this year and before analysts in 2017, he
put a positive spin on the results of two Roche-sponsored clinical trials that
many others considered disappointments, without disclosing his relationship to
the company. Since 2014, he has received more than $3 million from Roche in
consulting fees and for his stake in a company it acquired.” (G)
“Dr. José Baselga, the chief medical officer of Memorial
Sloan Kettering Cancer Center, resigned on Thursday amid reports that he had
failed to disclose millions of dollars in payments from health care companies
in dozens of research articles…
Thompson echoed comments he made to the hospital staff on
Sunday, saying that the cancer center had “robust programs” in place to manage
employees’ relationships to outside companies, but that “we will remain
diligent.” He added, “There will be continued discussion and review of these
matters in the coming weeks.” (H)
“An artificial intelligence start-up founded by three
insiders at Memorial Sloan Kettering Cancer Center debuted with great fanfare
in February, with $25 million in venture capital and the promise that it might
one day transform how cancer is diagnosed.
The company, Paige.AI, is one in a burgeoning field of
start-ups that are applying artificial intelligence to health care, yet it has
an advantage over many competitors: The company has an exclusive deal to use
the cancer center’s vast archive of 25 million patient tissue slides, along
with decades of work by its world-renowned pathologists.
Memorial Sloan Kettering holds an equity stake in Paige.AI,
as does a member of the cancer center’s executive board, the chairman of its
pathology department and the head of one of its research laboratories. Three
other board members are investors…
Hospital pathologists have strongly objected to the Paige.AI
deal, saying it is unfair that the founders received equity stakes in a company
that relies on the pathologists’ expertise and work amassed over 60 years. They
also questioned the use of patients’ data — even if it is anonymous — without
their knowledge in a profit-driven venture.” (I)
“…The AAMC is continuing to work with member institutions,
other associations and societies, journals, and the continuing education
community to develop tools and resources to help institutions and individuals
manage the disclosure of conflicts of interest.
Institutions looking for immediate steps to take could:
Remind faculty of the importance of full disclosure, not
only to your institution, but in other writing, speaking and teaching
situations, as well as grant applications.
Use relevant current events as an opportunity to recommit to
the institution’s obligation to facilitate transparency about the ways in which
faculty and industry may be collaborating, and the processes that are in place
to review and manage those relationships.
Encourage faculty to review the information posted about
them publicly on the Open Payments website, and to ensure its accuracy as well
as consistency with complete disclosures in all aspects of their professional
responsibilities.” (J)
* “Under FDA regulations, an IRB is an appropriately
constituted group that has been formally designated to review and monitor
biomedical research involving human subjects. In accordance with FDA
regulations, an IRB has the authority to approve, require modifications in (to
secure approval), or disapprove research. This group review serves an important
role in the protection of the rights and welfare of human research subjects.
The purpose of IRB review is to assure, both in advance and
by periodic review, that appropriate steps are taken to protect the rights and
welfare of humans participating as subjects in the research. To accomplish this
purpose, IRBs use a group process to review research protocols and related
materials (e.g., informed consent documents and investigator brochures) to
ensure protection of the rights and welfare of human subjects of research.” (K)
“A vice president of Memorial Sloan Kettering Cancer Center
has to turn over to the hospital nearly $1.4 million of a windfall stake in a
biotech company, in light of a series of for-profit deals and industry
conflicts at the cancer center that has forced it to re-examine its corporate
relationships…
The move to hand over his stake is one of several steps now
underway as the cancer center tries to contain a crisis that has already led to
the resignation of its chief medical officer and a review of its
conflict-of-interest policies. Several board members and some executives of the
nonprofit institution have maintained close ties to the health and drug
industries at a time when stunning cancer breakthroughs are generating
excitement among investors and spawning a flurry of biotech startups.
At other cancer centers and research institutions, employees
are barred from accepting personal compensation when they represent their
institution on corporate boards. But Memorial Sloan Kettering had no such
prohibition until now.” (L)
PART 2. Conflict of Interest continued. Memorial Sloan Kettering/
University of Maryland Medical System
“In forging partnerships with a New Jersey hospital and a
data analytics startup, Memorial Sloan Kettering Cancer Center has created a
web of interlocking financial interests and conflicts that, ethics experts told
STAT, raise doubts about whether the prominent New York City hospital can
always put its patients’ interests first while using information in their
medical records to make money.
In late 2016, Memorial Sloan Kettering signed a deal with
Hackensack Meridian Health, one of New Jersey’s largest hospital systems,
giving the cancer center access to a larger pool of patients and a bulwark
against encroaching competition from other national players in cancer care.
Within a year, MSK launched another collaboration with a
data analytics startup called Cota, and invested $1.4 million in the company.
Its founder: a Hackensack Meridian executive and oncologist named Dr. Andrew
Pecora, who was Hackensack’s lead negotiator in striking the blockbuster 2016
partnership and serves on the board overseeing the hospitals’ joint venture…
The cancer center is also collaborating with IBM in the
development and sale of Watson for Oncology, a product that combines its
clinical expertise with artificial intelligence to deliver cancer treatment
recommendations. The cancer center receives royalties on the sale of IBM’s
product.
Ethics experts said these deals fall into a regulatory gray
area in which hospitals and other private companies are trading on patient data
in novel ways that may cross ethical lines and trigger a backlash among
patients.” (A)
“Hundreds of doctors packed an auditorium at Memorial Sloan
Kettering Cancer Center on Oct. 1, deeply angered by revelations that the
hospital’s top medical officer and other leaders had cultivated lucrative
relationships with for-profit companies.
One by one, they stood up to challenge the stewardship of
their beloved institution, often to emotional applause. Some speakers accused
their leaders of letting the quest to make more money undermine the hospital’s
mission. Others bemoaned a rigid, hierarchical management that had left them
feeling they had no real voice in the hospital’s direction.
“Slowly, I’ve seen more and more of the higher-up meetings
happening with people who are dressed up in suits as opposed to white coats,”
said Dr. Viviane Tabar, chairwoman of the neurosurgery department.
“The corporatization of this institution is clear to many of
us who have been here a long time,” said Dr. Carol L. Brown, a gynecologic
cancer surgeon, according to an audio recording of the meeting.
The meeting ended after several doctors advocated an
immediate no-confidence vote in the hospital’s senior leadership. The turmoil
followed reports by The New York Times and ProPublica that the hospital’s chief
medical officer, Dr. José Baselga, had been paid millions by drug and health
care companies and failed to disclose those ties more than 100 times in medical
journals, and that hospital insiders had made lucrative side deals that stood
to earn them handsome profits, sometimes for work they had done on the job.
The day after the meeting, the hospital’s chief executive,
Dr. Craig B. Thompson, promised greater openness with rank-and-file doctors
about decision-making. He also committed to doing the “root-cause analysis”
requested by the doctors of how “egregious conflicts of interest,” as one
physician put it, had been allowed to happen…
The predicament of Memorial Sloan Kettering also reflects a
shift in its own culture. Its prior chief executive, Dr. Harold E. Varmus, a
Nobel-prize winning scientist, personally kept companies at arm’s length, while
Dr. Thompson, also a respected cancer researcher, has more fully embraced such
relationships. The new approach has been applauded by some for expanding access
to the cancer center’s discoveries, even as others have worried that the
hospital may be losing sight of its mission…
Even as Memorial Sloan Kettering leaders have promised
greater transparency, they have engaged a public affairs firm,
SKDKnickerbocker, to manage their message and have aggressively pushed back
against the idea that the hospital’s leaders are too close to industry.” (B)
“Memorial Sloan Kettering Cancer Center, one of the world’s
leading research institutions, announced on Friday that it would bar its top
executives from serving on corporate boards of drug and health care companies
that, in some cases, had paid them hundreds of thousands of dollars a year.
Hospital officials also told the center’s staff that the
executive board had made permanent a series of reforms designed to limit the
ways in which its top executives and leading researchers could profit from work
developed at Memorial Sloan Kettering, a nonprofit with a broad social mission
that admits about 23,500 cancer patients each year.” (C)
“While MSK’s situation has drawn the most attention for its
ties to industry, leaders of nonprofit health systems commonly lead
pharmaceutical companies at the same time, a BioPharma Dive review from
November found.
From that analysis, about two-thirds of the industry’s
largest drugmakers had at least one board member who was also leading a
nonprofit, creating a potential financial conflict of interest between the two
roles.
The typical compensation package from the pharma companies
to these directors was worth more than $475,000, while the average director
also held roughly $1.7 million in stock of the particular drugmaker they helped
to lead.
This MSK memo from Debra Berns, the cancer center’s senior
vice president and chief risk officer, establishes some new limits the
organization will put in place on its leaders.
The five highest-ranking roles will not be permitted to
serve on boards of external, for-profit health- or science-related companies, the
memo stated. These roles are the chief executive, chief operating officer,
chief financial officer, physician-in-chief and director of MSK.
However, these five leaders can be exempt from the ban if
they provide a compelling institutional reason for board service and obtain
approval from the executive committee of MSK’s board of managers, according to
the document.
Another new policy will limit the relationship with
for-profit spin-off companies that MSK officers can have. MSK officers cannot
serve on boards of spin-off companies, and the Board of Overseers and Managers
cannot invest in or serve on these boards.” (D)
“Top officials at Memorial Sloan Kettering Cancer Center
repeatedly violated policies on financial conflicts of interest, fostering a culture
in which profits appeared to take precedence over research and patient care,
according to details released on Thursday from an outside review.
The findings followed months of turmoil over executives’
ties to drug and health care companies at one of the nation’s leading cancer
centers. The review, conducted by the law firm Debevoise & Plimpton, was
outlined at a staff meeting on Thursday morning.
It concluded that officials frequently violated or skirted
their own policies; that hospital leaders’ ties to companies were likely
considered on an ad hoc basis rather than through rigorous vetting; and that
researchers were often unaware that some senior executives had financial stakes
in the outcomes of their studies.
In acknowledging flaws in its oversight of conflicts of
interest, the cancer center announced on Thursday an extensive overhaul of
policies governing employees’ relationships with outside companies and
financial arrangements — including public disclosure of doctors’ ties to
corporations and limits on outside work…
Scott Stuart, chairman of the cancer center’s Boards of
Overseers and Managers, said in an emailed statement: “We took a deep and
honest look at what went wrong at our own institution, examined what was
occurring in the wider cancer research community, and are putting in place best
practices that will not only allow us to learn from our mistakes, but will
contribute to best practices for the wider research community.”..
The policy changes that Memorial Sloan Kettering announced
on Thursday include the creation of a board committee to focus on overseeing
conflicts, an existing hospital policy that the law firm learned had not been
carried out.
The hospital also said it would disclose financial interests
of faculty members and researchers on its website and create a more centralized
review of conflicts between employees’ work at the hospital and their outside
duties.
Other changes included new limits on how income is
distributed from research discoveries that originate at Memorial Sloan Kettering,
and regular audits to ensure the hospital is complying with its own rules. The
cancer center reinforced its earlier statements that many profits from outside
work should flow back to M.S.K. research.” (E)
“Dr. José Baselga, who resigned his position as the top
doctor at Memorial Sloan Kettering Cancer Center after failing to disclose
millions of dollars in payments from drug companies, is now going to work for
one of them.
AstraZeneca, the British-Swedish drug maker, announced on
Monday that it had hired Dr. Baselga as its head of research and development in
oncology, a newly created unit that reflects the company’s shift toward cancer
treatments, one of the hottest areas in the drug industry.
In a statement, AstraZeneca’s chief executive, Pascal
Soriot, described Baselga as “an outstanding scientific leader.” “José’s
research and clinical achievements have led to the development of several
innovative medicines, and he is an international thought leader in cancer care
and clinical research,” he said…
In December, the American Association for Cancer Research
said that Baselga, at its request, had resigned his post as one of two editors
in chief of its medical journal Cancer Discovery because he did “not adhere to
the high standards” of conflict-of-interest disclosures that the group expects
of its leaders. Some of his omissions involved articles that were published in
Cancer Discovery while he was an editor in chief.” (F)
“Two more members of the University of Maryland Medical
System’s board of directors have resigned amid intense scrutiny over the
system’s contracting practices — and as the hospital network announced a
“comprehensive review” of its business deals.
Stephen A. Burch, chairman of the University of Maryland
Medical System board of directors, said Tuesday that he has accepted the
resignations of board members John W. Dillon and Robert L. Pevenstein.
“I take very
seriously the concerns raised regarding Board members that have business
relationships with UMMS,” Burch said in a statement. “Addressing this issue is
of the highest priority for me and the organization. There is nothing more
important than the trust of those who depend on our leadership.”
Dillon reported in both 2017 and 2018 that his health care
consulting firm, Dillon Consulting, generated more than $150,000 a year through
a contract with the system for “capital campaign and strategic planning.” He
reported the contract was paying his firm $13,000 a month.
Pevenstein, the founder of technology companies, reported
that in 2017 his firms pulled in more than $150,000 through system contracts,
including more than $108,000 in pay for himself. In 2018, Pevenstein reported
his son also made more than $100,000 from the system.
In tax forms, Maryland hospital system labeled book purchase
from Baltimore mayor a ‘grant’ to city schools
The resignations follow Baltimore Mayor Catherine Pugh
stepping down from the board Monday. Pugh resigned from the system’s board of
directors as Baltimore school officials acknowledged that 8,700 copies of
children’s books the medical system purchased from her are sitting unread in a
warehouse.
The three departures from the board came after The Baltimore
Sun reported nine members of the University of Maryland Medical System’s Board
of Directors have business deals with the hospital network that are worth
hundreds of thousands to millions of dollars each.
Board chair Burch said Tuesday he also has asked board
members who currently have relationships with the medical system to immediately
take a voluntary leave of absence during a review of the system’s governance
practices. Those members are: August J. Chiasera, Francis X. Kelly, James A.
Soltesz and Walter A. Tilley Jr…
Medical system CEO Robert Chrencik has said some of the
contracts went through a competitive bidding process, while others did not. The
medical system has thus far declined to release a list detailing which of the
deals went through a bidding process.” (G)
“The president and chief executive of the University of
Maryland Medical System will take a leave of absence amid a growing scandal
surrounding its board of directors, several of whom have profited from
contracts with the hospital network they oversee.
Robert A. Chrencik, who has led the system since 2008, will
be on leave beginning Monday, board chairman Stephen A. Burch announced
Thursday. Burch said the board asked Chrencik to step aside and unanimously
agreed at an emergency meeting Thursday to engage an independent accounting and
legal firm to conduct an audit of the board’s contracts.
Several of the board’s 27 members — including Baltimore
Mayor Catherine Pugh (D), who resigned this week from the board — have had
business deals with the hospital system they oversee, in some cases worth
hundreds of thousands of dollars. The deals, first reported last week by the
Baltimore Sun, have been sharply criticized by Gov. Larry Hogan (R) and the
Democratic leaders of the General Assembly.” (H)
Several of Maryland’s largest hospitals engage in business
transactions with members of their governing boards while avoiding — for the
most part — the type of political dealings that ensnared the University of
Maryland Medical System in management turmoil this week.
The medical system has faced intense scrutiny since The
Baltimore Sun revealed last week that a third of its 27-member board of
directors have business dealings with the health care network…
The Baltimore Sun’s review of state disclosure records and
federal tax forms for MedStar Health, LifeBridge Health, Mercy Medical Center,
Greater Baltimore Medical Center and St. Agnes Hospital showed all have some
dealings with board members.
GBMC said it always uses competitive bidding when awarding
contracts.
LifeBridge Health officials said in a statement that board
members with “conflicts may be required to be recused from any discussion where
the potential conflict may influence their vote and are recused from any vote
where a conflict may exist.” In addition, they said, an “audit and compliance
committee also oversees conflicts of interest to ensure that there is no undue
influence on any contract or vote.”
MedStar Health, which has seven hospitals in Maryland,
reported business transactions with board members at five of its hospitals:
Franklin Square Medical Center, Good Samaritan Hospital, Union Memorial
Hospital and Harbor Hospital in the Baltimore area and St. Mary’s Hospital in
Leonardtown in Southern Maryland.
Dr. P. Justin Tortolani, who serves on Union Memorial
Hospital’s board and is director of MedStar’s spine program, reported receiving
royalties of nearly $155,000 last year from contracts with two companies he is
associated with.
At LifeBridge, relationships ranged from catering services
with no reported value provided by Miss Shirley’s owner David Dopkin, a Sinai
Hospital of Baltimore board member, to $9.2 million in leasing and construction
services from the company of Thomas Obrecht, who serves on the boards of
LifeBridge Health and Northwest Hospital Center Inc. In an email, Obrecht said
he joined the board to use his experience in business and real estate to help
guide “an organization focused on helping people in Baltimore and across
Maryland.”.. (I)
“Legislation to overhaul the University of Maryland Medical
System board was amended to require all current board members be fired.
