The Wild West Sits One Out: AB 52 is delayed until 2012 as California backs down to health insurance company interests0

As expected, the 2010 Patient Protection and Affordable Care Act (PPACA) has had a dramatic impact on the American health care system. One of the more admirable objectives deeply entrenched in health care reform is the establishment of a clear and understandable infrastructure so that its many moving parts and pieces can seamlessly coexist under proper supervision. To this effect, at the end of 2010, the federal government published proposed regulations addressing health insurance rates, including strict disclosure and careful review of any significant price adjustments by insurers.

Focusing on the exorbitant 131 percent increase in health insurance premium rates for families since 1999, these reform-based regulations required all rate increases of 10 percent or more to be publicly disclosed and justified as of 2011. With an eye to the future, PPACA further dictated that by 2012, each state shall be responsible for setting and enforcing its own rate threshold to reflect appropriate cost trends and other meaningful date when reviewing future rate hikes. For states that fail to establish such a system of oversight, either by design or due to lack of resources, the U.S. Department of Health and Human Services (HHS) will step in and satisfy the intent of the legislation.

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Preparation Does Not Guarantee Perfection0

This article first appeared on California Healthcare News.

California has always found its way into the public spotlight, and 1975 was no exception. That is the year in which Jerry Brown became the state’s 34th governor, Nolan Ryan started the season for the California Angels, President Ford survived an assassination attempt in Sacramento, actors Jon Voight and Marcheline Bertrand gave birth to their daughter Angelina Jolie Voight in Los Angeles, and the state’s Medical Injury Compensation Reform Act of 1975 (MICRA) was passed.

At its core, MICRA was the end result of efforts to save California’s physicians from the fallout of a multitude of lawsuits, runaway jury verdicts, and draconian responses by insurance liability companies. With its $250,000 cap on non-economic damages in medical malpractice litigation, MICRA made history as its backers trumpeted the salvation of medicine in California. Controversial from the day Governor Brown first signed it into existence, MICRA continues to face challenges these 36 years later. For better or worse, however, MICRA addressed a critical issue and assuaged what were at the time very real fears that issues of liability and catastrophic jury verdicts would bring California’s medical system to a halt.

California’s hospitals are not alone in their need to proactively address situations involving unforeseen events. In this present era of health care reform, providers across the nation have an even greater abundance of legal issues on which they must focus their attention. For example, in the not too distant past a new concern appeared on the horizon some 2,700 miles from Sacramento. August 2005 saw Hurricane Katrina wreak havoc throughout southeastern Louisiana, with a death toll in excess of 1,800 and an $80 billion price tag, to say nothing of the sociological and environmental collateral damage that quickly followed.

Once the storm had passed and the dust had begun to settle, a frightening discovery at Memorial Medical Center in New Orleans captured the nation’s attention anew and resonated in the hearts and minds of every hospital administrator across the nation. Forty-five Memorial Medical Center patients died from the Hurricane, a number greater than any other New Orleans hospital, and blame was quickly directed to the hospital and its failure to provide for its community in an emergency situation. … Read more →

Instructions Never Included0

“Man cannot discover new oceans unless he has the courage to lose sight of the shore.”

— André Gide, French author

This article was first published on the PBS affiliated website This Emotional Life.

I have decided at last to forgo my search for instructions. Though it was nearly a decade ago that I first hoped to uncover an operational manual at work during my first tenuous days in an unfamiliar hospital environment, such guidance always escaped my discovery.

Seven months ago a new job of sorts presented itself to my wife and me, and not surprisingly, this owner’s manual also turned up missing. The resultant experiences brought about by new fatherhood have only served to reinforce my decision to trust my instincts from this point forward, as while there is an abundance of literature that purports to bridge such gaps in both professional and personal knowledge, I have yet to encounter any crisis brimming with patience, be it related to emergency department protocol or an unexpected and unexplainable late night tantrum.

