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Healthcare
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InDepth Medical Education

The curriculum is changing.

Should GME funding be next? Page 16

CBO gives Q1 was a

its take on $9.3 billion
single payer / boon for
Page 6 insurers /
Page 10
 MAY 16-17, 2019 | AUSTIN, TX
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 InDepth
Medical Education Opinions/Ideas
24 Editorial 25 Guest Expert
16 Cover story Medicare for All looks like a Private-equity investors have
nonstarter right now. But if begun casting their nets for
Pushing the med-school
single-payer advocates were primary-care practices. But
curriculum into the future
smart, they would start with a docs would be advised to
By Maria Castellucci long-term care plan for all. look before they leap.
A growing number of medical schools
are re-imagining the traditional 26 Letters
curriculum, jettisoning long-held Hate-fueled violence in this country must end, and it starts with
practices in the hopes of arming all of us, says Scripps Health CEO Chris Van Gorder, citing the
the next generation of doctors with recent shooting in a San Diego-area synagogue.
essential skills for the 21st century.
29 Bold Moves
20 Paying the tab for graduate Virginia Mason Health System CEO Dr. Gary Kaplan discusses
medical education the rewards and challenges of his relentless war on waste.
By Steven Ross Johnson
With limits on how many graduate 30 Innovations
medical education slots the federal By Jessica Kim Cohen
government will fund, teaching Drug diversion plays a major role in the nation’s opioid epidemic,
hospitals find themselves having to so hospitals are using analytics to detect incidents much sooner.
bear a greater share of the financial
burden to meet the demand for 32 Q&A
physician services.
American Medical Association
Online only: Med schools CEO Dr. James Madara
focus on diversity explains how his organization
is partnering with the nation’s
ModernHealthcare.com/
medical schools to revamp how
MedSchoolDiversity
doctors are trained.

News
Data
2 Late News 6 Government 8 Regulation
After unusually strong CBO warns of FDA to end program that 31 Data Points
March, healthcare complexities, disruption hid millions of reports on Workplace violence persists as a threat in healthcare, with nearly
hiring dips in April. of a single-payer faulty medical devices. half of ER physicians reporting they’ve been assaulted on the job.
system. 34 By the Numbers
4 The Week Ahead 9 Behavioral
ONC, CMS brass to 7 Insurers health Largest healthcare outsourcing vendors, ranked by 2018 revenue.
lay out progress on AHA wants feds to Walgreens offers
interoperability. block Centene- pharmacists first aid for Diversions
WellCare merger. mental health traning. 36 Outliers
5 Regionals
7 Technology 10 Finance What better way to get college
Independent Mass.
students engaged in health-
hospitals, systems CMS’ new tech policy Acquisitions boost
related activities than some fun
collaborate on contract approach targets bottom lines for Cigna,
and games. That was the idea
negotiations. “outdated” regulations. CVS Health.
behind an event hosted by the
New Jersey Hospital Association.

ModernHealthcare.com/WebExclusives
As price becomes an increasingly important factor in where people
seek care, many academic medical centers will have to transform their
high-cost structures to remain viable, according to new research.
Veterans Affairs Secretary Robert Wilkie set out new proposals
to cut federally funded union time as the VA looks to renegotiate its
collective-bargaining agreement.
Allscripts Healthcare Solutions reported its highest-ever first-
quarter for bookings, even as the company’s revenue remained flat
year-over-year.
House lawmakers are trying to eliminate a waiver requirement
that clinicians must clear before they can prescribe buprenorphine to
patients for opioid addiction.

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May 6, 2019 | Modern Healthcare 1