The bill has bipartisan support and has significantly
changed since it was first introduced. The measure, as amended, is headed to
the House floor.
A House committee voted unanimously Friday in favor of
legislation to completely overhaul the UMMS board. The board remains under fire
following reports nine of its 30 members benefited from business deals with the
hospital system, including a children’s book contract with Mayor Catherine
Pugh.
Pugh returned $100,000 she made in profits, resigned from
the UMMS board and recently made a public apology.
The legislation calls for the termination of all the current
board members.
“They will be terminated in two different batches, so
that we separate some in June and some in October,” House Health and
Government Operations Committee Chairwoman Shane Pendergrass said.
The committee adopted an amendment mandating that no elected
officials can serve on the board. Committee members paid close attention to
ways to find out how these no-bid contracts happened…
The bill covers much ground, including limiting the number
of board members to 25, prohibiting members from using their position for
private gain and prohibiting sole source contracts. Financial disclosure
statements and notification of any potential conflicts of interest would become
a requirement by law.” (J)
“On the last day of Maryland’s General Assembly session,
lawmakers gave final approval to sweeping legislation that would reform the
University of Maryland Medical System’s board of directors amid revelations of
single-source contracts for some board members.
The legislation — which comes after Baltimore Sun reporting
sparked an outcry over the board’s practices, including a $500,000 deal to buy
Mayor Catherine Pugh’s self-published “Healthy Holly” books — would bar no-bid
contracts for board members, force all members to resign and reapply for their
positions (if they want to return), and mandate an audit of contracting
practices.
By a vote of 46-0, Maryland’s senators approved the
legislation sponsored by Baltimore Democratic Sen. Jill P. Carter.
The bill now goes to Republican Gov. Larry Hogan for his
consideration; he supports reforms for UMMS. (K)
“After weeks of mounting pressure, Mayor Catherine Pugh of
Baltimore resigned on Thursday amid a widening scandal involving hundreds of
thousands of dollars worth of children’s books that she wrote and that the
University of Maryland Medical System paid for while she was serving on its
board of directors.
Her resignation comes days after the Baltimore City Council
proposed amending the city charter to make it possible to remove her, and after
the F.B.I. raided her two homes and her office at City Hall…” (L)
“Robert A. Chrencik, president and CEO of Baltimore-based
University of Maryland Medical System, has resigned, effective April 26,
according to the Baltimore Sun.
The health system’s board placed Mr. Chrencik on a leave of
absence March 25, as a scandal unfolded involving board members profiting from
contracts with hospital networks they oversee.” (M)
“The University of Maryland Medical Center has requested a
$75 million rate increase from state regulators, a nearly 5 percent increase.
The request was made before news broke of the University of
Maryland Medical System’s inside deals with its board members.
Since then, Catherine Pugh resigned her position on the
board and as mayor of Baltimore, and the system’s CEO Robert Chrencik stepped
down.
“The rate increase requested by UMMC is necessary to provide
funding for ongoing investment in operations and mission-driven goals – vital
initiatives that enable the hospital to deliver first-class care to our
patients,” a UMMS spokesperson said in a written statement. “Ultimately, this
is about UMMC being able to meet the complex needs of our patients while
continuing to serve as a safety net provider for the West Baltimore community.”
State Sen. Jill Carter, (D-Baltimore City) said the timing
of the request could not be worse.
“Right now, of course, there’s going to be a perception that
this rate massive rate increase somehow is a result of the self-dealing,” Sen.
Carter said. “Maybe they should hold off until some of the investigations are
done or the internal or external audits are done, that the legislation called
for that.”” (N)
“The chairman of the embattled University of Maryland
Medical System board of directors announced his resignation Tuesday — along
with two other board members — as an additional contract with one of the
departing board members was revealed.
Board Chairman Stephen Burch, who attended a contentious
meeting in March with Republican Gov. Larry Hogan and Democratic state Senate
President Thomas V. Mike Miller over the board’s contracting practices,
announced his resignation effective July 1.
Burch, who also served as a member of Democrat Catherine
Pugh’s transition team when she became mayor of Baltimore, was joined in
resigning from the UMMS board by Kevin O’Connor and Dr. Scott Rifkin.
O’Connor’s resignation is effective July 1, while Rifkin’s
takes effect immediately.
The system said in a statement that Rifkin and the hospital
network had an “active agreement” in which his company “provides
software for a pilot program designed to reduce hospital readmissions.”..
Federal, state and local investigations are underway.
System President and CEO Robert Chrencik — who was paid
$4.3 million in total compensation in 2017 — resigned last month. Pugh
resigned last week from her office as mayor of Baltimore.” (O)
“Former Baltimore mayor Catherine Pugh and her colleagues on
the University of Maryland Medical System board were not the only ones who
profited from business deals with the hospitals they oversaw.
At least two dozen people who sit on boards of smaller,
affiliated institutions in the massive system had contracts with those
institutions, in some cases worth hundreds of thousands of dollars annually,
according to financial disclosures.
The contracts show the pervasiveness of the kinds of deals
that led to Pugh’s resignation as mayor this month and, lawmakers say, point to
challenges that remain as they grapple with how to make the system more
accountable.
Among those who had deals with hospitals they oversaw were a
Harford County veterinarian who has made nearly $3 million since 2013 from
rental leases; a vascular surgeon whose Bel Air practice made $2.4 million
since 2013; and the former president of an ambulance company whose contracts
were worth at least $1.3 million since 2010.
Michael Schwartzberg, a spokesman for UMMS, said those
relationships are “all appropriate and consistent with fair market value.” Some
of the contracts predated members’ service on the boards, he said; others were
signed after members joined their respective boards. He said some deals were
competitively bid and did not provide information about others.
There were at least two dozen local board members who had
contracts with the hospitals they oversaw, according to the disclosure forms,
which in some cases listed the specific amount their contracts were worth but
in others required a range, such as “greater than $100,000.” The commission
said it was missing forms from UM Rehabilitation & Orthopaedic Institute.”
(P)
Gov. Larry Hogan has decried contracts that board members of
the University of Maryland Medical System held with the organization they were
tasked with overseeing and promised to “clean house.”
But state law long has called for housecleaning along the
way, specifying that board members can’t serve more than two consecutive
five-year terms. Hogan (R) and his predecessors, who appoint the board members,
allowed some to stay well past a decade.
A spokesman for the governor, who took office in 2015, said
Thursday that term limits will be enforced from now on.
“These practices were handed down from both Republican and
Democratic administrations,” spokesman Michael Ricci said in an email.
“Governor Hogan is working to put an end to them so we can help restore public
trust in UMMS.”
Members who lingered on the board include former state
senator Francis X. Kelly, whose insurance company held some of the largest
contracts that are under review as part of a broad investigation of the
hospital board.
Kelly, who did not respond to requests for comment, joined
the board in 1986 and most recently was reappointed by Hogan in 2016. He took a
voluntary leave of absence from the board while auditors probe the contracts.”
(Q)
“The University of Maryland Medical System (UMMS) Board of
Directors reviewed and voted unanimously to approve a new Conflict of Interest
Policy. This is another milestone as the organization continues to improve
Board governance and oversight while managing conflicts of interest
appropriately. The new Policy is adherent to recently passed Maryland legislation
and is effective July 1, 2019.
“This is another major step forward as we improve Board
governance, change corporate culture and put UMMS on a strong path forward,”
said Interim President and CEO John Ashworth. “We thank the legislators for
their work in guiding this policy during the session and helping us focus on
providing a sound, long-term foundation for a sustainable, effective Board.”
Of note, the Policy includes:
A prohibition on sole source contracting with any UMMS Board
member
Requirements for the recusal of non-independent Board
members from certain deliberations and decision-making activities
Provisions that restrict relevant Board leadership positions
to independent Board members
Detailed procedures for the disclosure of interests by UMMS
Board members, officers and management level employees
The process for identifying and addressing conflicts of
interest
The process for handling violations of the Conflict of
Interest Policy
A requirement that every Board member attest to compliance
with the Conflict of Interest Policy
The new Conflict of Interest Policy was delivered to
Governor Hogan and the presiding officers of the Senate and House of Delegates
today, as required by Maryland law. The Policy will also be presented to the
UMMS affiliate boards for review and approval within 60 days.” (R)
“Four top executives at the University of Maryland Medical
System have resigned amid investigations into accusations of self-dealing among
the hospital network’s board members, the system announced Thursday.
Those resigning are Megan Arthur, the system’s primary
lawyer; Jerry Wollman, the chief administrative officer; Christine Bachrach,
the system’s chief compliance officer; and Keith Persinger, the chief
performance improvement officer.” (S)
“Maryland Gov. Larry Hogan named Wednesday his initial batch
of new appointees to the troubled board of directors at the University of
Maryland Medical System, the first step toward reorganizing the board following
a scandal over board members having lucrative contracts with the 13-hospital
system.
The volunteer board came under fire in March when The
Baltimore Sun reported a third of its 30 members or their companies had deals
with the hospital system, some of which were not competitively bid. They
included then-Mayor Catherine Pugh of Baltimore, a Democrat who made hundreds
of thousands of dollars selling children’s books in a sole-source arrangement
with UMMS. She later resigned from the board and as mayor amid multiple
investigations into the book deals.
In a separate action Wednesday, the hospital board elected
new leadership from among its current members and invited four members who
voluntarily took leaves of absence to return.
The new appointments to the board are required under a law
state legislators passed this year that mandated several reforms at the
hospital system. All previously appointed board members must step down by the
end of the year, to be replaced or reappointed by the governor.
All new board members are subject to confirmation votes by
the state Senate, but can serve until the Senate votes on their appointments.
They will take office July 1.
Board members can serve up to two five-year terms. In the
past, board members often stayed past the end of their terms if a governor
didn’t replace them.
“I pledged that I would appoint new board members who will
serve with integrity and accountability, and today, I am delivering on that
promise,” Hogan, a Republican, said in a statement. “This is another critical
step as UMMS works to restore public trust.”
The medical system board met Wednesday morning and elected
James “Chip” DiPaula Jr. as chairman and Alexander Williams Jr. as vice
chairman. They’ll serve in those roles for the remainder of the year. Former
Chairman Stephen A. Burch was among several board members who resigned amid the
scandal.
DiPaula, who Hogan appointed to the board in 2016, is a
former state budget secretary and chief of staff to then-Gov. Robert L. Ehrlich
Jr., a Republican. DiPaula later founded an e-commerce firm.
Williams is a retired federal judge who has been tapped for
other leadership roles, including chairman of the state’s Commission to Restore
Trust in Policing and co-chairman of a commission on redistricting that drew up
a proposed map for Maryland’s 6th Congressional District. Hogan appointed
Williams to the hospital system board in 2015.
In a statement released by UMMS, DiPaula said members of the
board “regret the actions and poor decisions which have jeopardized confidence
in the system.”
The new board members nominated by Hogan are:
» Eliza Basnight, senior vice president of supply chain for
the American Red Cross. Previously, she was chief of staff for the U.S. Mint
under the Obama administration and head of the Center for Women Veterans at the
U.S. Department of Veterans Affairs.
» Kathleen A. Birrane, an attorney with the firm DLA Piper
who previously was the top lawyer for the Maryland Insurance Administration.
» Dr. Joseph Ciotola, health officer for Queen Anne’s County
and medical director for that county’s Department of Emergency Services.
[Most read] As Maryland leaders condemn expected ICE
enforcement in Baltimore region, Gov. Hogan ‘monitoring the situation’ »
» Matthew Clark, Hogan’s chief of staff. Clark will hold a
seat that is reserved for the governor or the governor’s designee.
» Wanda Queen Draper, former director of the Reginald F.
Lewis Museum of African-American History and Culture in Baltimore.
» Jason Frankl, senior managing director of FTI Consulting,
where his work includes helping companies defend against activist investors and
takeover attempts.
» Glenn T. Harrell, retired senior judge of the Maryland
Court of Appeals.
» Dr. Joyce M. Johnson, a physician who retired from the
U.S. Public Health Service, where she held the rank of rear admiral and was director
of health for the U.S. Coast Guard.
» Bonnie Phipps, senior vice president and group operating
executive for Ascension Health, a Catholic health system that operates in 21
states and the District of Columbia, including Southwest Baltimore’s St. Agnes
Hospital, where she was president from 2005 to 2015.
» Joseph T.N. Suarez, a director at Booz Allen Hamilton, a
business consulting firm.
» John T. Williams, chairman and CEO of Jamison Door Company
in Hagerstown. He previously served as a newspaper and TV executive.
In addition to mandating a gradual replacement of the
current board and requiring term limits, the new law banned no-bid contracts
for board members and required a state audit of the hospital system’s
contracting practices.” (T)
“Francis Kelly Jr., the former Maryland state senator whose
insurance company benefited from contracts with the University of Maryland
Medical System while he served on the hospital network’s board of directors ,
announced Friday that he will give up that seat.
“It has been a tremendous honor for me to have served
on the UMMS Board for nearly 35 years, under six different Governors,”
Kelly wrote in a resignation letter to board chairman Stephen Burch. “I
have decided it is time to move on, and allow someone else the fantastic
opportunity of serving.”
Kelly and his sons, John and David, who served on
UMMS-affiliated boards, took voluntary leaves of absence in April as probes
were opened to review the health system’s contracts with businesses affiliated
with board members.
In the resignation letter, Kelly said his sons have also
decided not to return to their board positions.
The UMMS board voted Wednesday to ask Kelly and three other
members on leave to rejoin the board, after an outside probe of the contracting
scandal placed most of the blame with former hospital system chief executive
Robert Chrencik, who resigned in April.
Several state lawmakers raised concerns about the board’s
decision, however, and said board members who had contracts with the system
should not return to the board.
“[W]e feel that the best way to serve the system and
its affiliated hospitals at this time is not come back onto these boards,”
Kelly wrote in a letter to John Ashworth III, the interim president and chief
executive.
Kelly & Associates Insurance Group has had
multimillion-dollar transactions with the medical system since at least 2005,
the first year for which financial disclosure records are available, handling
more than $100 million in premiums.” (U)
“A review of contracts the University of Maryland Medical
System had with members of its board of directors and their companies revealed
more no-bid and self-dealing practices — including that executives pressured
staff to use board members’ products — and blamed former CEO Robert Chrencik
and other system leaders.
“Many of these contracts were not competitively bid, were
not declared to be necessary by the board or senior leaders, and, if vetted,
were without full transparency to the entire board,” concluded the review by
Nygren Consulting, which was hired and paid by the 13-hospital network.
The report released Wednesday reviewed business deals with
nine board members and found:
» Seven of nine of the deals were entered into without
competitive bids;
» In four cases, the board of directors was not properly
informed of the business relationships;
» The board member who was in charge of auditing financial
dealings himself had a no-bid deal;
» In at least two instances, staff felt pressured to promote
the use of software from companies that would have benefited individual board
members financially.
The report focused its harshest criticism on deals with four
board members that hospital officials described as “personal services”
contracts: Former Baltimore Mayor Catherine Pugh, who was paid $500,000 for her
self-published children’s books; Robert Pevenstein, a consultant who was paid
more than $100,000 a year; John W. Dillon, who was paid $892,000 since 2013 for
providing “healthcare consulting services;” and Dr. Scott Rifkin, who runs a
health care software company.
The system commissioned the review in response to
revelations in The Baltimore Sun, beginning in March, about the contracting
practices.
“These arrangements reflect a pattern by management of
making decisions without full board approval,” the report found of members’
contracts. “The board was insufficiently informed and, for the most part, had
no specific advance knowledge that would have caused the board to consider
alternatives that would have forestalled or eliminated perceived and real
self-dealing.” “ (V)
“The report on self dealing among UMMS board members comes
after the departures of the system’s CEO and board members, including former
Baltimore Mayor Catherine Pugh. Controversy arose over board members —
including Pugh — who made money in business deals with the system.
Regarding Pugh’s “Healthy Holly” book arrangement,
Nygren wrote, “Our review has determined that management did not present
the book purchases to the board or any committee for prior approval, as
required by then-in-effect Conflict of Interest policies, and the purchase was
not subject to any competitive bidding process.”
The report concluded that then-CEO Robert Chrencik
“agreed to enter into an agreement with Ms. Pugh without consent of the
board.”
Between 2010 and 2018, UMMS agreed to pay a total of
$500,000 for the self-published books Pugh authored. She repaid $100,000.
The report also investigated other former board members and
found similar violations of board policies.