In my professional role as health care attorney and consultant, I have come to grips with the fact that the federal government may not publish an “executive summary” covering all 2,700 pages of last year’s Patient Protection and Affordable Care Act (PPACA, more commonly referred to as health care reform) anytime soon.  … Read more →

Looking Back to Move Ahead: Leading Hospitals Through Fast-Paced Change (Becker’s Hospital Review)0

The article was first published August 26, 2011 on Becker’s Hospital Review (written by Molly Gamble).

Healthcare executives might remember time moving a bit more slowly before March 23, 2010. That was the day President Obama penned his signature, supposedly letter by letter, onto the Patient Protection and Affordable Care Act. The average workday for healthcare or hospital CEOs was probably filled with slightly different concerns or agendas before that moment. Since then, though, the industry has been flung into fast motion to accommodate the policy changes mandated in that 2,700 page bill along with its larger overarching themes that are shaping modern-day healthcare.

For the rest of the article, visit the Becker’s Hospital Review Website.

California’s Unique Funding Picture1

This article first appeared in the August 25, 2011 edition of Payers and Providers.

As President Obama’s Patient Protection and Affordable Care Act (PPACA) continues to evolve, the structure of health care in the United States grows ever more complicated, and California is no exception to the rule. One of the nation’s most expensive states when it comes to treating an average hospital patient, California makes up more than 10% of what the U.S. spends on health care annually.  Therefore, it is not surprising that state legislation has designated certain opportunities for its hospitals to benefit from special programs designed to fortify their financial stability in the short term.

However, with these conditional programs come additional regulations, making an already complex system even more difficult to navigate.  Leapfrogging over the myriad requirements relating to authorizations, categorization of in- and out-of-network providers, and the other combinations of factors that exist as a condition precedent to accessing non-emergency care, many of California’s hospital administrators have recently found themselves in the eye of health care’s hurricane, temporarily lulled into submission by the peace of mind granted by such programs and their promised funding, even as the chaos surrounding the nation’s health care reform is presented daily in the press. … Read more →

Will Health Care Reform Survive Its Sophomore Term?0

This article first appeared in the Daily Journal on August 17, 2011.

When President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA) last year, he effectively gave the United States a map to describe the route of American health care for the foreseeable future. And if its initial robust 2,700 pages were not enough, additional regulations proved quickly forthcoming. As necessary and expected as these supplements may be in the grand scheme, pouring through their merits can be daunting.  To make matters worse, the frequency with which the federal government updates health care reform through regulatory addendums is not only confusing to the general public and health care professionals alike, but it provides opportunities to infuse partisan politics on either side, which detract from the gravitas of the situation at hand.

The last few months have seen clarifications to some key components within PPACA. For example, in April the federal government released the long awaited and much anticipated details defining Accountable Care Organizations (ACOs). Although ACOs are not set to take effect until 2012, these proposed regulations may have unexpectedly stalled the fervent collaboration between private payers, physicians, and health system leaders previously occurring nationwide.

On the surface, ACOs may trigger well-established violations of law without the benefit of a new, expected safe harbor provision or other comparable exceptions, especially in California where the corporate practice of medicine is prohibited. Moreover, proper formation of ACOs under the regulations will necessitate a significant capital commitment, a commodity that has been depleted in a state like California with serious financial burdens separate and apart from an underfunded health care system, which is in the process of entering the electronic health records age with physical structures that must meet state mandated seismic safety standards.

Perhaps as a way to provide some assurance that the fledgling ACO-collaborations stay on track, the federal government subsequently offered details on its Pioneer ACO Model. The Pioneer Model caters to health care alignments with preexisting experience in coordinating patient services, thus creating a “fast track” from the shared savings model to a population-based model. Similar in structure to the Medicare Shared Savings Program, the federal government hopes that its Pioneer Model will set the gold standard for ACOs in the future as these new entities scramble to align payers, providers, and patients.