 Briefs
After unusually strong March, „„
„
Medicare spending would climb
by $187 billion and Medicaid by
$7 billion over the next decade if the
healthcare hiring dips in April CMS finalizes a rule to get rid of the
safe harbor for rebates for Part D
Healthcare hiring fell in April, which shouldn’t come as a surprise following drugs, according to an analysis from
March’s strong jobs report. the Congressional Budget Office. The
Hiring in the healthcare sector declined 45% in April, having added 27,000 jobs, figure is slightly below the $196 billion
according to the U.S. Bureau of Labor Statistics’ newest report, released Friday. in new spending over the next decade
That’s compared with March’s 49,100 new hires, a number that approached that the CMS’ Office of the Actuary
December 2018’s historic high. predicted earlier this year. The Trump
As usual, most healthcare hiring took place in the ambulatory sector, which administration proposed replacing
grew by 17,200 jobs. But that number was down 36% from March’s tally.
the safe harbor for rebates from
April marked the second consecutive month that home health saw the
prosecution under the anti-kickback
strongest hiring within the ambulatory sector, adding 5,900 jobs, down 26% from
statute with a new one for discounts at
March. Physicians’ offices again took second in the sector, hiring 5,000 new
the point of sale, by January 2020.
workers, a 29% decline from March. Hospitals made 8,300 new hires in April, „„
„
A wealthy drug company founder
down 39% from March’s 13,600 hires. was convicted of directing a scheme
Nursing-care facilities shed 3,100 jobs last month, and residential mental health to bribe doctors across the country
facilities lost 1,400 jobs. Other residential-care facilities shed 900 jobs. to prescribe a highly addictive
April was a strong month for community-care facilities for the elderly, however, fentanyl spray. John Kapoor, the
which added 7,000 jobs. That marked an 84% spike from March, which already founder and former chairman of Insys
saw stronger hiring than February. Therapeutics, was found guilty of
The U.S. unemployment rate fell to 3.6% in April from 3.8% in March, having racketeering conspiracy after 15 days
added 263,000 total nonfarm jobs during the month. —Tara Bannow of deliberations in a trial that put a
spotlight on the federal government’s
efforts to go after those it views as
HHS finalizes faith-based and those who prepare rooms. responsible for fueling the deadly
The rule is meant to protect individ- opioid crisis. Four other former
protections for uals and healthcare organizations in employees of the company were also
healthcare workers HHS-funded programs from discrimi- convicted. Kapoor and the others were
nating on the basis of religion, according accused of conspiring to pay doctors
The Trump administration last week to Roger Severino, director of the OCR. bribes and kickbacks in order to boost
finalized a “conscience rule” to protect The OCR said that the rule largely sales for Subsys, which is meant for
healthcare workers who refuse to per- reinforces current laws and regula- cancer patients with severe pain.
form certain services—such as abor- tions that protect a medical provider’s „„
„
The CMS finalized a rule preventing
tion—because of religious beliefs. rights to refuse to perform certain pro- unions for home healthcare workers
HHS’ Office for Civil Rights issued cedures, while adding new standards to get dues paid via state Medicaid
the 440-page final rule, which offers that Medicare and Medicaid providers payments. The rule, which overturns
protections for providers, health in- will need to follow. a 2014 rule, no longer allows a state
surers and employers that decline to If providers don’t comply with the to divert payments from Medicaid
provide, participate in, pay for, provide conscience regulations, they could lose to anyone but the provider with few
coverage of or offer referrals for services federal funding. The OCR’s Conscience exceptions. The agency contends the
that violate their religious or moral be- and Religious Freedom Division, which 2014 rule that allowed unions to get
liefs. The rule also covers healthcare the office established in 2018, will over- dues from payments stretches the
staff who “assist in the performance” see complaints from providers that feel meaning of the federal statute and
of such services, including schedulers their rights have not been respected. must be struck down. “This final rule
is intended to ensure that providers
Corrections and clarifications receive their complete payment, and
that any circumstance where a state
The April 29 Outlier “An Epic Easter in London,” (p. 36) misstated who paid for Children’s Hospital
redirects part of a provider’s payment
of Philadelphia employees’ travel and lodging. Great Ormond Street Hospital paid those expenses.
is clearly allowed under the law,” CMS
The source line for a chart (“Planned use of VA healthcare services,” April 29, p. 21) accompanying Administrator Seema Verma said in a
the feature “As VA races to launch private-care program in June, the worries mount,” should have
statement.
read: Veterans Health Administration.