UMMS said in a statement that the report details “both
management and various board members share responsibility for the lack of
transparency and strong, modern governance policies that resulted in improper
relationships.”
UMMS said the following recommendations have been or will be
adopted:
A new, comprehensive Conflict of Interest Policy was
authored by Nygren and accepted by the Board of Directors. The policy was
delivered to Maryland’s governor, Senate president and Speaker of the House on
May 31.
A Governance Committee will be chartered as a permanent
Committee of the Board, and tasked with overseeing all board practices,
policies and relationships. All appropriate guiding documents will be authored.
A new, research-based “competency” model will be
implemented to ensure the makeup of the board is determined based on two levels
of competencies: those required of each individual member, and those required
by the Board as a whole. This will ensure the board is representative of the
communities it serves and has the experience and skills necessary to advance
the organization’s strategic direction and mission.
The education process related to disclosures and conflicts
will be redesigned and will include an official “Code of Conduct” to
ensure all board members and senior management are acutely aware of compliance
requirements moving forward.
Board committees will be restructured so chair positions of
the Finance Committee and the Audit and Compliance Committee are held by
separate individuals, and the chair of the latter maintains no financial or
contractual relationship with the organization.
“While Nygren confirmed that outside business interests
between a board member and a nonprofit Board of Directors are not uncommon or
illegal, great care and caution must be given to ensure there is proper vetting
and no real or perceived conflicts of interest. To that end, any proposed
professional services agreements with board members will be revealed to the
full board, carefully vetted with the Board’s Audit and Compliance Committee
and reported to the Compliance Officer. The new Conflict of Interest Policy
will be strictly adhered to in all cases. Additionally, the system will no
longer allow any board member to engage in a personal services agreement,
regardless of circumstance,” the UMMS statement read.” (V)
“The recent ethical lapses within the University of Maryland
Medical System and its board have been appalling, with much of the focus on
former Baltimore Mayor Catherine Pugh, state legislation passed to improve
board oversight and resignations of certain board members.
Scant attention has been paid, however, to an elephant in
the room: Most of the board members were, as required by statute, appointed by
Gov. Larry Hogan, with some improperly reappointed beyond the two-term legal
limit. And many of them, including several of the 11 newly appointed board
members, donated to his campaign as individuals or through affiliated
businesses — some in apparent excess of campaign finance limits — for a
combined total of over $115,000.
While donors receiving appointments isn’t inherently
unlawful, it undermines public confidence, particularly when combined with the
fact that some of these donor-appointees, including former state Sen. Frank
Kelly Jr., appear to have received generous “insider” contracts from UMMS.
And, despite the governor’s professed outrage over UMMS’
dealings, he recently vetoed an important bill that would improve transparency
and strengthen accountability of the Governor’s Appointments Office, whose
primary purpose is to vet political appointees to represent Mr. Hogan on boards
and commissions and in a small handful of high-level leadership positions in
state agencies.
The governor prefers to point the finger at UMMS for its
failed internal controls, but he, too, should have known that many of his
appointees had business dealings with UMMS. His appointments office requires
all appointees to complete a form that probes for conflicts of interest and
problematic affiliations.
In examining the governor’s campaign finance records,
publicly available from the State Board of Elections, I found at least eight
UMMS board members — Stephen Burch, R. Alan Butler, John Coale, James “Chip”
DiPaula Jr., Barry Gossett, Mr. Kelly, Robert Pevenstein and Walter Tilley Jr.
— who donated to Governor Hogan the $6,000 maximum permitted by law.
Businesses apparently connected to Mr. Tilley, James
Soltesz, Mr. DiPaula and Robert Rauch also contributed a combined $16,000 to
Governor Hogan’s campaign.
Four board members or related businesses appear to have
contributed above the $6,000 legal limit in total over a four-year period:
Kelly Integral Solutions LLC, contributed $11,000 — all
while Kelly & Associates received a lucrative UMMS contract reportedly
worth $16 million. (Mr. Kelly is among those who recently announced his
resignation from the board.)..
In order to boost accountability, and in response to
numerous complaints of politicization of the state workforce, I introduced and
passed legislation (Senate Bill 751) during this past session that would
increase transparency regarding the information gathered by the appointments
office by requiring annual aggregated reporting back to the General Assembly.
The governor vetoed it.” (X)
“For its report, Nygren reviewed system documents and
interviewed about 60 people, including current and former board members,
executives and staff. Here are some of the firm’s key findings:
1) Blaming the old boss.
Chrencik was blamed for cutting deals with individual board
members without the full board’s approval. In four cases, the board was not
properly informed of the deals…
2) Most deals with board members weren’t competitively bid.
Seven of nine of the deals with individual board members
were entered into without competitive bids…
3) Who’s doing oversight?
The board member who was in charge of monitoring financial
dealings himself had a no-bid deal. Robert Pevenstein, who was chairman of both
the audit and finance committees, had several arrangements with the system,
including for-profit relationships for the firms Profit Recovery Partners and
Optime, as well as a consulting deal. He was paid more than $100,000 a year…
4) Staff felt uncomfortable.
In at least two instances, UMMS employees felt pressured to
promote the use of software from companies that benefited individual board
members financially…” (Y)
ASSIGNMENT:
What are the Lessons Learned from the Johns Hopkins All Children’s Hospital and
North Carolina Children’s Hospital pediatric open cardiac surgery program
failures? What are the regulatory implications?
New PART 3 after
PARTs 1 and 2.
PART 1. February 26, 2019. Johns Hopkins All Children’s
Hospital (St Petersburg, Florida) – problems in the hospital’s heart surgery
unit
PART 2. June 1, 2019. “The situation that the New York
Times described in North Carolina parallels that at Johns Hopkins All
Children’s Hospital in St. Petersburg, which stopped performing heart surgeries
after the Tampa Bay Times reported on problems in the unit
PART 1. February
26, 2019. Johns Hopkins All Children’s Hospital (St Petersburg, Florida) –
problems in the hospital’s heart surgery unit
“The Patient Safety and Healthcare Quality Masters
program is a fully online, interdisciplinary degree offered by Johns Hopkins
University. It is a first-of-its-kind collaboration between the Johns Hopkins
Bloomberg School of Public Health, Johns Hopkins School of Medicine, Johns
Hopkins School of Nursing and the Armstrong Institute for Patient Safety and
Quality. It combines coursework from JHU’s top ranked schools and the Armstrong
Institute’s pioneering advances in patient safety-educating students in the
transformative mechanisms and evidence-based protocols that reduce preventable
patient harm and improve clinical outcomes.
Renowned, industry-shaping experts lead this exciting new
program designed for working adults. The program focuses on: Measurement of
safety and quality; Designing safer systems; Organizational and cultural
change. ” (A)
“Patient Safety and Quality at Johns Hopkins Medicine.
Each day in a hospital, staff members undertake complicated
tasks caring for patients. Johns Hopkins Medicine’s patient safety efforts aim
to ensure that all of these steps work together to deliver high-quality,
compassionate care to all patients across our health system.
Johns Hopkins Health System hospitals and services
consistently receive awards and honors for patient safety and quality,
including Top Performer on Key Quality Measures by the Joint Commission, Magnet
designation for nursing, HomeCare Elite and Delmarva Foundation Excellence
Awards. The Johns Hopkins Hospital has been ranked No. 1 in the nation by U.S.
News & World Report for 22 years of the survey’s 25-year history, most
recently in 2013.
Patient Safety and Quality Measures
This website shares data for the Johns Hopkins Health
System. Here, you will find information about key safety issues and the
patient’s experience of care, including:
Patient Experience – Based on survey results from previous
patients, you can see how others rated their experience of care from a Johns
Hopkins Medicine hospital or home health care provider.
Infection Prevention – These measures include the rate of
CLABSIs, a bloodstream infection caused by a central line (large IV) that are
considered preventable and hand hygiene, the percentage of medical staff
members observed washing their hands or using hand sanitizer before and after
caring for a patient.
Core Measures – These measures are national standards of
care and treatment processes for common conditions. Core measure compliance
shows how often a hospital follows each of these steps.
Surgical Volumes – Studies have shown a strong relationship
exists between the number of times a hospital performs a specific surgical
procedure and the outcomes for those patients. In 2016, we started sharing our
hospitals’ surgical volumes for many common and high-risk procedures.
Quality of Care Ratings – The quality of patient care star
rating is a summary of how well the Johns Hopkins Home Care Group and Potomac
Home Health Care perform on nine quality measures such as ambulation.
Pediatrics – These measures include national standards of
treatment for common conditions, infection prevention, pain management and
emergency department wait times for Johns Hopkins’ pediatric divisions.
Hospital Readmissions – Patients are most vulnerable for
readmission to a hospital immediately following discharge. This measure tracks
how many Medicare patients with specific conditions were readmitted to the
hospital within 30 days for any reason.
Our Commitment to Transparency
Patients and their loved ones deserve to be informed about
the quality of their heath care. At Johns Hopkins Medicine, we are dedicated to
sharing our performance and how we work to provide the best care with past,
present and future patients. The Johns Hopkins Armstrong Institute for Patient
Safety and Quality coordinates safety and quality improvement efforts and
training across our health system.
We hope you will find this website a valuable resource and
encourage you to ask your health care team if you have any questions or
concerns. (B)
“Patient Trust, Confidence Built on Interprofessional
Innovation
Medical errors and preventable patient infections and
injuries together make up the third-leading cause of death in the United
States, a startling statistic.
The Johns Hopkins School of Nursing understands that an
increasing focus on patient safety and quality of care depends upon a
healthcare workforce that knows the risks and the proper responses from patients’
arrival to their safe discharge.
The Helene Fuld Leadership Program for the Advancement of
Patient Safety and Quality (The Fuld Fellows Program) emphasizes
interprofessional education and training, simulation, and service-learning
experiences involving nurses, medical students, pharmacists, and other health
professionals whose collaboration is critical for reducing preventable harm to
patients.
Nurses, as the primary contact with patients, play a key
role in their safety. Hopkins Nursing, as part of an interprofessional team
that includes the Armstrong Institute for Patient Safety & Quality and the
Johns Hopkins Health Systems, works to prepare nurses ready to communicate,
cooperate, innovate, and lead on issues of patient safety and quality of care.”
(C)
“Johns Hopkins Medicine Armstrong Institute for Patient
Safety and Quality
A roadmap for patient safety and quality improvement
This month the Agency for Healthcare Research and Quality
(AHRQ) published a new report that identifies the most promising practices for
improving patient safety in U.S. hospitals.
An update to the 2001 publication Making Health Care Safer:
A Critical Analysis of Patient Safety Practices, the new report reflects just
how much the science of safety has advanced.
A decade ago the science was immature; researchers posited
quick fixes without fully appreciating the difficulty of challenging and
changing accepted behaviors and beliefs.
Today, based on years of work by patient safety
researchers-including many at Johns Hopkins-hospitals are able to implement
evidence-based solutions to address the most pernicious causes of preventable
patient harm. According to the report, here is a list of the top 10 patient
safety interventions that hospitals should adopt now.
Top 10 Recommended Patient Safety Strategies
1. Preoperative checklists and anesthesia checklists to
prevent operative and postoperative events.
2. Bundles that include checklists to prevent central
line-associated bloodstream infections
3. Interventions to reduce urinary catheter use, including
catheter reminders, stop orders, or nurse-initiated removal protocols
4. Bundles that include head-of-bed elevation, sedation
vacations, oral care with chlorhexidine, and subglottic-suctioning endotracheal
tubes to prevent ventilator-associated pneumonia
5. Hand hygiene
6. The do-not-use list for hazardous abbreviations
7. Multicomponent interventions to reduce pressure ulcers
8. Barrier precautions to prevent healthcare-associated
infections
9. Use of real-time ultrasonography for central line
placement
10. Interventions to improve prophylaxis for venous
thromboembolisms…
Even with a list of sound strategies, creating a plan to
implement all or even half of them may sound like a daunting task. The
Armstrong Institute for Patient Safety and Quality has created a checklist to
help you get started.
1. Identify priorities and assess readiness for change.
2. Establish engagement and accountability at all levels of
the organization.
3. Communicate constantly (the good and the bad).
4. Measure, measure, measure… and then measure some more.
(D)
“Johns Hopkins All Children’s Hospital provides expert
pediatric care for infants, children and teens with some of the most
challenging medical problems in our community and around the world.
Named a top 50 children’s hospital by U.S. News & World
Report, we provide access to innovative treatments and therapies. Taking part
in pediatric medical education and clinical research helps us to provide care
in more than 50 specialties.
With more than half of our 259 beds devoted to intensive
care level services, we are the regional pediatric referral center for
Florida’s West Coast. Physicians and community hospitals count on us to care
for critically ill patients and perform complex surgical procedures.
Parents count on us, too. Our philosophy of family-centered
care means family members are an important part of our health care team. We
include parents in making decisions and plans for their child’s care. We also
include patients who are old enough to take part in these discussions.
To help us design our hospital that we opened in January
2010, we asked patients, parents and our staff to share ideas. The result was a
spacious and bright hospital with individual rooms where parents can
comfortably spend the night. With the latest technology and our commitment to
family-centered care, our hospital provides an ideal environment for
healing.” (E)
“Quality, Outcomes and Patient Safety at Johns Hopkins
All Children’s
We are committed to treating you and your child with
compassion and respect. We believe that you deserve honesty in our
communication about the plan for your child’s care and we will demonstrate
uncompromising integrity to earn your trust. We will be responsible for
including each family as a part of our care team that is committed to safe and
innovative care practices. Our goal is to inspire hope for you and your child
through our focus on inquiry, collaboration, and team work.
Johns Hopkins All Children’s Hospital believes in Creating
healthy tomorrows… for one child, for All Children. Our focus on Quality
assures that we are continually improving our processes in an effort to achieve
this vision. Using a team approach we tap into the know-how of our expert
medical staff and employees to improve the quality and safety of the care we
provide.
Our Quality Model provides the basis for understanding
patient needs, measuring and using data, and achieving real improvement.
Improving continuously is our goal. To do this we encourage each member of our
team to find ways to do their work better and to make patient safety a
priority. Together we are focused on pursuing perfection for All Children.
Quality Measures
There are many ways to look at and measure quality. Our data
uses information from key areas to help families, healthcare providers, and
others learn about our progress in pursuing perfection for All Children.”
(F)
“Sandra Vázquez paced the heart unit at Johns Hopkins
All Children’s Hospital.
Her 5-month-old son, Sebastián Vixtha, lay unconscious in
his hospital crib, breathing faintly through a tube. Two surgeries to fix his
heart had failed, even the one that was supposed to be straightforward.
Vázquez saw another mom in the room next door crying. Her
baby was also in bad shape.
Down the hall, 4-month-old Leslie Lugo had developed a
serious infection in the surgical incision that snaked down her chest. Her
parents argued with the doctors. They didn’t believe the hospital room had been
kept sterile.
By the end of the week, all three babies would die…
The internationally renowned Johns Hopkins had taken over
the St. Petersburg hospital six years earlier and vowed to transform its heart
surgery unit into one of the nation’s best.
Instead, the program got worse and worse until children were
dying at a stunning rate, a Tampa Bay Times investigation has found.
Nearly one in 10 patients died last year. The mortality
rate, suddenly the highest in Florida, had tripled since 2015…
Times reporters spent a year examining the All Children’s
Heart Institute – a small, but important division of the larger hospital
devoted to caring for children born with heart defects…
They discovered a program beset with problems that were
whispered about in heart surgery circles but hidden from the public.
Among the findings:
All Children’s surgeons made serious mistakes, and their
procedures went wrong in unusual ways. They lost needles in at least two
infants’ chests. Sutures burst. Infections mounted. Patches designed to cover
holes in tiny hearts failed.
Johns Hopkins’ handpicked administrators disregarded safety
concerns the program’s staff had raised as early as 2015. It wasn’t until early
2017 that All Children’s stopped performing the most complex procedures. And it
wasn’t until late that year that it pulled one of its main surgeons from the
operating room.
Even after the hospital stopped the most complex procedures,
children continued to suffer. A doctor told Cash Beni-King’s parents his
operation would be easy. His mother and father imagined him growing up, playing
football. Instead multiple surgeries failed, and he died.
In just a year and a half, at least 11 patients died after
operations by the hospital’s two principal heart surgeons. The 2017 death rate
was the highest any Florida pediatric heart program had seen in the last
decade.
Parents were kept in the dark about the institute’s
troubles, including some that affected their children’s care. Leslie Lugo’s
family didn’t know she caught pneumonia in the hospital until they read her
autopsy report. The parents of another child didn’t learn a surgical needle was
left inside their baby until after she was sent home.