Last month the federal government released approximately 300 pages of guidelines addressing the ways in which states must implement new ”affordable insurance exchanges” by the Jan. 1, 2014 deadline, although California was the first state to pass legislation in this regard. Last week, the government directed another $185 million in “establishment grants” to assist the individual states with their health exchange endeavors. The exchanges intend to provide consumers with a variety of private health insurance options displayed in such a way as to allow an easy comparison of covered services, premiums, co-pays and deductibles.  This is indeed the quintessential harbinger of health care’s future under PPACA.

At least one article reporting on the new regulations last month (Los Angeles Times, July 12, 2011) commented that the exchanges are designed to make the purchase of health insurance much like employing the Internet to purchase airline tickets and hotel reservations.  Whether accurate or not, such an analogy is frightening and evokes images of innocent hospital patients shopping for coverage just prior to an appendectomy, and ending up on standby for gallbladder surgery with a layover in the ICU.

One of the primary objectives of the exchanges is simplification. Necessary or not, these new regulations do very little to ease the minds of most health care consumers. Instead, this outpouring of information strikes fear in the hearts of hospital patients. Both fan and foe of PPACA can agree that there is plenty of information to process at present, and even more assembling on the horizon.

And if that was not enough information to digest, last week the 11th U.S. Circuit Court of Appeals held that the individual insurance mandate is unconstitutional, thus creating a split amongst the circuit courts. In ruling against this component of health care reform, the court argued:  “The uninsured have made a decision, either consciously or by default, to direct their financial resources to some other time or need than health insurance.” (Florida v. United States Dept. of Health and Human Srvs.,(11th Cir., Aug. 12, 2011.)

But have the 50 million uninsured really made a decision, or is their inaction simply a reaction to the confusion inherent in our current health care system? Making sense of the situation will take time, and any rush to judge these developments will result in a disservice to all those involved. As lengthy as it is, the original text of PPACA did little more than outline a new way of delivering health care to a nation in need of support.  In fact, a majority of PPACA’s initial draft relates to pilot programs, preventative care measures, and other studies that focus on the future of medicine, rather than the delivery of health care.

And while the fight to repeal PPACA moves closer to the U.S. Supreme Court, as well as into the hands of the debt ceiling legislation’s “Super Committee,” it is important to remember that from a practical standpoint, PPACA’s legacy remains difficult to quantify until it has been given the chance to mature into a definable entity.


No Choice But To Care: What Happens When a Hospital Can’t Shut Its Doors?0

This article was first published on Becker’s Hospital Review.

Well into its second year, President Obama’s Patient Protection and Affordable Care Act continues to exhibit a series of growing pains as it struggles to flex its muscles and mature. As with any rapidly evolving entity, our nation’s healthcare system has been reshuffling a number of core options lately, and though only a select few draw national attention, the recent vote to keep Oak Forest Hospital up and running in Illinois’ Cook County sheds new light on an escalating problem within the American healthcare structure. Namely, who pays the greatest price when a hospital is not allowed to shut its doors?

As the fledgling PPACA gains momentum, change is certainly afoot. Earlier this year the federal government placed strict requirements on those insurance companies who intend to raise plan premiums in excess of 10 percent. Last month, the same federal government announced that hospitals could no longer ignore patient satisfaction if they wanted to maintain their Medicare reimbursements without additional cuts. Prior to that, the Centers for Medicare & Medicaid Services released a set of much anticipated proposed regulations for accountable care organizations, which will arguably become the blueprints for the future of American healthcare. The draft requirements, however, make it clear to any but the largest health care providers that the future of medicine is both cost prohibitive and fraught with even more regulatory minefields than the existing system.