2 Modern Healthcare | May 6, 2019

EXECUTIVE INSIGHT
Basic Social Needs Are Driving Future Care Models
Comprehensive, personalized care focused on long-term patient needs is key to success
Chris Smedley
Vice President
Physician Enterprise at Premier Inc.
Chris has more than 20 years of
experience in healthcare, with a focus on the
physician enterprise in both practice plan and consulting
environments. His experience includes administering
practice plan operations as well as overseeing the delivery
of comprehensive engagements at academic medical
centers and health systems throughout the U.S. He has
specialized expertise in the areas of physician solutions,
children’s hospitals and cancer centers.
How is consumerism redefining the patient
experience in healthcare?
CS: As the Apples and Amazons of today inch closer to the
point of care, they will certainly drive innovation in terms of
how patients manage their health. Knowing this, there are
two very important things to remember.
First, while many of these efforts allow self-sufficient
consumers to proactively manage their health in more
effective ways, they often omit the portion of society that
needs the most help – people that are affected by chronic
conditions and social determinants of health. These individuals
account for the vast majority of healthcare spending and need
much more than the latest gadget in wearable technology
to address their complex needs. While they need more
personalized care in order to understand and address their
needs, these patients are thrust into our paradoxical episodic
system of care. Many of these patients are finding themselves
in emergency departments (EDs) anytime they need care.
Second, as more apps and care touch points are unveiled,
while innovative, they are contributing to an abyss of
disconnected health management initiatives. In most cases,
we don’t need more technologies, we need more connected
technologies. This is amplified in patients that require even
greater levels of coordination and communication, such as
pediatrics and oncology. Cancer patients, and especially the
parents of children with cancer, require and expect prompt
access, exceptional care delivery, evidence-based protocols
and proactive communication -- all of which challenge
current day technologies and care teams.
With the move to value-based care, are physician
practices expecting an uptick in patient visits?
CS: While many physician organizations still largely rely
on fee-for-service revenue, most are preparing for a shift
to more preventative care in primary settings to avoid
unnecessary hospitalizations and ED visits for their patients.
To do so, physician offices need new modes of care that
decompress the ambulatory office (e.g. evisits, virtual visits,
telemedicine), and address the needs of patients with
chronic conditions as well as increased demand.
In a recent analysis by Premier, ED visits from more than a
third of patients with one of the six most prevalent chronic
conditions were potentially preventable across nearly
750 hospitals. Additionally, in our work with more than
120 accountable care organizations (ACOs), Premier has
observed that approximately 30 percent of ED visits could
be addressed in primary care and other outpatient settings.
That’s why the physician practices and health systems we
are working with are actively engaging with each other to
implement more comprehensive patient-centric, physician-
aligned care management models.
How can physician practices improve patient
retention in the age of consumerism?
CS: Patients generally opt to seek a new practice or
location because of better access to care. While quality and
reputation are essential factors, if the playing field is even,
patients will prioritize practices that deliver prompt and
convenient access.
However, same day appointments and family-friendly hours
can be difficult to maintain, especially in medical groups
that are well regarded and sought out as the first option
by patients. Organizations need the ability to continually
evaluate and manage access, capacity and optimal staffing
models. It’s critical that medical group leaders make
effective and timely decisions relative to practice growth
opportunities and the need for additional providers.
Are patients willing to pay a premium for more
preventive care?
CS: Patients with means are often willing to pay for
differentiated healthcare services. Concierge medicine
has become increasing popular due to its prompt and
comprehensive approach. Additionally, integrated medicine has
grown in popularity for patients with complex care needs and
health conscious individuals looking for a more proactive model
to manage overall wellness. These models place an emphasis
on the long-term needs of the patient, often requiring that
patients pay the provider directly, and then recoup a portion of
the cost from their insurance plans.
This Executive Insight was
produced and brought to you by:
To learn more about Physician Enterprise
Services at Premier Inc., visit explore.
premierinc.com/physician-enterprise-solutions
 EDITORS
Aurora Aguilar Editor

CMS, ONC brass to

312-649-5218 aaguilar@modernhealthcare.com
Matthew Weinstock Managing Editor
312-397-7585 mweinstock@modernhealthcare.com

lay out progress on

Paul Barr Features Editor
312-649-5418 pbarr@modernhealthcare.com
Erica Teichert News Editor