The Times presented its findings to hospital leaders in a
series of memos early this month. They declined interview requests and did not
make the institute’s doctors available to comment.
In a statement, All Children’s did not dispute the Times’
reporting. The hospital said it halted all pediatric heart surgeries in October
and is conducting a review of the program.
“Johns Hopkins All Children’s Hospital is defined by
our commitment to patient safety and providing the highest quality care
possible to the children and families we serve,” the hospital wrote.
“An important part of that commitment is a willingness to learn.” (G)
The top three leaders of Johns Hopkins All Children’s
Hospital in Florida resigned Tuesday following a Tampa Bay Times investigation
that revealed increasing mortality rates among heart surgery patients.
The resignations from the 259-bed teaching hospital in St.
Petersburg included CEO Jonathan Ellen, M.D., and Vice President Jackie Crain,
as well as Jeffrey Jacobs, M.D., who is the heart institute’s deputy director,
the Tampa Bay Times reported. Paul Colombani, M.D., stepped down as chairman of
the department of surgery but will continue working in a clinical capacity, a
statement from the health system said.
“Losing a child is something no family should have to
endure, and we are committed to learning everything we can about what happened
at the Heart Institute, including a top-to-bottom evaluation of its leadership
and key processes,” a statement from Johns Hopkins read. “The events
described in recent news reports are unacceptable.”
Johns Hopkins, which owns and operates the hospital, said it
would install Kevin Sowers, who is president of the Johns Hopkins Health System
and executive vice president of Johns Hopkins Medicine, to lead the hospital in
a temporary capacity while a plan for interim leadership is put into place.
George Jallo, M.D., who is medical director of the Institute
for Brain Protection Sciences and chief of pediatric neurosurgery, will serve
as interim vice dean and physician-in-chief, and Paul Danielson, M.D., who is
chief of the Division of Pediatric Surgery at Johns Hopkins All Children’s
Hospital, will serve as interim chair of the surgery department.
Johns Hopkins’ board also said it commissioned an external
review to examine the heart surgery program and said it would share its lessons
from the review to help hospitals around the country avoid the same mistakes.
The moves come following the Tampa Bay Times investigation
that highlighted a growing number of heart surgery deaths at the hospital amid
warnings about safety from staffers that went unheeded. (H)
“Three additional senior administrators have left Johns
Hopkins All Children’s Hospital in the wake of a Tampa Bay Times investigation
into high mortality rates at the hospital’s Heart Institute, the hospital
announced Wednesday.
A total of six senior officials have left since the Times
report, including the hospital’s CEO, three vice presidents and two surgeons
who held leadership roles at the Heart Institute. A seventh official stepped
down as chairman of the surgery department but remained employed at the
hospital as a doctor.
The resignations announced Wednesday included vice
presidents Dr. Brigitta Mueller, the hospital’s chief patient safety officer,
and Sylvia Ameen, who oversaw culture and employee engagement and served as the
hospital’s chief spokeswoman.
The hospital also said Dr. Gerhard Ziemer, who started as
the Heart Institute’s new director and chief of cardiovascular surgery in
October, would leave the hospital. The hospital never publicly announced Ziemer
had been hired, and he had not yet obtained his Florida medical license when
the Times investigation was published at the end of November. At that point,
the hospital said the Heart Institute had already stopped performing surgeries.
“While Dr. Ziemer is not responsible for the current
state of the program, we agreed that a fresh start was needed to ensure success
for the program,” Johns Hopkins Health System President Kevin Sowers said
in a letter to the hospital’s staff.” ..
In his letter to the staff, Sowers said that several
hospital executives had been tasked with leading “critically important
work around advancing our culture of safety.”
“As we work to rebuild the trust of our community, we
must also work to fully embrace and support a culture where we are each
empowered and encouraged to speak up and speak out if we see or hear something
that concerns us,” he wrote. “This commitment applies to clinical
concerns as well as inappropriate workplace behavior.”
Sowers also announced that Johns Hopkins had hired external
experts to develop a plan to restart heart surgeries at All Children’s.
That is a separate effort from an external review of the
problems in the Heart Institute, which Johns Hopkins announced its board had
commissioned last month, spokeswoman Kim Hoppe said…
Johns Hopkins is one of the most prestigious brands in
medicine and is internationally renowned for developing innovative patient
safety protocols that are used at hospitals across the world. But last weekend,
the Times published a story detailing a series of safety problems at hospitals
across its network. In response, the health system pledged to “do
better.” (I)
“The Johns Hopkins Medicine Board of Trustees has
appointed a former federal prosecutor to lead its investigation into the Johns
Hopkins All Children’s Hospital’s heart surgery unit, the health system
announced late Tuesday.
F. Joseph Warin, of the global law firm Gibson Dunn, and his
team will review the high mortality rates and other problems at the hospital’s
Heart Institute and report back to a special committee of the board of trustees
by May, the health system said.
Once the review is complete, the health system said it would
also name an independent monitor at All Children’s to “make sure that the
hospital is being held accountable for taking corrective action where
necessary.”
The announcement was accompanied by a video of Johns Hopkins
Health System president Kevin Sowers, who acknowledged for the first time that
the hospital had been warned about problems by frontline workers.
“I know personally that many of you courageously spoke
out when you had concerns but were ignored or turned away,” he said.
“That behavior is unacceptable and will not be tolerated going
forward.”
Sowers, who is also interim president at All Children’s,
said he hoped to meet with the families of patients affected by problems in the
Heart Institute in the coming days to share his “profound sadness for the
failures of care they experienced.” (J)
“The external review was prompted by multiple reports
by the Tampa Bay Times about problems at the center which could have
contributed to its mortality rate tripling between 2015 and 2017…
Health News Florida’s Stephanie Colombini talked about what
could come next with Kathleen McGrory, one of the lead reporters.
One of the big problems you uncovered in your reporting was
the lack of available data about mortality rates at a lot of these heart
surgery programs…
Officials have either refused to release it or they only
release four-year averages, which could mislead families about the current
state of the program they’re choosing.
How is the state looking at making these programs more
transparent?
There were some problems at another pediatric heart surgery
program in 2015 in Palm Beach County (St. Mary’s Medical Center), and after
those problems surfaced, the legislature put together a panel (Pediatric
Cardiology Technical Advisory Panel) tasked with looking at transparency and
ways we could, as a state, make these programs better and more accountable.
That panel is in the middle of doing its work right now and
in fact has come close to finalizing some recommendations.
The panel would like all of these heart surgery programs to
be reporting their one-year data (on mortality rates) rather than their
four-year data because that four-year data can sometimes hide serious problems…
So the state is looking into making heart surgery programs
more accountable, but is anyone calling for change when it comes to the
government’s role in this?
You reported that multiple times state and federal
regulators were alerted to problems at All Children’s and yet little, to no
action was taken.
We saw U.S. Reps. Kathy Castor and Charlie Crist put some
really tough questions to federal regulators asking what they had investigated
and when. We haven’t heard back yet on that front but we know it’s something
they’ll be looking into.
The state told us that they did the best they could do with
the information that they had, same thing with the federal government.
But ACHA has a new chief (Mary Mayhew). We haven’t gotten a
chance to connect with her yet and see what her thoughts are on this, but we certainly
will do that in the new year. (K)
“State and federal inspectors descended on Johns
Hopkins All Children’s Hospital this week, following sharp calls for an
investigation into problems in the hospital’s heart surgery unit, the Tampa Bay
Times has learned.
The scope of the inspection is unclear. But hospital
regulators had been criticized in recent weeks for their lax response to early
signs of an increase in mortality at the hospital’s Heart Institute.
A Florida Agency for Health Care Administration spokeswoman
said her agency had been at the facility.
A spokeswoman for the hospital confirmed federal inspectors
had been there, too.
“We appreciate the oversight role that our regulators
play and we will, as always, be fully cooperative and collaborative as they
conduct any reviews necessary,” a statement from the hospital said.
A spokeswoman for the federal Centers for Medicare and
Medicaid Services declined to comment beyond saying the matter remained
“an ongoing review.”
In November, the Times reported that the mortality rate for
heart surgery patients at All Children’s tripled from 2015 to 2017 to become
the highest rate in Florida. The increase occurred after staff members warned
the hospital’s leaders about problems with two heart surgeons, the Times found.
State and federal regulators knew the institute was having
problems months earlier. In April, the hospital’s CEO told the Times that the
institute had “challenges” that led to an uptick in mortality, and
acknowledged the hospital had left surgical needles inside two children.
In May, state regulators cited the hospital for not properly
reporting two medical mistakes, which is required by state law. Days later, a
spokeswoman for the federal agency told the Times that it would perform its own
investigation.
But state regulators didn’t fine the hospital, and
overlooked several subsequent warnings that its surgical results had been poor.
And federal inspectors later changed course and decided not
to undertake a comprehensive review of the heart surgery program, the Times
reported last month. One reason was that state inspectors hadn’t found any
violations of federal rules, a spokeswoman said. Another was that a nonprofit
hospital accreditor was due to perform a scheduled review.” (L)
Two Omaha surgeons filed a lawsuit Friday against Children’s
Hospital & Medical Center, alleging that they were wrongfully suspended and
forced to resign privileges there after they raised patient safety concerns.
In the suit, Dr. Jason Miller and Dr. Mark Puccioni say that
the hospital suspended their privileges to practice at the Omaha facility after
they raised concerns about the death of a 7-month-old during an operation. That
operation was performed this fall by another surgeon, Dr. Adam Conley, the suit
says.
In their communications, according to the suit filed in
Douglas County District Court, the two also questioned Conley’s “skill and
ability.”
In addition to the hospital, the lawsuit names as defendants
Conley, as well as Dr. Richard Azizkhan, who took over as Children’s president
and CEO in October 2015.
Children’s officials said in a statement that the hospital
does not comment on pending litigation “other than to say we strongly
disagree with these allegations…
Children’s has faced other issues in recent months.
In late November, a former pharmacy director at the hospital
was accused of funneling more than $4.4 million from the organization into her
personal account over six years. She was terminated in June and faces a hearing
regarding possible disciplinary action later this month.
About three weeks ago, the Nebraska Medical Association sent
a letter to the board of Children’s Hospital expressing concerns about
“patient care, safety and quality” at the Omaha hospital, in addition
to the loss of longtime physicians.
In the Dec. 11 letter, the president of the group, Dr. Britt
Thedinger, wrote, “We as physicians are concerned about the summary
suspensions, terminations and resignations of long-time outstanding physician
colleagues.” The letter also expressed concern that children were being
transferred to outside institutions because of “complications” and
inadequate staffing at the Omaha hospital.
Thedinger said the organization did not intend for the
letter to become public. The intent, he said, was to bring issues that had been
raised by members to the hospital board and administration.” (M)
“The New Jersey Department of Health is investigating
four Acinetobacter baumannii cases in the neonatal intensive care unit (NICU)
of University Hospital in Newark, authorities announced Thursday evening.
DOH officials stated:
“The department first became aware of this bacterial
infection on Oct. 1 and two department teams have been closely monitoring the
situation. Those department teams, which have been at the facility last week
and this week, have been ensuring that infection control protocols are followed
and are tracking cases of the infection. The department’s inspection revealed
major infection control deficiencies.”
According to the DOH, a premature baby with the bacteria who
had been cared for at University Hospital was transferred to another facility
and passed away toward the end of September, prior to the department’s
notification of problems in the NICU.
“Due to the other compounding medical conditions, the
exact cause of death is still being investigated,” DOH officials said.
The department has ordered a Directed Plan of Correction
that requires University Hospital to employ a full-time Certified Infection
Control Practitioner consultant, who will report to the DOH on immediate
actions taken in the coming days.
DOH officials said they are also exploring further actions
the agency may need to take in the coming days to “ensure patient
safety.” (N)
“Four New Jersey pediatric care facilities and one
hospital are now under the state’s microscope after nine children died and 26
people were sickened by a deadly virus over the past month.
A Department of Health team of infection control experts and
epidemiologists will visit University Hospital in Newark and four pediatric long-term
care facilities in November to conduct training and assessments of infection
control procedures, Commissioner Dr. Shereef Elnahal has announced.
The team of experts will visit University Hospital, the
Wanaque Center for Nursing & Rehabilitation in Haskell, Voorhees Pediatric
Facility in Voorhees and Children’s Specialized Hospital in Toms River and
Mountainside. The department reached out to the facilities last week to
schedule visits in November.
The decision comes after nine children at a Wanaque facility
have died since an outbreak of the adenovirus was declared there. Victims
became sick between Sept. 26 and Oct. 22. Authorities confirmed that the virus
killed eight of the nine kids.
Twenty-six kids and a staff member, who has since recovered,
have become ill as part of the outbreak, state health officials said.
Laboratory tests confirmed the 26th case. (O)
“Two decades ago, the Institute of Medicine shook the
medical profession with its “To Err is Human” report which said
nearly 100,000 people a year lost their lives to preventable medical errors…
During the 7th Annual World Patient Safety, Science &
Technology Summit over the weekend, the Patient Safety Movement Foundation
released a new tool on its website to help with the training.
The patient safety curriculum is one of 17 Actionable
Patient Safety Solutions (APSS) made available to organizations for free to
help train health professionals in systems science so they can help find ways
to reduce preventable patient deaths, officials said.
“The goal is to get every health professional to think
in a system way,” said Steven Scheinman, M.D., the president and dean of
Geisinger Commonwealth School of Medicine. He led a Patient Safety Movement
working group which included experts from Geisinger, San Diego State,
University of Pittsburgh Medical Center, Johns Hopkins Health, and MedStar
Georgetown to develop the curriculum over an 18-month period.
The Patient Safety Movement was founded in 2013 to help
reduce preventable deaths in healthcare and in 2015 set a goal of zero
preventable deaths by 2020. More than 90,000 patients who might have died as a
result of medical errors were saved in 2018 due to efforts made by more than
4,700 hospitals that committed to patient safety efforts, according to figures released
by the foundation. In all, a total of 273,077 lives have been saved since the
first summit, officials said.
The newly released safety curriculum can be adapted to any
healthcare profession including medicine, nursing, pharmacy, and behavioral
health and can be used for student training, as well as training for
experienced professionals.
“We want to train every health professional to take
ownership of the patient’s safety and experience so they understand safe
communication and know when they are telling another person about the patient
or handing them over or referring them over, how to make sure they get all the
critical information there,” Scheinman said…
“The airline industry solved safety by creating the
right systems,” Scheinman said. “Medical errors are very widespread.
But they usually aren’t a doctor making a mistake. They can be. But they’re
more often the system failed to pick something up or allowed something bad to
happen.”
And with this training, he said, those medical professionals
might be that much more likely to help figure out a new solution to make sure
something bad doesn’t happen again.” (P)
“.. experience showcases the promise of a much-touted
but little understood collaboration in health care: alliances between community
hospitals and some of the nation’s biggest and most respected institutions.
For prospective patients, it can be hard to assess what
these relationships actually mean – and whether they matter.
Leah Binder, president and chief executive of the Leapfrog
Group, a Washington-based patient safety organization that grades hospitals
based on data involving medical errors and best practices, cautions that
affiliation with a famous name is not a guarantee of quality.
“Brand names don’t always signify the highest quality of
care,” she said. “And hospitals are really complicated
places.”..
To expand their reach, flagship hospitals including Mayo,
the Cleveland Clinic and Houston’s MD Anderson Cancer Center have signed
affiliation agreements with smaller hospitals around the country. These
agreements, which can involve different levels of clinical integration,
typically grant community hospitals access to experts and specialized services
at the larger hospitals while allowing them to remain independently owned and
operated. For community hospitals, a primary goal of the brand-name affiliation
is stemming the loss of patients to local competitors…
In some cases, large hospital systems opt for a different
approach, largely involving acquisition. Johns Hopkins acquired Sibley Memorial
and Suburban hospitals in the Washington, D.C., area, along with All Children’s
Hospital in St. Petersburg, Fla. The latter was re-christened Johns Hopkins All
Children’s Hospital in 2016…
Although affiliation agreements differ, many involve payment
of an annual fee by smaller hospitals. Officials at Mayo and MD Anderson
declined to reveal the amount, as did executives at several affiliates.
Contracts with Mayo must be renewed annually, while some with MD Anderson
exceed five years…
“It is not the Mayo Clinic,” said Dr. David Hayes,
medical director of the Mayo Clinic Care Network, which was launched in 2011.
“It is a Mayo clinic affiliate.”
Of the 250 U.S. hospitals or health systems that have
expressed serious interest in joining Mayo’s network, 34 have become members.