This is not good news for smaller, independently owned hospitals struggling to stay afloat in the current economic climate. It also emphasizes the frightening fact that each year fewer emergency departments are available nationwide, in urban neighborhoods in particular. A recent study by a doctor at University of California at San Francisco states that one out of every four hospital emergency departments has shut down in the past 20 years, even as ED visits have increased by 35%. The strain of regulatory pressures on today’s medical facilities is causing significant cracks in the foundation of America’s healthcare structure as a whole, and if not rectified in the short term, it will ultimately be the patient who is forced to do without.

When the Emergency Medical Treatment and Active Labor Act (EMTALA) was passed in 1986, requiring hospitals to provide medical care to anyone needing emergency treatment, regardless of citizenship, insurance, or ability to pay, hospital administrators across the country clamored that such a mandate would be the death knell of many of the nation’s hospitals. Imagine their surprise to hear that we as a nation have progressed so far this past quarter century as to not allow a failing hospital to close when it can no longer afford to provide for its community.

Though the basic tenets of the PPACA are laudable in their attempts to provide a broader range of coverage, in the final analysis healthcare is a business, and as such must be allowed to follow the traditional rules of commerce if it is to be expected to successfully provide an acceptable quality of service. By forcing hospitals to stay open when they are financially unable or unwilling to do so, the system effectively creates a smoke screen, tricking patients into thinking they have access to reasonable medical care when in fact the facility is scraping bottom.

While federally mandated health care does its best to ensure that no one slips through the cracks, such blanket coverage comes at a price. And that price just might be your local hospital.

Professional Advice From A Newborn0

“The aim of education is the knowledge, not of facts, but of values.”

– William S. Burroughs, American author and poet

This article was first published on the PBS Affiliated Website This Emotional Life.

It has always seemed to me that life is a series of stages. And yet, rarely do we recognize such fleeting moments when one stage ends and another begins. Irrespective of who or what may be behind the impetus for any given change, these significant, transitory periods in life often accompany opportunities to reflect upon individual priorities. Such was recently the case with me, as I found myself on the cusp of not one, but two major life changes, as well as with an unusual amount of free time with which to think.

Although my titles, job descriptions, and central focus may have shifted through the years, health care has always been my industry. For well over a decade my work has involved legal matters, consulting opportunities, hospital management, academia, and creating a foundation in a public benefit enterprise. These two most recent changes, the birth of my first child and my transition from head of a community hospital to the private sector, occurred simultaneously and permeated practically every aspect of my life and touched upon my inner most thoughts and feelings.  Such intensity in transition can be unsettling, and when reliance upon intuition and instinct is called upon to surpass experience and knowledge in utility, there is often not much time to recover from vacillations in self-confidence and pride.

My father instilled in me the notion that professions were not to be seen as mutually exclusive, and he taught me the importance of finding ways to create an individual path whenever possible. In reflecting upon the past sixteen years since completing my academic studies, I would like to think that I succeeded in reaching the appropriate professional autonomy he espoused, even if I existed under his gentle influence and sometimes watchful eye during the first 41 years, 1 month and 16 days of my life.

Parents can play many different roles, and for me the union between my mother and father formed something like a trapeze net that waited to protect my siblings and me should we find ourselves falling as we attempted great heights. Of course my vantage point toward my family changed over the years as I matured and tried new things, and at times my height was such that I could not confirm their existence below. Still, that net has proven quite sturdy even today as my mother holds it alone, nine years after my father’s passing.  My mother’s firm grip still reminds me of the ways in which my parents influenced my many decisions by providing that rock solid foundation, but I was recently surprised to note that it is a newcomer who seems to have the most influence over my security these days. Weighing in at a cool sixteen pounds, I am talking about my son.

When I reached a rather significant crossroads in my career last fall, my son was still nesting safely inside his mother’s womb. At the pinnacle of my professional transition, he was a mere six weeks old. And yet, when I recently looked below to see if anyone was holding the net for me as I prepared to make my next leap, my son stood there by himself, smiling up at me.  This recent lesson from my son is of equal significance to my father’s instructions a decade ago, yet the two sets of truths could not be any more different from each other.