interoperability
212-210-0209 eteichert@modernhealthcare.com
David May Assistant Managing Editor
312-649-5451 dmay@modernhealthcare.com
Merrill Goozner Editor Emeritus
mgoozner@modernhealthcare.com
MAY 6: What can be done to “eliminate barriers” to let insurers sell plans
across state lines? The CMS wants to know. The agency posted a request for CREATIVE SERVICES
Patricia Fanelli Creative Services Director
information seeking input back in March. Today is the last day to comment. 312-649-5318 pfanelli@modernhealthcare.com
In particular, the CMS wanted feedback about how states could use Section Joanne Yj Kim Graphic Designer
1333 of the Affordable Care Act, which allows insurers to enter into a 312-649-5338 jykim@modernhealthcare.com
“healthcare choice compact” to sell out-of-state coverage if state regulators Paul Romejko Graphic Designer
agree. The CMS’ goal is to boost competition and increase access to more 312-649-5335 promejko@modernhealthcare.com
affordable coverage. But the American Academy of Actuaries claimed savings DIGITAL
would be limited because premiums are driven by the local cost of care, Saman Creel Digital Content Strategist
312-649-5225 screel@modernhealthcare.com
regardless of where the care is purchased. We’ll have coverage early this week
on our website analyzing industry comments. Emily Olsen Web Producer
312-649-5482 eolsen@modernhealthcare.com
MAY 7: The debate over drug prices often swings to the cost of innovation. SENIOR REPORTER
The Senate Judiciary Committee aims to tackle the topic during a hearing Harris Meyer Chicago
titled, “Intellectual Property and the Price of Prescription Drugs: Balancing 312-649-5343 hmeyer@modernhealthcare.com
Innovation and Competition.” REPORTERS
Tara Bannow Finance | Chicago
MAY 7: For the second time in as many months, the Senate Health, 312-649-5362 tbannow@modernhealthcare.com
Education, Labor and Pensions Committee will examine the Trump Maria Castellucci Safety & Quality | Chicago
administration’s work to make good on 312-397-5502 mcastellucci@modernhealthcare.com
the 21st Century Cures Act. ONC chief Jessica Kim Cohen Technology | Chicago
Dr. Donald Rucker and Dr. Kate Goodrich, 312-649-5314 jcohen@modernhealthcare.com
director of clinical standards and quality Steven Ross Johnson Population Health | Chicago
312-649-5230 sjohnson@modernhealthcare.com
and chief medical officer at the CMS,
are slated to testify. During a hearing in Dr. Donald Rucker Dr. Kate Goodrich Alex Kacik Operations | Chicago
312-280-3149 akacik@modernhealthcare.com
March, committee members expressed
Robert King Rules and Regulations | Washington
cautious optimism for proposed rules the agencies released in February 540-907-9238 rking@modernhealthcare.com
aimed at increasing data-sharing. “The rules will reduce administrative burden
Shelby Livingston Insurance | Nashville
on doctors so they can spend more time with patients,” Committee Chairman 843-412-6857 slivingston@modernhealthcare.com
Lamar Alexander (R-Tenn.) said at that hearing. But he also sounded a note Susannah Luthi Politics | Washington
of caution: “I also want to be aware of unintended consequences from these 202-670-1438 sluthi@modernhealthcare.com
rules. Are these rules moving too fast … Are the standards for data elements RESEARCH AND DATA
too rigid?” Drs. Rucker and Goodrich, what say you? —Matthew Weinstock Tim Broderick Graphics & Data Reporter
312-649-5409 tbroderick@modernhealthcare.com
Megan Caruso Research Associate
312-649-5471 mcaruso@modernhealthcare.com
Upcoming Modern Healthcare events
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Julie A. Johnson Copy Desk Chief
May Transformation Summit 312-649-5236 jajohnson@modernhealthcare.com
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312-649-5259 jggreene@modernhealthcare.com

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4 Modern Healthcare | May 6, 2019

 SOUTH
W.Va. hospitals sue opioid
companies; want damages
NORTHEAST Hospitals in West Virginia have band-

Independent Mass. hospitals,

ed together to sue some of the coun-
try’s largest opioid companies, saying
they flooded Appalachia with powerful
systems collaborate on painkillers and forced medical centers
to deal with the financial repercussions.

contract negotiations Nearly 30 West Virginia hospitals and

10 affiliates in Kentucky have signed on
to the suit filed in Marshall County, W.Va.
An alliance of independent hospitals and N.Y. VT. N.H. The hospitals are seeking monetary
health systems across Massachusetts 5
7 damages to cover the costs of treating
expanded from three to 10 organizations, 1 3 Boston people with opioid addictions.
MASS.
enabling them to leverage cheaper 6 8 OxyContin maker Purdue Pharma
4 2
contracts while maintaining their autonomy. 10 and members of its controlling family,
The Massachusetts Value Alliance, which CONN. R.I. 9 the Sacklers, are named as defendants,
initially formed in 2016, is a collaboration of along with distributors such as Ameri-
14 hospitals in the state that work together sourceBergen and Cardinal Health. In a
on group purchasing contracts and share Independent hospitals and statement, AmerisourceBergen called
best practices to help stay competitive health systems in the the suit “counterproductive.”
Massachusetts Value Alliance
in their market while still remaining Also last week, the state reached a
independent. The hospitals combined 1) Berkshire Medical Center $37 million settlement with McKesson
2) Brockton Hospital
serve about 2 million people.
3) Emerson Hospital
Corp. in a lawsuit accusing the company
Collaborating with others allows 4) Harrington Healthcare of shipping millions of suspicious pain-
providers to leverage their collective scale, System killer orders to the state as it was being
said Dr. Gene Green, CEO of South Shore 5) Henry Heywood ravaged by the opioid epidemic.
Health, a founding member of the alliance, Memorial Hospital
which he called a “virtual system.” A similar 6) Holyoke Medical Center CEO of Maryland health system,
7) Lawrence General
organization, the Value Care Alliance,
Hospital Baltimore mayor resign
operates in Connecticut. 8) South Shore Health amid scandal
Since the Massachusetts alliance formed 9) SouthCoast Health
three years ago, the member organizations 10) Sturdy Memorial Hospital The CEO of a major medical sys-
have worked together to negotiate on tem in Maryland resigned April 26
lab referral contracts as well as other following revelations of numerous
contracts. The members waited until their contracts were up and decided questionable financial arrangements
to go forward with one contract with Quest Diagnostics. The alliance is now involving board members, includ-
working on ways to negotiate for better Medicare Advantage rates with ing Baltimore’s mayor, who resigned
insurers. —Maria Castellucci late last week.
Robert Chrencik had led the Uni-
versity of Maryland Medical System
MIDWEST The center will be operated by De- since 2008 before being put on a leave
Three health systems troit-based not-for-profit Metropolitan of absence in late March. He left on the
Detroit Area Hospital Services, which leave amid embarrassing allegations of
plan laundry center
has also run a joint laundry facility for “self-dealing” involving members of the
in Detroit the health systems on Oakman Boule- $4 billion hospital system’s volunteer
Three Michigan health systems vard on Detroit’s west side. board. About one-third of them received
are banding together to build a All three health systems are mem- compensation through the network’s
$48 million medical laundry service bers of MDAHS, which was established murky arrangements with their busi-
center in Detroit’s Northwest Goldberg in the 1970s, the release said. Michi- nesses, ranging from pest control to in-
neighborhood. Henry Ford Health Sys- gan Medicine joined the cooperative surance and management consulting.
tem; Michigan Medicine and the Uni- arrangement in February. Henry Ford, Then-Mayor Catherine Pugh became
versity of Michigan’s healthcare arm; Trinity Health and Michigan Medi- the public face of the UMMS scandal
and St. Joseph Mercy Health System, cine will enter long-term linen supply after selling tens of thousands of her
owned by Livonia-based Trinity Health, agreements with the not-for-profit, self-published children’s books to the
have formed a joint venture to build the committing to pay its monthly debt hospital network and somehow earning
facility, according to a news release. service charges. a half-million dollars in the process.