For patients considering a hospital that has such an
affiliation, Binder advises checking ratings from a variety of sources, among
them Leapfrog, Medicare and Consumer Reports, and not just relying on
reputation.
“In theory, it can be very helpful,” Binder said
of such alliances. “The problem is that theory and reality don’t always
come together in health care.”
Case in point: Hopkins’ All Children’s has been besieged by
recent reports of catastrophic surgical injuries and errors and a spike in
deaths among pediatric heart patients since Hopkins took over. Hopkins’ chief
executive has apologized, more than a half-dozen top executives resigned and
Hopkins recently hired a former federal prosecutor to conduct a review of what
went wrong.
“For me and my family, I always look at the data,”
Binder said. “Nothing else matters if you’re not taken care of in a
hospital, or you have the best surgeon in the world and die from an
infection.” ” (Q)
L.State and federal inspectors visit All Children’s after reports on heart surgery deaths, by Kathleen McGrory and Neil Bedi, https://www.tampabay.com/investigations/2019/01/11/state-and-federal-inspectors-visit-all-childrens-after-reports-on-heart-surgery-deaths/
Q.Community Hospitals Link Arms With Prestigious Facilities To Raise Their Profiles, by Sandra G. Boodman, https://khn.org/news/community-hospitals-link-arms-with-prestigious-facilities-to-raise-their-profiles/
PART 2. June 1,
2019. “The situation that the New York Times described in North Carolina
parallels that at Johns Hopkins All Children’s Hospital in St. Petersburg,
which stopped performing heart surgeries after the Tampa Bay Times reported on
problems in the unit
“Johns Hopkins All Children’s Hospital in St.
Petersburg, Fla., has been given another extension from federal regulators to
correct its problems. The pediatric hospital came under fire in late 2018 after
the Tampa Bay Times uncovered widespread problems at the facility, including a
rising death rate in the pediatric heart unit.
The reporting from the Times led to the resignation of
several high-profile executives at the hospital and a federal investigation
from CMS that led to a series of corrective actions with the government.
Now, the hospital still needs more time to meet the demands
of inspectors, the Tampa Bay Times reported. Inspectors found problems with All
Children’s infection control unit, which the hospital must fix by “early
May.” The agreement with CMS to meet corrective actions underscores how
the hospital has been at risk of losing public funding, which covered more than
60% of its patients in 2017, according to the Times.” (A)
“Care in a special heart surgery unit at Johns Hopkins
All Children’s Hospital in St. Petersburg, Fla., became so troubled that last
year one in 10 patients died and others suffered devastating complications
before procedures were halted, a year-long investigation by the Tampa Bay Times
found.
The investigation found that staff raised safety concerns as
early as 2015 but the hospital, led by administrators sent by Hopkins,
disregarded warnings and didn’t stop performing the most complex procedures
until early last year. All surgeries were curtailed eventually and a review
launched. The status of two surgeons connected to most of the complications is
unclear…
In a statement to the Tampa Bay Times, All Children’s said
it “is defined by our commitment to patient safety and providing the
highest quality care possible to the children and families we serve. An
important part of that commitment is a willingness to learn. When we became
aware of challenges with our heart institute we took action to address
them.”
The hospital said it initially stopped performing complex
cases and brought in a surgeon from Baltimore. Then it halted all surgeries
after that surgeon left. The hospital said it is currently reviewing the
program and recruiting new surgeons with aid from Hopkins and plans to resume
surgeries “when all involved are confident that the care being delivered
meets the high standards set by this organization.”
A statement from Johns Hopkins Medicine to The Baltimore Sun
said, “We are devastated when children suffer, and losing a child is
something that no parent should have to endure. We are continuing to take a
very close look at the program, and will not resume open heart surgeries until
we are confident this program at Johns Hopkins All Children’s Hospital delivers
care that meets the highest standards.”” (B)
“Johns Hopkins All Children’s Hospital posted an
operating loss in the three months ended March 31, as the St. Petersburg
pediatric hospital dealt with the fallout of federal and state probes into its
practices.
The hospital had an $11.5 million quarterly operating loss,
according to a May 13 financial report from The Johns Hopkins Health System
Corp. and affiliates. Operating revenue dropped 7.1 percent to $119.9 million,
while operating expenses climbed 10.5 percent to $131.4 million.
The operating loss was attributed to closing the hospital’s
Heart Institute. The facility closed after an investigation by the Tampa Bay Times
found seven children had died or were permanently injured due to substandard
care in the cardiovascular surgery program…
“The decrease in income from operations and operating
margin percentage was mainly driven by lower net patient service revenue at
[Johns Hopkins All Children’s Hospital] as a result of the closing of the Heart
Institute,” the May 13 report said.” (C)
“Tasha and Thomas Jones sat beside their 2-year-old
daughter as she lay in intensive care at North Carolina Children’s Hospital.
Skylar had just come out of heart surgery and should recover well, her parents
were told. But that night, she flatlined. Doctors and nurses swarmed around
her, performing chest compressions for nearly an hour before putting the little
girl on life support.
Five days later, in June 2016, the hospital’s pediatric
cardiologists gathered one floor below for what became a wrenching discussion.
Patients with complex conditions had been dying at higher-than-expected rates
in past years, some of the doctors suspected. Now, even children like Skylar,
undergoing less risky surgeries, seemed to fare poorly.
The cardiologists pressed their division chief about what
was happening at the hospital, part of the respected University of North
Carolina medical center in Chapel Hill, while struggling to decide if they
should continue to send patients to UNC for heart surgery…
That March, a newborn had died after muscles supporting a
valve in his heart appeared to have been damaged during surgery. At least two
patients undergoing low-risk surgeries had recently experienced complications.
In May, a baby girl with a complex heart condition died two weeks after her
operation. Two days later, Skylar went in for surgery.
In the doctors’ meeting, the chief of pediatric cardiology,
Dr. Timothy Hoffman, was blunt. “It’s a nightmare right now,” he
said. “We are in crisis, and everyone is aware of that.”
That comment and others – captured in secret audio
recordings provided to The New York Times – offer a rare, unfiltered look
inside a medical institution as physicians weighed their ethical obligations to
patients while their bosses also worried about harming the surgical program.
In meetings in 2016 and 2017, all nine cardiologists
expressed concerns about the program’s performance. The head of the hospital
and other leaders there were alarmed as well, according to the recordings. The
cardiologists – who diagnose and treat heart conditions but don’t perform
surgeries – could not pinpoint what might be going wrong in an intertwined
system involving surgeons, anesthesiologists, intensive care doctors and
support staff. But they discussed everything from inadequate resources to
misgivings about the chief pediatric cardiac surgeon to whether the hospital
was taking on patients it wasn’t equipped to handle. Several doctors began
referring more children elsewhere for surgery.
The heart specialists had been asking to review the
institution’s mortality statistics for cardiac surgery – information that most
other hospitals make public – but said they had not been able to get it for
several years. Last month, after repeated requests from The Times, UNC released
limited data showing that for four years through June 2017, it had a higher
death rate than nearly all of the 82 institutions nationwide that do publicly
report…
The best option, Dr. Kelly said, was to combine UNC’s
surgery program with Duke’s. For years, physicians at both children’s hospitals
talked informally about joining forces, but nothing came of it. They were
“basically destroying each other’s capacity to be great,” Dr. Kelly
said, by running competing programs less than 15 miles apart. But even
combining the programs wasn’t an instant fix: It would take at least a year and
a half, he said…
At a conference last fall, Dr. Backer, the Chicago heart
surgeon, urged fellow surgeons to consider “rational
regionalization,” or joining forces in an effort to reduce mortalities
nationwide for congenital heart defects, potentially saving hundreds of lives.
Reaching adequate case volumes to keep up skills is a
challenge because so many hospitals are competing for patients – surgical
programs are an important driver of revenue. The Orlando, Fla., and San Antonio
metropolitan areas, for example, each have three hospitals doing pediatric
heart surgeries. Cleveland has two about a mile apart. A study last year by Dr.
Backer and other physicians found that 66 percent of hospitals doing the
surgeries were within 25 miles of another one.” (D)
“The situation that the New York Times described in
North Carolina parallels that at Johns Hopkins All Children’s Hospital in St.
Petersburg, which stopped performing heart surgeries after the Tampa Bay Times
reported on problems in the unit.
A Tampa Bay Times analysis found that the death rate among
pediatric heart surgery patients at All Children’s had tripled from 2015 to
2017…
UNC Health Care only made some of its death rate data public
to the New York Times after numerous requests from the newsroom. The statistics
showed that UNC’s children’s heart surgery program had one of the highest
four-year death rates in the country.
The newspaper said it is suing the health system for more
data.
UNC Health Care told the New York Times that the physicians’
concerns had been handled appropriately.
After the New York Times started reporting, the hospital
ramped up efforts to find a temporary pediatric heart surgeon and reached out
to families whose children had died or had unusual complications to discuss
their cases…
The turmoil at UNC underscores concerns about the quality
and consistency of care provided by dozens of pediatric heart surgery programs
across the country. Each year in the United States about 40,000 babies are born
with heart defects; about 10,000 are likely to need surgery or other procedures
before their first birthday.
The best outcomes for patients with complex heart problems
correlate with hospitals that perform a high volume of surgeries – several
hundred a year – studies show. But a proliferation of the surgery programs has
made it difficult for many institutions, including UNC, to reach those numbers:
The North Carolina hospital does about 100 to 150 a year. Lower numbers can
leave surgeons and staff at some hospitals with insufficient experience and
resources to achieve better results, researchers have found.
“We can do better. And it’s not that hard to do
better,” said Dr. Carl Backer, former president of the Congenital Heart
Surgeons’ Society, who practices at Lurie Children’s Hospital of Chicago.
“We don’t have to build new hospitals. We don’t have to build new ICUs. We
just need to move patients to more appropriate centers.”
North Carolina Children’s Hospital, part of the University
of North Carolina medical center, performs about 100 to 150 pediatric heart
surgeries a year.
Studies show that the best outcomes for patients with
complex heart problems correlate with hospitals that do a higher volume of
surgeries – several hundred a year.
At least five pediatric heart surgery programs across the
country were suspended or shut down in the last decade after questions were
raised about their performance; a Florida institution run by the prestigious
Johns Hopkins medical system stopped operations after reporting by The Tampa
Bay Times in 2018. At least a half-dozen hospitals have merged their programs
with larger ones to achieve more consistent results. And more institutions are
considering such partnerships.” (E)
“UNC Health declined a CBS 17 request for an interview.
Phil Bridges, UNC Health’s Integrated Communications Executive Director issued
a written statement:
We are proud of our pediatric congenital heart surgery
program, and our current team is receiving top results that would place us
among the best in the nation. We have been engaged in continuous quality
improvement efforts for decades and have made significant improvements in the
past 10+ years.
As the state’s leading public hospital, the UNC Pediatric
Congenital Heart Surgery program often receives the most complex and serious
cases. For many of these very sick children, we are often parents’ last hope.
As we shared with the New York Times, there were team
culture issues back in 2016. They were handled appropriately. That, combined
with decades of continuous quality improvement (CQI) efforts, have led us to
today in which we have a very strong program. For our team, and each family,
even a single death is too many, and we will continue our CQI work.
To characterize today’s program as anything but strong,
would not only be misleading, but not factual. To say we ignored issues would
also be false.” (F)
“First and foremost, we are physicians who have
dedicated our lives to caring for and caring about patients. We celebrate with
families the joys of curing illness; and we are deeply impacted by any death,
particularly that of a young child. We lead our respective areas of surgery and
pediatrics with the mindset of always doing what is right for children and
families. Caring for these children is a privilege. Children and families are
always our top priority. Our mission is to provide the best care for all
children across North Carolina. We and our colleagues live this mission every
day.
Regarding this week’s story from The New York Times
(“Doctors Were Alarmed: Would I have my children have surgery here”):
We are proud of the medical care provided to all patients at UNC Children’s.
They become part of our family, and as providers we wouldn’t hesitate to bring
our own loved ones here for treatment. Any negative outcome or death is taken
incredibly seriously and we strive to constantly look for ways to improve the
care provided.” (G)
“North Carolina’s secretary of health on Friday called
for an investigation into a hospital where doctors had suspected children with
complex heart conditions had been dying at higher than expected rates after
undergoing heart surgery.
Dr. Mandy Cohen, the secretary, said in a statement that a
team from the state’s division of health service regulation would work with
federal regulators to conduct a “thorough investigation” into events
that occurred in 2016 and 2017 at North Carolina Children’s Hospital, part of
the University of North Carolina medical center in Chapel Hill.
“As a mother and a doctor my heart goes out to any
family that loses a child,” Dr. Cohen said in the statement. “Patient
safety, particularly for the most vulnerable children, is paramount.”
The investigation is in response to an article published by
The New York Times on Thursday, which gave a detailed look inside the medical
institution as cardiologists grappled with whether to keep sending their young
patients there for surgery.
The article included discussions among doctors that were
captured on secret audio recordings provided to The Times, in which the
physicians talked openly about their concerns, including that some might not
feel comfortable allowing their own children to have surgery at the hospital.
The physicians also discussed unexpected complications with lower-risk
patients.
While the doctors could not pinpoint what might be going
wrong, they considered everything from inadequate resources to misgivings about
the chief pediatric cardiac surgeon to whether the hospital was taking on
patients it was not equipped to handle.” (H)
The 2018-19 Best Children’s Hospitals Honor Roll (I)
1. Boston Children’s Hospital
2. Cincinnati Children’s Hospital Medical Center
3. Children’s Hospital of Philadelphia
4. Texas Children’s Hospital
5. Children’s National Medical Center
6. Children’s Hospital Los Angeles
7. Nationwide Children’s Hospital
8. Johns Hopkins Children’s Center (BALTIMORE)
9. Children’s Hospital Colorado
10. Ann and Robert H. Lurie Children’s Hospital of Chicago
North Carolina Children’s Hospital at UNC. Pediatric
Cardiology & Heart Surgery Scorecard.
PART 3. Hopkins
All Children’s Hospital/ North Carolina Children’s – pediatric cardiac surgery
debacles.
“Johns Hopkins All Children’s Hospital has begun
implementing some of the dozens of recommendations from a law firm hired to
identify deficiencies at the hospital and its parent organization, Johns
Hopkins Medicine, in the wake of high death rates in the St. Petersburg
hospital’s pediatric cardiology program…
The recommendations focus on four key areas, said Dr. Kevin
Sowers, president of Johns Hopkins Health System and executive vice president
of Johns Hopkins Medicine.
He outlined those four areas in a video posted online. They
are: strengthen the management and culture at Johns Hopkins All Children’s
Hospital; improve processes for evaluating patient clinical quality and safety;
clarify and streamline the reporting structure between the six Johns Hopkins
Hospitals and the Johns Hopkins Health System; and review the ways in which the
boards of Johns Hopkins All Children’s Hospital and Johns Hopkins Medicine
should advance their governance responsibilities…
…In the coming weeks, the board of Johns Hopkins Medicine
will appoint a monitor to track and report regularly back to them on the
hospital’s progress.” (A)
“The recommendations for improvement include:
Prioritize a culture of absolute commitment to patient
safety and of raising and addressing problems and concerns, including
throughout the process of hiring and evaluating senior executives
Give physician leaders a stronger voice, create a more
robust check-and-balance on the president
Better educate staff and faculty about JHM’s commitment to
transparency and a culture of “see something, say something” and to improve
channels to submit complaints and provide for independent review
Separate the medical staff office responsibilities from the
patient safety and quality department responsibilities, which previously were
overseen by a single vice president of medical affairs…
In the coming weeks, the board of Johns Hopkins medicine
will appoint an external monitor to track and report back regularly to them on
the hospital’s progress,” he said.
The initial focus will be on the St. Petersburg hospital, a
team will go to the other five hospitals in the network to ensure the changes
are taking place.” (B)
“The review recommended a commitment to patient safety and
said the “see something, say something” culture is a vital part of
that.
The hospital published the report on its website along with
a video of Sowers talking about the results.
“Above all, we must work each and every day to support a
culture in which each of us is supported and empowered to speak up and speak
out,” Sowers said in the video.
He provided a toll free number where employees can
anonymously report any issues: 1-844-SPEAK2US.
“If you have any concern about a patient safety issue,
misconduct, a legal or unethical behavior or anything else, please call the
Johns Hopkins medicine hotline,” Sowers said.
Problems with the hospital’s heart institute did not come to
light until they were reported in the Times. The stories prompted inquiries by
federal and state regulators and led to the resignation of six top officials.”
(C)
“The changes include new checks and balances on the
hospital’s president, more rigorous evaluations for top executives, better
tracking of internal complaints, more thorough vetting of doctors and improved
monitoring of patient safety and quality metrics.