When my position at the hospital came to an end, I redirected my attention to the various job experiences I had gathered over these past 16 years, with the only common denominator being the industry. Under the umbrella of health care, I sought to combine legal, administrative, and literary acumen as I set out to define the next chapter in my existence. Without the security stemming from the job that had been my professional centerpiece for the past nine years, however, I knew this task would be quite challenging, and my frustration grew when I found I could not readily identify the origins of my perceived obstacles. I feared that something had changed within me, so my response was to increase my efforts in even greater directions. This, of course, did not help my focus.

And then it occurred to me what had caused my recent change. All along, I had been blaming this previously undefined shift in personality for preventing me from advancing my career to its next logical stage. And yet, as it turns out, this change did not blunt my focus or energies at all, but rather readjusted my priorities in such a way so that I now find myself proceeding along the path I had been seeking all along.  I have held many positions in my life, but there is one for which I had no experience up until recently, and its impact stands in stark contrast to everything I’ve ever learned in an office or hospital.

Though I may be new at my role as father, the old adage continues to ring true in my ears – timing is everything. For just when I realized that my career was teaching me how to be a better father, I’ve come to learn that my son has improved upon my professional abilities. As it turns out, this is very convenient for both of us, and I cannot wait to see where this partnership will lead.


Big Changes Ahead: Medicare IPPS 2012 and What It Means for Hospitals (Becker’s Hospital Review)0

The following article first appeared at Becker’s Hospital Review on July 29, 2011 (written by Molly Gamble).

Medicare and hospitals go hand in hand. Hospital payments account for the greatest share of the federal program’s spending, and Medicare is the largest payor for hospital services, comprising a significant portion of most hospitals’ revenue. As of Oct. 1, though, hospitals will operate under a revised inpatient prospective payment system — one that could put many hospitals at risk.

The proposed changes to IPPS for fiscal year 2012
Imagine if the method of assessing individual taxes changed and the government scrapped its traditional, income-based approach for a model that taxed Americans based upon their personal caliber.

This may sound far-fetched, but healthcare leaders might share a strange yet familiar connection with the scenario — particularly in light of the Centers for Medicare & Medicaid Services’ proposed changes to IPPS. These rules, unveiled in April 2011 for fiscal year 2012 (thus going into effect Oct. 1), contain payment rate changes, coding adjustments, and the quality reporting program which mandates hospitals to report on 55 measures for FY 2012. 

More than 60 percent of hospitals already lose money on Medicare, according to the American Hospital Association. Section 3401 of the Patient Protection and Affordable Care Act detailed across-the-board Medicare payment reductions for hospitals. These cuts are estimated to reduce reimbursements by $155 billion from 2010-2019, a strategy hospitals agreed to accept in 2009 to help fund healthcare reform. While good news for CMS, these additional Medicare cuts could prove devastating to hospitals, particularly when paired with extensive performance-based healthcare delivery reforms, such as value-based purchasing, which is set to begin in Oct. 2012.

Putting IPPS into context
From an academic and legal standpoint, Craig B. Garner, a professor of law at Pepperdine University in Malibu, Calif., says the proposed changes are fascinating. “Throughout its history, Medicare has employed variations of cost-based reimbursement, originally factoring in the actual cost to a provider and then transitioning to a predetermined rate based upon a patient’s particular diagnosis. Soon it may not matter anymore,” says Mr. Garner. “The new regulations are changing a very complex system and steering it in a totally new and equally complicated direction, only this time based on performance.  This will include what people think of a hospital, the patient experience during a hospital stay, and ultimately the reliability of a hospital in its delivery of patient care,” says Mr. Garner.

The complete article can be viewed HERE.


How My Career Taught Me To Be a Better Father0

This article first appeared on the PBS affiliated Website This Emotional Life.