May 6, 2019 | Modern Healthcare 5

 Government

CBO warns of complexities,

disruption of a single-payer system
By Susannah Luthi traction: the costs of the status quo. elements of a multipayer system that
“Because healthcare spending in the could be used to achieve universal cov-
THE CONGRESSIONAL BUDGET Of- United States currently accounts for erage, including some policies already
fice last week put a damper on the idea about one-sixth of the nation’s gross ingrained in the Affordable Care Act
of a U.S. single-payer healthcare system. domestic product, those changes could such as guaranteed issue, community
The nonpartisan CBO issued famil- significantly affect the overall U.S. econ- rating of premiums, heavily regulated in-
iar warnings that a single-payer system omy,” the report said. surance markets, subsidies and a “robust
could increase demand and overtax The CBO highlighted some potential mandate” to purchase insurance, which
hospitals and clinicians while imposing benefits of going single-payer: was stripped away in the 2017 tax law.
hefty new costs. The report also echoed Administrative savings: Com- “But what needs to be asked, is it worth
hospital arguments that adopting uni- mercial plans spend about 12% of total the risk of upending healthcare for every
versal Medicare fee-for-service rates for costs on administrative functions. That American when the law on the books al-
hospitals would “probably reduce the compares with 1.4% for Medicare and ready contains a road map to universal
amount of care supplied and could also 6% for Medicare Advantage and Part D coverage?” said Chip Kahn, CEO of the
reduce the quality of care.” plans in 2017. Federation of American Hospitals.
Independent analyses Preventive medicine: Dr. Doris Browne, immediate past
have put the price tag of THE TAKEAWAY Eliminating turnover in president of the National Medical As-
single payer at roughly enrollment could lead to sociation representing black physicians
$32 trillion over a decade. The Congressional greater incentives to invest and their patients, argued that a univer-
Yet in highlighting the Budget Office’s new in preventive medicine sal coverage option would force wide-
potential economic dis- analysis largely put a and population health, al- spread adoption of preventive medicine,
damper on the idea
ruption of a single-payer though the CBO added it’s which has so far baffled the U.S.
of a single-payer
overhaul, the CBO pointed healthcare system “unknown” if that would “We have been talking about it for
to one of the key reasons in the U.S. actually happen. years and years, and it has gone by the
Medicare for All is gaining The CBO pinpointed wayside,” Browne said. 