Top executives will now report to both the hospital
president and Johns Hopkins Health System leaders in Baltimore. And officials
in Baltimore will be more involved in hiring, firing and discipline in St.
Petersburg…
System leaders will analyze whether the same steps are
needed at the five other Johns Hopkins hospitals, Sowers said.
Sowers said the firm discovered a culture of “fear of
retaliation and retribution” across the hospital but determined that the
quality and safety issues were limited to the heart unit…
Other recommendations addressed key findings in the Times
report.
One example: The Times reported that procedures started
going wrong after All Children’s became part of the Johns Hopkins network and
hospital leaders made a series of personnel changes within the Heart Institute.
The firm recommended “more strategic planning” when changing
clinical programs and more quality monitoring during transitions, especially
for units that handle complex procedures.
It made the point bluntly: “In making personnel decisions,
consider the effect on team dynamics.”..
As All Children’s carries out the policy changes, it will
also work to address systemic problems flagged by the federal government.
Hospital leaders recently agreed to hire an external consultant to oversee
improvement for 12 months in order to maintain public funding.
Separately, a team of national experts has been working on a
plan to restart the heart surgery program. Sowers said the team had drawn up
recommendations and given them to the board. But he said he did not have a
timeframe for surgeries beginning and that the program would first need to hire
another surgeon.” (D)
“Children’s heart surgery departments across Florida will
soon be subject to more oversight.
Gov. Ron DeSantis signed a bill late Tuesday that will let
physician experts visit struggling programs and make recommendations for
improvement…
The bill signed into law Tuesday makes significant changes.
It lets a committee called the Pediatric Cardiac Technical
Advisory Panel appoint physician experts to visit Florida’s 10 children’s heart
surgery programs. They will be able to examine surgical results, review death
reports, inspect the facilities and interview employees.
Dr. David Nykanen, the chairman of the advisory panel and a
pediatric cardiologist at Arnold Palmer Hospital for Children in Orlando,
called site visits “crucially important,” especially when departments are
having problems.
He said visits could start within the next six months…
The hospital has not yet resumed heart surgeries. The
results of a review commissioned by the Johns Hopkins Medicine board are
expected soon.” (E)
“A state regulatory process that limited the number of
hospitals and some specialty services like transplant programs are going away
on July 1.
Despite attempts by two hospitals, Central Florida doesn’t
have a pediatric heart transplant program. But that could change in the coming
years because a state regulatory process that limited the number of hospitals
and some specialty services like transplants is going away on July 1.
For nearly five decades, the program known as certificate of
need has required hospitals to get authorization from the state before building
new facilities or offering new or expanded services — a complicated process
that’s costly, includes reams of paperwork and potential challenges from
competitors, and can take months or years…
Starting July 1, general hospitals are no longer required to
obtain a certificate of need to build a facility or to start services such as
pediatric and adult open heart surgery, organ transplant programs, neonatal
intensive care units and rehab programs…
The second part of the bill goes into effect on July 1,
2021, when the certificate of need requirement will be eliminated for certain
specialty hospitals such as children’s and women’s hospitals, rehab hospitals,
psychiatric and substance abuse hospitals and hospitals that offer intensive
residential treatment services for children.” (F)
“It’s unclear how long a state health department team will
take to investigate questions raised in The New York Times about pediatric
heart surgeries performed at the North Carolina Children’s Hospital in Chapel
Hill.
State regulators were at the UNC Medical Center on Monday as
part of an inquiry launched last week by Mandy Cohen, secretary of the state
Department of Health and Human Services…
Cohen announced late last week that she had assembled a team
from the state Division of Health Service Regulation, which licenses and
oversees health care facilities, to “conduct a thorough investigation into
these events.” They are coordinating with the U.S. Centers for Medicare &
Medicaid Services, a federal oversight agency…
Kelly Haight Connor, a spokeswoman for the state health
department, said Monday it’s difficult to know how long an investigation will
take. In other DHHS investigations, a team often interviews a range of people,
from caregivers, staff and those in their care.
Wesley Burks, CEO of UNC Health Care since December 2018 and
dean of the UNC School of Medicine, sent a five-paragraph email to staff on May
30 at 10:16 a.m. and attached the Times’ article he described as “critical of
UNC Medical Center’s pediatric congenital heart surgery program.”
“While this program
faced culture challenges in the 2016-2017 timeframe, we believe the Times’
criticism is overstated and does not consider the quality improvements we’ve
made within this program over many years,” Burks wrote in the email. “As the
State’s leading public hospital, UNC Medical Center often gets the most complex
and serious cases in its pediatric congenital heart program. For many of these
very sick children, we are often parents’ last hope…
On Monday, UNC Health Care spokesman Phil Bridges released a
“timeline of Continuous Quality Improvement within the program over the past 10
years.”
The timeline mentions a four-month period from June to
September in 2016 in which “concerns and allegations against specific
individuals in the Congenital Heart Program” were “independently investigated
and reviewed” by the dean’s office and the chief medical officer.
“Allegations of misconduct and concerns determined to be
unfounded,” the document states, adding “allegations against specific
individuals and results of the investigations constitute personnel records,
which may not be disclosed,” citing public records law.
An ongoing initiative, according to the document, calls for
a Department of Pediatrics review after every death in the Pediatric Intensive
Care Unit, including pediatric cardiac patients, to assess the care provided
and evaluate any opportunities for improvement.” (G)
“UNC Health Care officials announced Monday they are halting
the most complex pediatric heart surgeries following a report that raised
serious safety concerns over a number of child deaths at UNC Children’s
Hospital…
Officials from UNC HealthCare said in a statement they plan
to create an advisory board of external medical experts and “pause the
most complex heart surgeries” until that board and regulatory agencies
review the program.
The external advisory board, which is expected to have
members from the University of Southern California, the University of Michigan,
University of Pittsburgh Medical Center and Nationwide Children’s Hospital,
will examine the efficacy of the UNC Children’s Hospital pediatric heart
surgery program and make recommendations for improvement. The group will report
to the UNC Health Care Board of Directors.
UNC Healthcare officials said they are also developing a new
structure to support internal hospital reporting and plan to publicly release
Society for Thoracic Surgeons’ (STS) patient outcome data, make a $10 million
investment in new technology and bring in new specialists as part of their
efforts to “restore confidence” in its pediatric heart program.
“Our pediatric heart program cares for very sick children
with incredibly complex medical problems, and our clinical team works
tirelessly to help those patients return to normal, healthy and productive
lives,” Wesley Burks, M.D., CEO of UNC Health Care said in a statement. “We
grieve with families anytime there is a negative outcome and we constantly push
to learn from those tragic instances.
UNC Health Care’s board also endorsed the creation of a
pediatric heart surgery family advisory council to provide a voice for
patients, family members and staff directly to hospital leadership…
Most recently, Johns Hopkins’ All Children’s Hospital came
under fire for increasing mortality rates among heart surgery patients at the
259-bed hospital following a Tampa Bay Times investigation. Top leaders of that
hospital ultimately resigned and Johns Hopkins’ board also said it commissioned
an external review to examine the heart surgery program.
In 2015, St. Mary’s Medical Center in Florida closed it’s
pediatric heart surgery program after a CNN investigation revealed it had a
mortality rate of more than three times the national average. In 2009,
Massachusetts General Hospital suspended its pediatric surgery program in the
wake of surgical errors.” (H)
“The actions are in response to a New York Times
investigation last month into the medical institution, where cardiologists,
department leaders and even the former head of the children’s hospital
expressed concerns about patients faring poorly after heart surgery there.
Secret audio recordings provided to The Times captured doctors talking openly,
some even saying they might not feel comfortable allowing their own children to
have surgery at the hospital.
The Times sued for the program’s mortality data and was
still in a yearlong legal battle to obtain it when UNC Health Care released
previously undisclosed statistics on Monday. The data shows that the mortality
rate for heart surgery patients continued to rise after doctors warned
administrators several years ago of possible problems.
The data, for four years through December 2018, showed that
the hospital’s mortality rate for pediatric heart surgery was higher than those
of most of the 82 hospitals in the United States that publicly report such
data. The death rate at the North Carolina hospital was especially high among
children with the most complex heart conditions — nearly 50 percent, the data
shows. Those are the types of cases that some doctors had urged the hospital to
temporarily stop handling in 2016 and 2017.
UNC administrators previously denied that there were any
problems affecting patient care in the heart surgery program, saying only that
there had been difficult team dynamics at the time of the doctors’ warnings,
and that they had since been resolved by staffing and leadership changes.
Concerns about the quality of pediatric heart surgery
programs have been noted at hospitals across the country. At least five
programs were suspended or shut down in the last decade after questions were
raised about their performance. At least a half-dozen hospitals have merged
their programs with larger ones to achieve more consistent results. And more
institutions are considering such partnerships.
After the Times article was published, the North Carolina
secretary of health opened an investigation into the children’s hospital. In
addition to an on-site investigation that finished on Friday after more than
two weeks, state regulators have reached out to former UNC medical staff,
asking to meet and interview them about concerns they had while employed there.
A spokeswoman for the state health department said it would
submit a report to federal regulators from The Centers for Medicare &
Medicaid Services within 10 business days.
In the statistics released on Monday, UNC Health Care
included for the first time the hospital’s risk-adjusted data. Risk-adjustment
helps account for prematurity, some genetic abnormalities and other factors
that could make a child less likely to survive, and to more fairly assess
hospitals that take on the most compromised patients. The statistical method
also helps evaluate if hospitals are losing patients who wouldn’t be expected
to die.
The health system first told The Times it was “critically
important” to use risk-adjusted data, but then later released only raw,
unadjusted numbers. The hospital subsequently said that no current risk
adjustment adequately accounted for the breadth and severity of its patients’
medical issues.
The hospital’s overall mortality rate for pediatric heart
surgery in the four years ending in 2018 was 5.4 percent, compared with a
national average of 2.8 percent. The hospital’s risk-adjusted mortality rate
was 5.6 percent…” (I)
“UNC Children’s Hospital should merge its pediatric heart
surgery program with the same work being done at Duke Health’s Children’s
Hospital, just 10 miles away. A common program would greatly enhance the
treatment of children and babies in need of complex heart surgery.
As it is, UNC Children’s does 100 to 150 pediatric heart surgeries
a year, a rate considered low volume. That makes it harder to recruit and
retain surgeons and limits surgeons ability to hone their skills. It also makes
it harder to maintain the other parts of the program, cardiologists,
anesthesiologists and staff for a pediatric heart intensive care unit.
East Carolina University’s hospital faced similar challenges
as it provided pediatric heart surgery at a low-volume level of 50 to 75
surgeries a year. Eighteen months ago, ECU started sending all its pediatric
heart surgery patients to Duke. The change helped boost Duke’s volume to where
it has done more than 800 surgeries in 18 months. During the same period, Duke
has posted a 1 percent mortality rate, despite a caseload in which a third of
the operations are high risk.
Unfortunately, UNC Children’s Hospital appears uninterested
in combining resources despite overtures from Duke. In a statement Thursday,
the hospital said, “While there have been discussions with Duke Health over the
years about ways to collaborate across various pediatric specialties, there are
no plans to combine our programs. Patients in this region benefit from having
two world-class medical institutions located so close together. Our clinicians
frequently collaborate with colleagues at Duke. We sometimes transfer patients
to them and vice versa.
UNC Children’s would prefer to run its own pediatric heart
surgery program as a matter of institutional pride and money — the most complex
operations can cost a half-million dollars. But pride and money aren’t — or
shouldn’t be — the primary concerns. What matters most is how to get the best
care for children in this highly specialized and high-stakes area of medicine.
To do that, North Carolina’s best hospitals should combine their resources and
expertise.” (J)
“Two Triangle hospitals showed up on the list of Best
Children’s Hospitals from U.S. News & World Report released on June 18.
The report broke out 10 different pediatric specialties and
ranked the top 50 hospitals in each. Duke Children’s Hospital & Health
Center and the North Carolina Children’s Hospital at UNC were the lone Triangle
representatives that ranked in the top 50 in any of the categories…
The only pediatric category where a Triangle hospital did
not appear in the top 50 was cardiology & heart surgery.” (K)
U.S. News & World Report ranked Johns Hopkins All
Children’s Hospital No. 44 out of 50 on the 2019-20 Best Children’s Hospitals
list for the two programs.
“Our cancer and pulmonology specialists care for some
of the region’s most medically complex children, and we are grateful for this
recognition of their hard work,” interim hospital president Tom Kmetz said in
the hospital’s blog.
The hospital received an overall score of 73.3 out of 100.”
(L)
Johns Hopkins Children’s Center ranked ninth overall and No.
1 in Maryland in U.S. News & World Report’s annual list of the top-ranked
children’s hospitals in the United States, which was released earlier today.
The Children’s Center also earned a spot on the U.S. News
Best Children’s Hospitals Honor Roll, a list of the 10 pediatric hospitals with
the highest point totals in the survey. This marks the Children’s Center’s
eighth appearance since the Honor Roll was established 11 years ago…
Founded in 1912 as the Children’s Hospital at Johns Hopkins,
the Children’s Center offers one of the nation’s most comprehensive pediatric
medical programs, with almost 110,000 patient visits and nearly 9,000
admissions each year. With 295 beds, it is Maryland’s largest children’s
hospital and is the only state-designated trauma service and burn unit for
pediatric patients. Since 2012, the Charlotte R. Bloomberg Children’s Center
Building has been its home.” (M)
Typically, with complex medical procedures, outcomes are
strongly correlated with volume. That means that if a program does more
procedures, it has more expertise, the healthcare team has more experience
working together — and as a result, patients have better results. Larger
programs often have better equipment and more personnel. Sadly, the pediatric
surgery program at North Carolina Children’s Hospital was a low-volume center…
Powerful forces stand in opposition to the closure of
low-volume centers. Low-volume centers are attractive because they are
geographically convenient; patients do not have to travel long distances for
their care. Some insurance coverage is regionally-restricted, and families
without resources are unable to access high-volume centers. Low-volume centers
are often staffed by entrepreneurial physicians who don’t want restrictions on
their right to practice medicine. And their goals are often closely aligned
with those of local political officials, who would like to imagine that
low-volume programs can replicate the results at large medical centers. Perhaps
most importantly, hospital administrators at low-volume centers do not wish to
see their revenues slashed — and their leadership positions eliminated.
So the problem of decentralized medicine and low-volume
centers is getting worse, not better. To an increasing degree, a larger and
larger proportion of specialized procedures in the United States are being done
at low-volume centers…” (N)
“One in four hospitals that participate in The Leapfrog
Group’s annual patient safety grades survey do not meet the national healthcare
quality group’s standard for handling serious reportable events that should
never happen to a patient.
Leapfrog’s 2019 Never Events Report is based on findings
from its 2018 Leapfrog Hospital Survey with data voluntarily submitted by more
than 2,000 U.S. hospitals. It is aimed at highlighting official hospital
policies for responding to the 29 serious reportable events as identified by
the National Quality Forum as never events.
Those events include errors and accidents that hospitals
should always prevent, such as surgery on the wrong body part, foreign objects
left in the body after surgery or death from a medication error…
The Leapfrog standard for hospital policies includes steps
such as offering an apology to the patient, not charging for the event,
conducting a comprehensive root cause analysis, reporting the event to
appropriate officials and implementing a protocol to care for the caregivers
involved.
“Patients and payors alike expect that 100% of
hospitals will adhere to these basic principles, but unfortunately, we are not
seeing that yet, with only 75% of reporting hospitals meeting Leapfrog’s
standard,” Leah Binder, president and CEO of The Leapfrog Group, said in a
statement.”..
In the report, released with the Johns Hopkins Armstrong
Institute for Patient Safety and Quality, officials estimated that 160,000
people died from avoidable medical errors in 2018.” (O)
“Affiliation with a top-ranked cancer hospital appeared to
offer no robust advantage for complex cancer surgery, a new study found…
“A favorable mix of hospital characteristics associated
with safety at affiliate hospitals appeared to contribute to this mortality
advantage,” they wrote in JAMA Oncology. “Thus, affiliate status
appears to be a marker, but not a robust, independent predictor of favorable
outcomes.”
For their study, the group examined cancer surgery outcomes
at 338 hospitals affiliated with a top-50 cancer hospital and 2,729 hospitals
that were not.
“This study helps to further our understanding of
patient safety after major cancer surgery at hospitals affiliated with
top-ranked cancer centers,” Lesly Dossett, MD, MPH, of the division of
surgical oncology at the University of Michigan in Ann Arbor, told MedPage
Today.