“There is no instinct like that of the heart.” Lord George Gordon Byron, British poet

The old adage is true: Timing is everything.  No matter how straight and narrow the road ahead may seem, one must always take into consideration the unexpected, that one, untamable variable that may at any time upset the apple cart and leave us scrambling to regain both composure and apples. For just over 108 months, I was the CEO of a hospital.  For three overlapping months, I was also a father.  The end to one significant stage of my life coincided with the joyous beginning of another.  Timing always rules the day, and, as I have found, it also enjoys irony.

Recently, I made the commitment to pursue certain credentialing and board certifications in health care management, even as my position in this field was in transition.  With a new child at home, a new career to forge, and a new professional distinction in my sights, I dived head first into an unrecognizable abyss, hoping that some yet-to-be-defined synergy (in the form of a very large net) would break my fall. As luck would have it, one of my first assignments was a book by Tom Atchison, Ed.D., which introduced me to “The Synergy Factor.”  As I understand it, this concept is a coalescing of sorts between certain intangible inter-relational ideas and tangible processes within health care administration.  There, in the middle of my matutinal study of the Synergy Factor and health care leadership, my mind started to wander toward my son, and I began to delve into the ways in which I could enhance our relationship in these early stages.

Young children (and many adults as well) exist in the crossroads of the tangible and intangible.  Matters of genetic makeup, demographics, and fiscal stability are common, tangible discussions for many new parents who aspire to provide for their latest family member. More often than not, however, that which is tangible is also hardest to control. The intangible part of parenting, namely the notion of instilling a mutual trust, respect, pride, and joy into the parent-child relationship, also happen to be what Atchison describes as “the source of a sense of purpose and meaningful work as a result of living the mission, values, and vision.” (Atchison, Leadership’s Deeper Dimensions: Building Blocks to Superior Performance, 2005).

Although not necessarily represented in equal proportion, certain factors such as the color of his eyes, the sound of his voice, the bed in which he sleeps and the neighborhood where we reside all share attributes that extend to varying degrees beyond my parental jurisdiction.  But the intangible ways in which I deliver certain messages that speak of and lead to trust, respect, pride, and joy are almost entirely within my control, regardless of those aforementioned tangible realities, as well as any challenges I may face now or in the future as a parent.

Now, as my studies force me to probe deeper into the core of health care management, I constantly find myself reflecting upon my real life lessons learned over the past nine years. No matter what educational background or prior experience a hospital CEO brings to the table, certain on-the-job assignments will necessitate fast, critical thinking.  With such knowledge comes the hope that I myself faced each hospital challenge with a combination of what I learned in school, what I learned from past work-related experiences, and what just felt like the right response. And as I continue to read about tangible and intangible notions in health care management as well as other industry terms and phrases, I begin to realize that I had in fact embraced most of these concepts during my tenure, in deed if not in word as well.

As I reflect upon the past decade with these thinly disguised affirmations from my present studies, I wonder also how I will come to assess my first nine years as a father. At the outset, I am very mindful that this new role differs from the last with respect to the events over which I was ultimately responsible. Now I share the top position with my wife, although to be sure my involvement is shaped by the needs of a newborn and the physical limitations of a father.

Without anything resembling an owner’s manual to follow as I try to build connections with my son while navigating the uncharted waters of new fatherhood, I realize that my instincts will be my second greatest ally, preceded only by those of my wife.  Thanks to the recent validation of these very instincts in hospital management, I am mindful that timing is still everything, and not all variables can be controlled.  Some must be dealt with as they emerge. Certain concepts that previously had no words in health care management may also be unknown terms to me in parenting.  For now, however, I can reassure myself by embracing both the tangible and intangible, and perhaps borrow some of these newly acquired definitions from health care to light my way.  After all, my goal is to build a solid foundation with which to give me footing among these intangibles in preparation for a lifelong journey with my son. In many ways, this is not so different from the way in which I approached the running of a hospital.  This time, however, the stakes are more profound, not to mention precious.