Sizing up Medicare for All Dean Baker, senior economist at

the Center for Economic and Policy
Providers and payers were in the crosshairs during last week’s Research, projected the policy would
congressional hearing on Medicare for All legislation. cost the government $33.4 trillion
“We’re spending an awful lot on healthcare right now, and we’re not getting over a decade, but he argued that
the services and effectiveness that we’re all demanding,” House Rules administrative savings would cut
Committee Chairman Rep. James McGovern (D-Mass.) said, directing his government costs by about $3.5 trillion
remarks at critics who decry the policy’s projected price tag. and hospital costs as well.
The House bill introduced by Rep. Pramila Jayapal (D-Wash.) proposes
global budgets to distribute payments to hospitals. Ady Barkan, a 35-year-old activist who
Some interesting moments during the hearing included: is dying of ALS, speaking through a
machine, testified that he and his wife
Rep. Donna Shalala (D-Fla.), a freshman Charles Blahous of the libertarian pay $9,000 out-of-pocket every month
in Congress who was HHS secretary Mercatus Center at George Mason for 24/7 home care, although they have
under President Bill Clinton, stating University, whose analysis last year of “comparatively good” insurance.
that private insurers “have been less Sen. Bernie Sanders’ Medicare for All Rep. Tom Cole (R-Okla.) got to
effective” than the government at bill predicted hospitals would bear most the heart of most observers’ skepticism:
controlling costs. This spurred Sara of the cost-cutting, noted that Congress Congress won’t have the will to throw
Collins of the Commonwealth Fund to has historically been loath to “impose people off employer-sponsored plans.
criticize the leverage that hospitals in significant cuts” on providers. He was “It simply doesn’t make sense, and the
concentrated markets in particular have skeptical they would be willing to do so reaction to something like that would be
to negotiate high reimbursement rates. when rolling out a single-payer policy. overwhelming.” —Susannah Luthi

6 Modern Healthcare | May 6, 2019

Insurers
AHA wants feds Government-sponsored plans
Centene-WellCare would have broad
state contracts.”
Centene CEO Michael Neidorff has
to block Centene- reach across the U.S. previously commented that there are
states where the insurers have three
WellCare merger
AK ME

VT NH
plans each and acknowledged that
WA MT ND MN WI MI NY MA RI
there would be divestitures.
By Robert King ID WY SD IA IL IN OH PA NJ CT
While the companies have said the
OR NV CO NE MO KY WV VA MD DE
merger should clear antitrust reviews
THE AMERICAN HOSPITAL Associa- CA UT NM KS AR TN NC SC D.C.
because Medicaid rates are set by the
tion last week urged the Trump admin- AZ OK LA MS AL GA
states, the AHA argued that shouldn’t
istration to halt Centene Corp.’s $17.3 HI TX FL
negate DOJ’s scrutiny of the deal.
billion acquisition of WellCare Health “There is no service more important to
Plans, claiming it will reduce compe- Health plan operations American consumers than healthcare,
tition in Medicaid managed-care and Medicaid or Medicare and vigorous competition among health
Medicare Advantage plans. Medicaid and Medicare insurance companies is necessary to en-
Centene and WellCare are major play- Medicaid/Medicare/Marketplace sure that consumers receive high quality
ers in government-sponsored health Sources: Centene and WellCare
at affordable rates,” the AHA wrote.
plans, with both having a presence in Both firms reportedly competed to buy
Medicaid and on the Affordable Care Aetna’s Medicare Advantage business
Act’s exchanges. All told, the two insurers “More and more states are moving when that insurer attempted to merge
would cover nearly 22 million people in toward a managed-care model for their with Humana, which the AHA said is a
Medicare, Medicaid and the exchanges. Medicaid programs in an attempt to sign they want to “enroll the exact same
The plans’ markets overlap in several control costs,” the lobbying group wrote. consumers in the exact same plans.”
states, the AHA said in a letter, and they “Accordingly, DOJ must carefully scruti- Neither Centene nor WellCare im-
control over half of the Medicaid market nize the transaction’s present and future mediately responded to a request for
in Florida, Georgia and Illinois. competition between the parties to win comment. l

Technology
CMS’ new tech policy approach local coverage determination, Verma
said Medicare contractors are not au-

targets ‘outdated’ regulations thorized to automatically forgo cov-

ering Category III items and services.
Instead, these contractors must fol-
By Jessica Kim Cohen lead to unpredictability for innovators.” low the agency’s new local coverage
The first CMS update would revamp determination process for each deci-
CMS ADMINISTRATOR Seema Verma the application process for codes un- sion they make. That process includes
last week unveiled new steps the agency der the Healthcare Common Procedure an evidence review of the technology
is taking to bolster Medicare coverage of Coding System. in question.
emerging medical technologies. Under the current system, the CMS These changes are part of the agen-
During remarks at the Medical De- only allows vendors to apply for new cy’s broader strategy to address barriers
vice Manufacturers Association’s an- Level II codes once per year. The agen- to innovation in the Medicare program,
nual meeting in Washington, D.C., cy plans to redesign the process as according to Verma.
Verma said the agency is removing a quarterly system for submissions “The advent of novel medical technol-
what she called government barriers and decisions related to drugs and a ogies requires CMS to remove barriers
to innovation. semi-annual system for to ensure safe and effective treatments
“When I came to CMS, submissions and decisions are readily accessible to beneficiaries
I inherited outdated THE TAKEAWAY related to devices. without delaying patient care,” she said.
government rules and CMS Administrator The second component “In essence, keeping new technologies
regulation that stifle in- Seema Verma clarifies coverage of Current and treatments moving from bench to
novation and access to in- unveiled new Procedural Terminology, or bedside—and into the hands of those
novative treatments,” she steps the agency CPT, temporary codes for who need them most.”
said. “Our often arcane is taking to boost emerging technologies, also As part of her remarks, Verma voiced
and outmoded regula- Medicare coverage known as Category III codes. opposition to Medicare for All-style pro-
tions around coverage, of emerging medical For technologies that posals, saying “Medicare for All leads to
technologies.
coding and payment can don’t fall under an existing innovation for none.” l