Dossett, who was not involved in the study, pointed to the
important fact that the researchers compared outcomes at non-affiliated
hospitals with the affiliates of top hospitals, rather than the flagship
hospitals themselves.
“While the study does show that outcomes at affiliated
centers are better than at non-affiliated centers, these differences are
explained by other hospital characteristics known to be associated with patient
safety,” Dossett said. “In the end, the study suggests that top-ranked
hospitals selectively affiliate with safer hospitals, rather than having an
independent effect on their outcomes.” (P)
“Rochester, Minn.-based Mayo Clinic has added Saudi German
Hospital Cairo in Egypt to the Mayo Clinic Care Network, a select group of
independent health systems that have access to Mayo Clinic’s knowledge and
medical expertise.” (Q)
“The announcement Thursday that Jewish Hospital would
suspend its heart transplant program was a blow to an institution that once led
the nation as an esteemed leader in heart care and innovative medical
procedures.
The decision directly affects 32 people on the hospital’s
waiting list for new hearts. Once the program is halted next month, officials
at Jewish Hospital are expected to help them transition to other transplant
programs — and there’s only one other program for adults in the state at the
University of Kentucky.
Jewish’s president Dr. Ronald Waldridge told staff on
Thursday morning that patients who’ve already had transplants at the downtown
Louisville hospital would continue to receive care, and that those who are
awaiting the procedure would get help transitioning to another program.
“Though our heart transplant program will not be able
to perform transplants or take new physician referrals, we will continue to
provide physician coverage to manage care of our current heart transplant
program patients,” Waldridge wrote, adding that as volumes of available
hearts dropped, Jewish also lost heart transplant cardiologists…
KentuckyOne officials said Thursday that Jewish was in
danger of falling out of compliance with federal regulations after its
transplant numbers fell far short of required minimums — with just one
procedure so far this year.
They blamed the drop on new rules that revised how donated
organs are allocated nationwide and, as a result, delivered fewer hearts to
Jewish starting last October.” (R)
From the Johns Hopkins Medicine Armstrong Institute for
Patient Safety and Quality:
“If there was a wonder drug to save the lives of infants with
serious heart abnormalities, doctors would be sure to prescribe it. Parents
would insist that their children get it. The company that invented it would get
rich.
But there already is something that can have as dramatic an
impact on these young lives as a blockbuster pill: having complex heart surgery
performed in a high-volume hospital.
Surgical volume — the number of certain procedures that a
hospital performs each year — has far greater impact on whether these patients,
most of whom are infants or children, survive than infection rates,
readmissions or other publicly reported measures. As U.S. News’ Steve Sternberg
reported, the risk of dying was 26 percent lower if a complex congenital heart
operation was performed at a high-volume hospital rather than at low- and
medium-volume hospitals. Yet, few parents know to ask about volumes, let alone
know how to find and evaluate the data.” (S)
“The American Nurses Credentialing Center (ANCC) named Johns
Hopkins All Children’s Hospital as a Magnet® designated hospital today. The
recognition is considered the highest nursing honor a hospital can receive.
There are only 498 Magnet hospitals across the world and fewer than eight
percent of U.S. hospitals have received the designation.” (T)
“I will be very soon introducing legislation in the
Senate to establish a $20 billion emergency trust fund to help states and local
communities purchase hospitals that are in financial distress,” Sanders
said. “In my view, any time a hospital is put up for sale in America, the
local community or the state must have the right to buy it first with emergency
financial assistance.”
ASSIGNMENT: After reading about Hoboken, N.J., find and
critique other NFP to local government ownership hospital conversions and local
public hospitals on the edge of sustainability.
PART 3. April 23, 2019. San Francisco General, a public
hospital with San Francisco’s only trauma center, all commercial insurance is
“out-of-network.”
Here’s what happened when the town of Hoboken, New Jersey
“bought” a failing NFP hospital.
January 8, 1863
This facility was founded as St. Mary Hospital, which was
opened on the 8 January 1863 in Hoboken as a community hospital by the Poor
Sisters of St. Francis, a religious congregation founded in 1845 in Germany.
The hospital was opened during the American Civil War as a
location to treat the returning wounded and was the second hospital ever to
open in the State of New Jersey.
December 13, 2006
When the owner, the Bon Secours Health Care System, a
Maryland company run by an order of Roman Catholic nuns, announced this spring
that it planned to close the hospital, city officials, including the mayor,
David Roberts, state legislators and the governor’s office pieced together an
unusual plan to keep it afloat by having the city take it over and pumping in
an infusion of public funds (with the City guaranteeing $52 million in bonds)
January 29, 2007
Bon Secours Health System put another struggling operation
on the block last week.
The planned sale of its Michigan operations is the latest
move in Bon Secours’ bid to improve finances and operations through divestiture
after the system’s expansion earlier in the decade (Feb. 14, 2005, p. 6). Since
2004, Bon Secours has sold or announced plans to sell operations in Florida,
New Jersey, Pennsylvania and Virginia, divestitures that boosted its cash by
$70 million and cut its debt load by $192 million, according to Moody’s
Investors Service.
Bon Secours agreed to sell its last New Jersey healthcare
facility, 313-bed St. Mary Hospital in Hoboken to the Hoboken Hospital
Authority in a deal expected to close by Jan. 31.
February 7, 2007
In a ceremonial handing over of keys today, the ownership of
St. Mary Hospital in Hoboken was transferred from the private Bon Secours New
Jersey Health System (BSNJHS) to the City of Hoboken. To reflect a new
beginning for the 144-year-old hospital, it was given a new name: Hoboken University Medical Center
April, 2007
The hospital was acquired debt-free and the agreement
provided for a $13 million cash payment from Bon Secours. Concurrent with the
agreement’s negotiations, the Hoboken Municipal Hospital Authority worked
toward the issuance of two series of bonds totaling $51,635,000. The bonds were
guaranteed by the City of Hoboken and sold in February after the asset transfer
agreement was executed.
But residents here who are skeptical of the proposal say it
is also missing other important pieces of information. Among their concerns are
these:
¶How will Hoboken pay off the bonds if the hospital fails
and the city’s real estate market continues to soften?
¶How will the city fill the hospital’s budget gap if the
anticipated federal aid does not materialize?
¶Who will cover the high pension and severance costs if the
hospital has to be closed…?
Governance/ Management Structure:
Hoboken Municipal Hospital Authority (HMHA) – the Governing
Board
Hudson Healthcare Inc. (HHI) – legislatively mandated NFP
management company
Hoboken University Medical Center (the Hospital)
July, 23, 2009
Hoboken Mayor Peter Cammarano has been arrested by the FBI
as part of a wide-reaching investigation that is swooping up dozens of people,
including other politicians and rabbis, according the WNBC-TV, Hudson County
Now is reporting.
July 31, 2009
HOBOKEN — Hoboken has an acting mayor.
City Council President Dawn Zimmer was sworn in Friday after
Peter Cammarano III resigned in the wake of federal corruption charges.
September 2009
New Mayor (Mayor Zimmer) inherited..
Licensed for 364 beds; operating 150 ; Average Daily Census
of 125; with appropriate Average Length of Stay ADS would be about 100
$52 million dollar City bond guarantee with $10 million
already converted to taxable bonds and squandered on operations
$23 million operating loss in 2008 but hidden in delayed
certified audit until September of 2009
The Hoboken Hospital Authority Board had abdicated its
oversight responsibility to the legislatively-required Management Company and
the CEO was making $800,000 a year.
$52 million dollar City bond guarantee with $10 million
already converted to taxable bonds and squandered on operations
$23 million operating loss in 2008 but hidden in delayed
certified audit until September of 2009
The Hoboken Hospital Authority Board had abdicated its
oversight responsibility to the legislatively-required Management Company and
the CEO was making $800,000 a year.
Finance Committee does not keep minutes.
Quality Committee is chaired by a practicing M.D. Commissioner
who gets referrals from other physicians (really a “Hospital” Committee not an
“Authority” Committee) – using out-of-date metrics
The HMHA Board does not get the Management Company Audit and
there seem to be no Management Company Committee Board and/ or Committee
minutes
The Authority “reports” to the Management Company! (ratifies
everything it is asked to ratify)
September, 2009
The Ordinance establishing the Hoboken Municipal Hospital
Authority names the Mayor as the Class I ex officio Authority member and
permits the Mayor to name a designee.
I am appointing Jonathan M. Metsch, Dr.P.H., as the Mayor’s
designee to the Authority, effective immediately.
I have instructed Dr Metsch to focus on my immediate
expectations for the Hospital Authority, which are:
– Complete transparency on financial results using generally
accepted hospital industry accounting standards, without any annual city
subsidy.
– Ability to services the $50 million+ in city guaranteed
bonds using these funds for capital projects only, and not for recurring
operating expenses.
– Designation by the State of New Jersey as an Essential
Safety-Net Hospital.
– High scores on external evidenced-based hospital quality
Report Cards and patient satisfaction surveys.
– A strategic plan developed with strong community input to
identify the appropriate scope of clinical programs.
– Ongoing successful recruitment of new members to the
medical staff, and
– Increasing use of the hospital by Hoboken residents.
The new “mantra”
“City ownership was always meant to be a ‘bridging’
strategy, not a permanent remedy.”
Mayor’s Zimmer’s Corrective Action Plan
Appointed 5 new Authority Boards members
– a former hospital
system CEO
– an EVP compliance/
regulatory lawyer at a major investment bank
– a University of
Chicago finance MBA with bond underwriting experience
– a Managing Director
of a Health Care Investment Banking firm
– and a respected
City Hall “watchdog
then elected a new
Chairman. All new members live and own property in Hoboken!
The Finance Committee was the only Board Committee and did
not keep minutes. Added an Audit & Compliance Committee and a Strategic
Planning and Government Affairs Committee.
The Board had been refused access to the Management
Company’s annual certified audit. The Management Company and Hospital Authority
audits are now done together by the same firm under the supervision of the new
Finance Committee chairperson.
Suspended further approvals of major capital projects to
conserve the remaining $9,000,000 of capital funds, until projects are properly
analyzed and approved or perhaps to pay down the bond principal to reduce the
City’s guarantee obligations.
Financial Uncertainties (with virtually no “cash on hand”)
1. ’09 audit result
of $15 million loss is the same as ‘08 (after $9 million ’08 revenue adjustment
is taken out)
2. Charity Care
funding needs to keep pace with Charity Care volume (and still pays less than
70 cents on the dollar compared to costs)
3. Hospital Relief
Fund money has to be actually awarded to the Hospital by the State
4. Proposed Medicare
cuts ($800,000 impact) need not to happen
5. Hospital
Stabilization Fund money of at least $5,000,000 needs to be granted
6. DSH needs to be
in the State budget to get the federal match
7. Better managed
care rates need to be negotiated but this is unlikely until current contracts
expire
8. Additional volume
from ER needs to have positive impact on payer mix (more private admissions)
and higher acuity, combined with much lower length-of-stay on all admissions
9. Good results from
Medicare and Medicaid audits (no take-backs)
10. Challenge to meet payroll and payroll taxes when
negative cash flow occurs several times in current sixteen week cash flow
projection
11. State could cut
Medicaid rates in final ’10 budget negotiations
12. Navigant Report
about hospital needs in Hudson County to be neutral
13. No big surprises
from PWC operational audit
14. Vendor
“payment plans” could become strangulating ($25 million in AP issue
must be resolved)
15. Viable
contingency plans that can be implemented immediately in $5 million chunks
16. Inappropriate
co-mingling of funds and use of one-time money for operations must be avoided
17. Union
negotiations cannot increase deficit
Administration’s Hospital Goals
A. Ensuring that Hoboken University Medical
Center (HUMC) remains open as a full service, acute care hospital providing
access to quality medical care for all Hoboken residents
B. Respecting the commitment of the Hospital’s
medical staff to the Hospital over the recent challenging years
C. Maintaining the 1000 jobs of our valued
hospital staff
D. Addressing the Commissioner of Health and
Senior Services regionalization objectives of reducing excess capacity and
Hudson County hospitals’ reliance on extraordinary State financial subsidies
E. Relieving the City of Hoboken from the
financial obligation of the bond guarantee.
Governor-elect Christie transition team report –
“On December 22, 2009, the Corzine Administration
announced $40 million in Health Care Stabilization awards to 9 hospitals,”
the memo says.” … at least one hospital, Hoboken University Medical
Center, will close in the next few months even given this grant funding. We
view this as a misuse of limited state resources for health care
stabilization.”
July 30, 2010
In another step toward privatization, the Hoboken Municipal
Hospital Authority unanimously approved a Request for Proposal Wednesday night
to solicit plans for the potential transfer of the hospital from city
sponsorship, the mayor’s office said.
“Mayor Zimmer inherited a complex set of legacy hospital
issues and has aggressively addressed them,” said Authority Chairperson Toni
Tomarazzo in a press release. “The Mayor developed a consensus around
privatization as a shared vision for maintaining access to hospital care, and
making quality metrics as important as financial performance.”
RFP requirements:
A party interested in acquiring the Hospital must provide
the Authority with a written proposal (“Proposal”) which includes the
following:
A. Proposed use of the Hospital facilities, including level
of service;
B. Proposed transaction structure, including price and form
of payment;
C. Proposed distribution or allocation of funds;
D. Proposed liabilities to be assumed by acquirer;
E. Planned capital investment programs;
F. Required financing for the proposed transaction;
G. Status of financing;
H. Identity of acquirer;
I. Prior health care experience of principals;
J. Proposed capital structure of acquirer;
K. Prior acquisitions or investments in the health care
industry;
L. Time table for due diligence, execution of a letter of
intent, and execution of an asset purchase agreement;
M. Conditions to completion of transaction, required
approvals and permits; and
N. Identity of financial advisor and legal counsel for
acquirer.
August, 2010
1. In every
administration there is a DHSS “liaison” with the Governor’s Office. That is
probably Deputy Commissioner O’Dowd. Assistant Commissioner Conroy’s role seems
to be expanding; he reports to DC O’Dowd
2. Deputy
Commissioner (Dr.) Susan Walsh is on the Public Health side so it is a little
surprising to see her involved with the Navigant Project. COS Gabrielle Charette handles some policy
issues and has the Commissioner’s ear
3. Might
be good just to assume that “O’Dowd, Walsh and Charette comprise the
Commissioner’s Policy Team. Typically O’Dowd’s slot is the #2 even though Walsh
has the same DC title
4. Other key health
policy “front office” players we need to get to know:
A. Wayne Hasenbalg,
Deputy Chief of Staff for Policy and Planning.
B. Robert
Schwaneberg, (health) Policy Advisor – reports to Wayne Hasenbalg
C. Lou Getting,
Cabinet Secretary – formerly VP, Administration at UMDNJ
D. Claudia Marchese,
Assistant Counsel – deals with health care legislation
E. Deputy Attorney
General Jay A. Ganzman – handles NFPs in AG’s office (e.g., Meadowlands’ sale)
F. State Health
Planning Board – Ms. Judy O’Leary Donlen RN
(reviews CN for “change of ownership)
G Mark Hopkins is
likely to be replaced as head of HCFFA when they get around to it. Steve
Fillebrown, now the #2, provides continuity and has been there at least 20
years
H. DCA Commissioner
Lori Grifa & Marc Pfeiffer, Division of Local Government Services
I. Lt Governor’s role in economic development??
October 8, 2010
Mayor Z –
“Deals” get done when key critical elements are in
alignment – when there is a “window of opportunity”
Right now we have this alignment for selling the
hospital, on or close to our goals and terms. Here’s why:
– You have made excellent appointments to the Hospital
Authority Board. The Authority has taken back its authority from the
Management Company.
– Your relationship with the Governor, and our
relationship with the Department of Health are very good.
– A new round of hospital mergers has started (Newton
joining Atlantic; SOCH and Bayshore joining Meridian….. probably
more to follow)
– For-Profits are welcome now in NJ (e.g. Bayonne,
Meadowlands, Hackensack/Pascack) giving us a broader spectrum of
possible “buyers”
– Jersey City Medical Center is no longer a major
teaching hospital, rather it is now a large community hospital with a a few
important regional services (trauma, cardiac surgery)
– Christ Hospital is struggling now more than H.U.M.C.