May 6, 2019 | Modern Healthcare 7

Regulation

FDA to end program that hid millions

of reports on faulty medical devices
By Christina Jewett and Shuren said in a statement. “This ally glad to see this, the sooner the better.”
Kaiser Health News is part of a larger effort to end the alter- The agency said its forthcoming data
native summary reporting program for release will be for alternative summary
THE FOOD AND DRUG Administra- all medical devices.” reports filed before mid-2017. The FDA
tion announced it is shutting down its FDA spokeswoman for years reached
controversial “alternative summary Angela Stark said the agreements with
“The No. 1 job of the FDA—
reporting” program and ending its de- agency will also end makers of about
cadeslong practice of allowing medi- “alternative summa- it shouldn’t be ‘buyer 100 devices, al-
cal-device makers to conceal millions of ry reporting” exemp- beware’—is to have the lowing them to
reports of harm and malfunctions from tions still in place for information available to cease public re-
the general public. makers of implantable people so they can have ports of certain
The agency said it will open past re- cardiac defibrillators, information about the types of problems.
cords to the public within weeks. pacemakers and tooth devices they are going to Going forward,
A Kaiser Health News investigation implants. The FDA has put in their body.” devicemakers will
in March revealed that the obscure pro- said the program was be required to file
gram was vast, collecting 1.1 million re- originally designed to Dr. S. Lori Brown individual reports
Former FDA official
ports since 2016. The program, which allow for more efficient describing each
began about 20 years ago, was so lit- internal review of well- case of patient
tle-known that forensic medical device known risks. harm related to a medical device.
experts and even a recent FDA commis- The agency said it began winding The FDA has not said it will stop allow-
sioner were unaware of its existence. down the program in mid-2017, revok- ing devicemakers to file other types of
Former FDA official S. Lori Brown ing many reporting exemptions, includ- device-harm exemption reports that are
called ending the program a “victory for ing those for saline breast implants and withheld from the public, such as when
patients and consumers.” for balloon pumps used inside patients’ there is mass litigation over a device or
“The No. 1 job of the FDA—it blood vessels. At that point, the agency when a company is submitting reports
shouldn’t be ‘buyer beware’—is to have required devicemakers with ongoing from an independent device-tracking
the information available to people so exemptions to file quarterly reports in registry. Nor has a plan been announced
they can have information about the de- its public device-harm database known to open those records, which contain re-
vices they are going to put in their body,” as MAUDE, short for the Manufacturer ports of harm related to pelvic mesh and
Brown said. and User Facility Device Experience. surgical robots and reports of deaths re-
FDA Principal Deputy Commissioner Still, FDA data provided to Kaiser lated to several cardiac devices.
Dr. Amy Abernethy and device center Health News shows that during the first The FDA had granted Covidien, now
Director Dr. Jeff Shuren announced the nine months of 2018 the FDA contin- a division of Medtronic, a long-standing
decision in a statement on increasing ued to accept more than 190,000 injury “alternative summary reporting” exemp-
transparency about the safety of breast reports and 45,000 malfunction reports tion for its surgical staplers.
implants. Makers of breast implants under the “alternative summary report- In 2016, when just 84 reports of sta-
for years were allowed ing” program. pler-related harm were disclosed in the
to report hundreds of Ronni Solomon, chief pol- FDA’s MAUDE database, almost 10,000
thousands of injuries THE TAKEAWAY icy officer of the ECRI Insti- more malfunction reports were sent di-
and malfunctions out of The FDA is shutting tute, which studies device rectly to the FDA’s in-house database,
the public eye, federal re- down its “alternative safety, said its staff uses the the agency acknowledged. The device
cords show. summary reporting” FDA’s open data on a daily has been subject to numerous lawsuits
“We believe these program and ending basis to look for signals that over patient deaths and grave harm. 
steps for more transpar- a decadeslong might show heightened risks
ent medical device re- practice of allowing with a particular device. Kaiser Health News is a national health
ports will contribute to devicemakers to “We think it’s really vital for policy news service. It is an editorially
conceal reports
greater public awareness the sake of transparency, for independent program of the Henry J.
of harm and
of breast implant ad- malfunctions. the sake of policy, for sake of Kaiser Family Foundation, which is not
verse events,” Abernethy science,” she said. “We’re re- affiliated with Kaiser Permanente.