(admissions are way down and doctors are leaving)
– “Buyers” see 30 million Americans getting
insurance
Windows” close and here’s what could happen to us –
– “Time is our greatest enemy” and moving too
slowly may cause interested parties to drop out (as they focus on other
opportunities, or their financing expires)
– Christ could do a deal before we do or be
force merged into Jersey City Medical Center by the State
– We fail to produce a timely 2090 Audited
Financial Statement and potential buyers cannot finish their due diligence
– The State stops giving the hospital cash advances and
it misses a payroll
– The Navigant Report could be made public – word
is it calls for closing Christ or Hoboken
– The Management Company has a Trenton lobbyist, we
don’t – they know more than we do
So we need to move thoughtfully, with transparency, and
quickly –
– There can be no confusion that the Authority owns the
hospital and is the seller
– The Management Company’s role in the sale must be clearly
defined by the Authority, in writing (and monitored)
– We need to talk directly to the medical staff
leadership, e.g. pick the right physicians for the RFP
Committee
April 21, 2011
After months of private negotiations the Hoboken Municipal
Hospital Authority unanimously approved a contract with HUMC Holdco LLC on
Wednesday night, to sell the Hoboken University Medical Center for $90 million.
The proposed sale would relieve the city of its nearly $52
million bond obligation on the hospital.
Why?
“Re-Privatizing” the Hospital will bring it
stability, access to capital, and the ability to compete in the hospital
marketplace without dependency on state subsidies and cash advances.
It will also relieve the City of the bond guarantee, freeing
up bond capacity for other necessary and immediate infrastructure
improvements.
This Essential Safety-Net Hospital management transformation
initiative – hospital sustainability through privatization – will be a
“self-sufficiency” model for replication elsewhere in New Jersey.
Summary of APA between Authority, as Seller, and HUMC
Holdco, as Purchaser
The Authority is selling the assets of HUMC.
The Purchaser is paying for the assets by:
(a) assuming post-closing obligations under certain
contracts and assuming Medicare and Medicaid obligations,
(b) defeasing the bonds guaranteed by the City of Hoboken,
(c) paying $2 million to be used to settle claims of
unsecured creditors,
(d) paying $8 million for HUMC’s accounts receivable,
(e) paying up to $4 million for tail insurance,
(f) paying up to $2.5 million for pension withdrawal
liabilities related to the two union pension funds, and
(g) paying the Authority 50% of the EMR funds, up to $1.9
million, received after the closing.
Purchaser will
(a) offer employment to no less than 75% of the employees
and will assume 75% of the outstanding amount of accrued vacation and sick
time, and
(b) assume 80% of the accrued vacation and sick time of
senior management and 80% of the severance payments related to senior
management up to a cap of $677,000.
Purchaser will not assume any pension obligations.
In order for the sale to close:
(a) Purchaser must obtain a certificate of need (the
application has been filed),
(b) Seller must obtain the settlement and release of at
least 90% of the aggregate dollar amount of all unsecured creditors’ claims,
and (c) the Hoboken Parking Utility must enter into a new parking agreement
with the Purchaser
Seller agrees to use its best efforts and assist Purchaser:
to obtain a property tax abatement, payment in lieu of
taxes, reduced assessment or similar arrangement
to have the entity that is the Public Service Dispatch Point
for 911 calls in Hoboken be the Purchaser
to obtain a transit hub tax credit
to receive DSH payments after the closing.
(No liability will result to Seller if Purchaser is unable
to obtain any of these items)
Purchaser will not seek indemnification from the City of
Hoboken.
Purchaser agrees:
to continue to operate the Hospital as a general acute care
facility and to maintain the clinics operated by the Hospital for at least 7
years
that it may make available, in its discretion, up to $20.9
million for working capital and capital expenditures for the Hospital
to use its commercially reasonable best efforts to negotiate
in-network hospital agreements with various health insurers, including Horizon
Blue Cross
to negotiate in good faith to enter into agreements prior to
closing with the City of Hoboken, the Hoboken Board of Education, the Hoboken
Housing Authority and HUMC so that the employees will be able to use HUMC as
though it were in-network
to negotiate in good faith with existing unions at the
Hospital
The significance of this plan
“Re-Privatizing” the Hospital will bring it
stability, access to capital, and the ability to compete in the hospital
marketplace without dependency on state subsidies and cash advances.
It will also relieve the City of the bond guarantee, freeing
up bond capacity for other necessary and immediate infrastructure
improvements.
This Essential Safety-Net Hospital management transformation
initiative – hospital sustainability through privatization – will be a
“self-sufficiency” model for replication elsewhere in New Jersey.
June 26, 2011
‘If this sale doesn’t go through…the hospital will close.’
– Mayor Dawn Zimmer
“Hoboken University Medical Center is bleeding money
and if this sale to HUMC Holdco (Bayonne) does not go through, the hospital
will close,” Zimmer said. “We will lose our hospital and the vital
services it provides our community, and the taxpayers will be obligated for a
$52 million bond guarantee. For this reason, the sale to [HUMC Holdco] is
crucial to saving our hospital and protecting our taxpayers.”
July 5, 2011
Hoboken University Medical Center stands to lose $11 million
in federal funding under Gov. Chris Christie’s 2012 budget.
The State of New Jersey will cut the federal matching funds it allots the
Medical Center, according to the State’s budget summary.
Once government owned, the summary cites the facility’s sale to a
non-government agency — which no longer makes them eligible for the funds —
as a reason for its discontinuing the aid.
July 12, 2011
Will hospital cancel insurance contracts?
Public documents provided to The Reporter reveal that the new buyers do not
plan to keep any existing insurance contracts, as they are negotiating with
insurance companies for new rates.
Some observers have been concerned because when Holdco took over Bayonne’s
hospital, they canceled the hospital’s contracts with various insurance
companies in order to negotiate better reimbursement rates. That caused some
customers to have to pay out-of-network fees.
The potential owners have responded, “HUMC Opco, LLC has no intentions of
assuming any of the existing managed care agreements. Their reimbursement rates
are below industry standards and are not adequate to sustain the operations at
HUMC.”
July, 29, 2011
State department staff tells state Health Planning Board to
recommend sale of Hoboken’s hospital
A staff report from the Department of Health and Senior
Services has recommended to the state Health Planning Board that they endorse
the sale of Hoboken University Medical Center to HUMC Holdco, the same group
that owns Bayonne Medical Center.
For the first year of ownership, the new owners would also be required to
assume the contracts of the current Health Maintenance Organizations (HMO) and
insurance contracts, according to the staff report.
The owners have said in their questions with the state that
they wish to negotiate new contracts with insurance companies when they take
over the hospital.
Buyer says proposed “stand-still” condition is a
deal-breaker!
August 4, 2011
State Health Planning Board approves sale of Hoboken
University Medical Center
The state Health Planning Board voted unanimously today in Trenton to approve
the sale of Hoboken University Medical Center to HUMC Holdco, a company whose
principals also own the Bayonne Medical Center.
Health Commissioner Mary O’Dowd, however, must approve the
sale before it becomes official.
Staff Proposed Condition is deleted: For the first year of
ownership, the new owners would also be required to assume the contracts of the
current Health Maintenance Organizations (HMO) and insurance contracts,
according to the staff report
August 4, 2011
Deep inside the 285-page budget was an $11 million earmark
to help Hoboken complete a controversial sale of the city-owned Hoboken
University Hospital, whose operator filed for bankruptcy protection on Monday.
The $11 million earmark shines a spotlight on Christie’s
efforts at building alliances in the Democratic stronghold of Hudson County,
whose turnout can often tilt elections. It also reveals the political
underbelly of a divisive deal to once again keep the troubled hospital open.
August 4, 2011
Hoboken University Medical Center property has been sold by
the prospective owner, HUMC Holdco, to Medical Properties Trust, the same real
estate investment trust that purchased the Bayonne Medical Center property.
Medical Properties Trust, the real estate investment trust
(REIT) that purchased the Bayonne Medical Center land, has now bought the
Hoboken University Medical Center property from HUMC Holdco for $70 million,
the company said on its website.
September 22, 2011
Hoboken University Medical Center may close as soon as Oct.
7 as the result of the Hoboken City Council last night, in a 5 to 4 vote,
rejecting an ordinance that would have provided a $5.5 million bond to meet
some of the hospital’s obligations to creditors.
The bond was key to a bankruptcy settlement that was
considered pivotal to the sale of the hospital to the ownership group of the
Bayonne Medical Center.
September 22, 2011
Gov. Chris Christie announced today that the state will put
up $5 million – if necessary — to help save the Hoboken University Medical
Center from possibly closing.
“It is completely unacceptable that the city council placed
local politics ahead of the 1,300 employees at the Hoboken University Medical
Center and the people in the community who rely on the critical services
provided by this hospital. This Administration is not going to allow political
bickering to put this hospital in jeopardy and potentially have a negative and
irresponsible impact on the city’s finances, which is why the state will
contribute the $5 million, if needed, to ensure the Hoboken University Medical
Center deal closes and the hospital stays open.“
October 14, 2011
Zimmer says city layoffs will happen if council doesn’t
approve parking agreement and bond refinancing
“It is important that every City Council member fully
understand the ramifications of these matters for our city, its residents and
its employees,” Zimmer said in the Oct. 14 memo. “If the Parking Agreement,
requiring 5 votes, and the bond refinance, requiring 6 votes, are not passed,
then unfortunately the city will be forced to begin implementing layoffs
immediately.”
October 19, 2011
Hoboken City Council rejects refinancing parking garage bond
In a 5 to 4 vote, the Hoboken City Council voted down an
ordinance to refinance the bonds on the Midtown garage, which is currently used
in part for Hoboken University Medical Center employee parking
October 21, 2011
State Approves Hospital Sale
A certificate of need was issued on Friday afternoon.
Transaction scheduled to be completed in next couple of days.
October 30, 2011
An agreement to allow the City Council Minority to designate
an appointee to the new hospital board. This appointment shows the buyer’s
commitment to increasing community participation in the future of the hospital
and allows all residents to have a voice.
October 30, 2011
STATEMENT FROM MAYOR ZIMMER ON HOBOKEN UNIVERSITY MEDICAL
CENTER
“Since my first day as mayor more than two years ago,
the saving of our hospital has been my number one priority. The effort to save
our hospital has been a long road, but today our community saved it together. I
thank everyone who contacted Council Members and turned out to raise their
voices – hospital and City employees, taxpayers and concerned citizens, and
members of the Hoboken Municipal Hospital Authority. I thank all members of the
City Council for doing the right thing for Hoboken – the majority members for
their support all along and the minority members for being willing to
reconsider and change their votes.
Today’s vote clears the way for saving Hoboken University
Medical Center, the jobs of 1,200 employees, and averts a financial catastrophe
for our City.”
November 4, 2011
The money just hit the account. Congratulations to all
of you. The deal is closed, and the bonds are paid!
Mayor Z to JMM –
“Jonathan, you made this happen and whenever I talk about
this success I will always thank you first!
(This never happened. Politically there was always someone
else who had to be acknowledged.)
On November 4th there was going to be a closing
Either closing the sale
Or closing the doors (we didn’t have money to
meet payroll that day)
November 5, 2011
Sighs of relief are heard in Hoboken as sale of hospital to
owners of Bayonne Medical Center is completed, saving 1,200 jobs and freeing
city from $52 million in bond debt
Hoboken University Medical Center officially has a new owner and the city is
out of the hospital business.
City officials announced yesterday that HUMC Holdco LLC, the
group which owns Bayonne Medical Center, completed the purchase of the Hoboken
hospital, relieving the city of its $52 million bond debt.
“Today is a great day for all of Hoboken and New Jersey. Our
state’s oldest hospital will remain open as a full-service acute care
facility,” said Hoboken Mayor Dawn Zimmer.
October 29, 2012
Hospitals Evacuate Ahead of Hurricane Sandy
Ambulances lined the streets of Hoboken, N.J. in the
relative calm before Hurricane Sandy last night as Hoboken University Medical
Center evacuated patients in the predawn darkness.
The Hoboken hospital evacuated because of fears that surges
from Sandy could breach Hoboken’s seawall, causing several feet of flooding.
The Emergency Room and OB-GYN services for emergency deliveries remained open.
Imagine the consequences if the City still owned the hospital! It would have never reopened and the City would have been responsible for the $50 million bonds.
December 11, 2013 HOBOKEN ISSUED AA+ CREDIT RATING BY STANDARD & POORS – Expected to Result in Immediate Additional Cost Savings The credit rating agency Standard & Poor’s has assigned a credit rating of AA+ to the City of Hoboken, a dramatic and unprecedented improvement from the City’s prior near junk bond rating. In assigning their second highest obtainable rating, S&P cited Hoboken’s “very strong economy,” “strong management,” “very strong budget flexibility,” “very strong liquidity,” “very strong debt and contingent liabilities profile,” and “good financial management practices.” Under Mayor Zimmer’s Administration, the City has established and maintained a responsible surplus for the first time in years, maintained a low debt level, consolidated and restructured departmental operations, eliminated the use of one-time budget gimmicks, and privatized Hoboken University Medical Center in order to relieve the City of a $52 million hospital bond guarantee.
Stop the name games. University hospitals and regional medical centers should live up to their billing, By Jonathan Metsch, Modern Healthcare
Remember when a hospital was just a hospital, and its reputation spoke for itself?
Now we have a plethora of self-named healthcare institutions such as clinics, community hospitals, institutes, medical centers, memorial hospitals, specialty hospitals, and teaching hospitals.
My home state of New Jersey, for example, started with one children’s hospital in Newark, followed by a few more designated under state Health Department competitive certificate-of-need guidelines, followed by a few politically designated by the Legislature, followed by a bunch of sound-alikes such as a “children’s medical center” mischievously bypassing the fact that “children’s hospital” is a legislatively restricted name.
For the most part these appellations are used to define the hospital to its community and publicly compare it most positively to other nearby competitors.
However, more and more hospitals are now calling themselves regional medical centers and university hospitals. These are very robust terms, sometimes used interchangeably or together, and imply characteristics such as comprehensive critical-care services, cardiac surgery/interventional cardiology, comprehensive stroke care, an academic environment, the latest cutting-edge technology, and a full-time cadre of 24/7 on-site super-specialist physicians, including intensivists.
And the not-so-subliminal message is that when you are very sick or injured you should bypass your local hospital.
The reality is that in New Jersey a hospital can call itself whatever it wants—there is no name regulation or oversight by state authorities. A few years ago Robert Wood Johnson University Hospital challenged and lost, when St. Peter’s Hospital added “University” to its name. Since then a number of other hospitals have added “University” as well, and more will follow. Certainly this phenomenon is not limited to New Jersey.
The Association of American Medical Colleges states: “Teaching hospitals are providers of primary care and routine patient services, as well as centers for experimental, innovative and technically sophisticated services. Many of the advances started in the research laboratories of medical schools are incorporated into patient care through clinical research programs at teaching hospitals.”
I believe a university hospital/regional medical center should have most of the following characteristics typical to “major league” hospitals:
First and foremost, it should have a written affiliation agreement with a medical school that includes the rotation of medical students to the hospital for required third-year clinical rotations in internal medicine, obstetrics and gynecology, pediatrics, psychiatry and surgery.
The hospital should have full-time chairmen in the core clinical departments (e.g., medicine, pediatrics, surgery) selected by a joint hospital-medical school search committee, and not as a reward for seniority or admitting a lot of patients.
There should be at least three physician residency-training programs under the supervision of the medical school.
All physicians teaching students and residents should qualify for faculty appointments at the affiliated medical school.
A dean’s committee composed of senior medical and administrative staff from the hospital and school should meet regularly to jointly set strategic priorities and evaluate program efficacy and performance.
The hospital’s medical staff bylaws should mandate automatic removal from the staff of any physician who does not achieve board certification after a given period of time, such as five years.
The hospital should have at least three state-designated critical-care services such as trauma center, regional perinatal center (high-risk obstetrics), stroke center, children’s hospital or cardiac surgery. There should be full-time intensivists in all ICUs.
The hospital should be a member of all major statewide multihospital clinical-care quality projects such as the New Jersey Hospital Association’s ICU and pressure-ulcer collaboratives. It should participate in clinical trials that the medical school has undertaken, and be a training site for students in nursing, pharmacy, physical therapy and other health professions.
It should have a full-time chief medical officer, a senior physician preferably with a master’s degree earned through the American College of Physician Executives (or equivalent) and a chief nursing officer with an appropriate doctoral degree.
Finally, the hospital’s board, administration and medical staff must have a demonstrable unwavering “safety net” commitment to the medically underserved.
These steps are, of course, easier said than done, so here are some initial steps for the states to consider:
State hospital associations should set up task forces to develop a policy and strategy to make sure hospital names are educational to the public, not exaggerations of capability.
A state could pass a law or the health department could promulgate regulations defining the requirements to be designated a university hospital or regional medical center. These designations should be subject to periodic state review.
Obtaining the appropriate and best hospital care should not be complicated by creative and clever hospital marketing but by easily understandable evidenced-based standards and metrics—and names.