8 Modern Healthcare | May 6, 2019

Behavioral health
Walgreens offers The Walgreens partnership is the
first collaboration of its kind with one
who complete Mental Health First Aid
training and worked with the National
pharmacists of the country’s giant retail pharmacy
chains.
Council for Behavioral Health to devel-
op a course for pharmacists.
first aid for The National Community Pharma-
cists Association, the leading orga-
An estimated 43 million American
adults experience a mental illness in a
mental health nization representing independent
pharmacies, also offers continuing
given year, but only 41% receive mental
health services, according to the Na-

training education credits to all pharmacists tional Alliance on Mental Illness. l

By Steven Ross Johnson

WALGREENS BOOTS ALLIANCE

launched a training program for phar-
macists to learn how to better identify
warning signs of mental health and
substance use problems in their pa-
tients and help them during crisis sit-
uations.
The retailer partnered with the Amer-
ican Pharmacists Association and the
National Council for Behavioral Health
to create an online version of the Mental
Health First Aid program, which was de-
veloped in 2001 in Australia to provide
individuals who weren’t clinicians with
strategies to help someone experiencing
a mental health crisis.
The National Council for Behavioral
Health, Maryland Department of Health
and Mental Hygiene, and Missouri De-
partment of Mental Health oversee the
program in the U.S.
“With the growing need for services
and resources to help those living with
mental health conditions, as well as
substance use and addiction, we can
play an important role by giving our
pharmacists and certain team mem-
bers the training to help those in crisis,”
said Alex Gourlay, Walgreens’ co-chief
operating officer, said in a statement.
In addition to pharmacists, up to 300
staffers in Walgreens’ human resourc-
es department will undergo training to
help them address mental health and
substance abuse issues among their
co-workers.
A Walgreens spokesman said a small
percentage of the company’s more
than 27,000 pharmacists will undergo
training initially, with plans to make it
available companywide and then in-
dustrywide to give any pharmacist an
opportunity to earn continuing educa-
tion credits.

May 6, 2019 | Modern Healthcare 9

Finance

Acquisitions boost
bottom lines for
Cigna, CVS Health
Earnings for the three months ended March 31
compared with the same period in 2018.

Cigna Corp. | Hartford, Conn. CVS Health | Woonsocket, R.I.

THE NUMBERS THE NUMBERS

$37.9 billion Revenue, up 232% $61.6 billion Revenue, up 34.8%

$1.4 billion Net income, up 49.6%
$9.2 billion Revenue from integrated medical business
(Medicare and employer-sponsored plans),
up 12.8%
$26.9 billion Revenue from Express Scripts’ PBM and
Cigna’s home drug delivery, up from $1.1 billion
78.9% Medical care ratio, up from 77.5%
TAKEAWAY Revenue and profit soared as Cigna
benefited from its takeover of pharmacy benefit manager
Express Scripts. Most new revenue was concentrated
in Cigna’s health services segment, which consists of
Express Scripts’ PBM services and Cigna’s legacy home
delivery pharmacy operations. —Shelby Livingston
$33.6 billion Revenue for the PBM business, up 3.1%
$21.1 billion Retail revenue, up 3.3%
$17.9 billion Revenue for new insurance line,
which includes Aetna
26.9% Increase over Q4 in Medicare Advantage
membership
TAKEAWAY CVS Health is beginning to see gains from
its acquisition of health insurer Aetna. CVS’ revenue
spiked and the company’s pharmacies are filling more
prescriptions. In total, CVS said the Aetna deal helped
boost its net income by 43% to $1.4 billion over the same
period a year ago. —Shelby Livingston

Healthy times for health insurers

The big eight publicly traded insurers boasted strong Q1 financial results. Combined, they made $9.3 billion in profit, up about
30% over Q1 2018.
Insurer earnings results, Q1 2018 compared with Q1 2019
NET INCOME ($ IN MILLIONS) REVENUE ($ IN MILLIONS)
COMPANY 2019 Q1 % change from 2018 Q1 2019 Q1 % change from 2018 Q1
Anthem $1,551.0 18.2% $24,666 9.4%
Centene Corp. 519.0 53.6 18,444 39.8
Cigna Corp. 1,372.0 49.6 37,946 232.5
CVS Health 1,427.0 43 61,646 34.8
Humana 566.0 15.3 16,107 12.8
Molina Healthcare 198.0 85 4,119 -11.3
WellCare Health Plans 151.4 48.9 6,762 45.5
UnitedHealth Group 3,557.0 21.6 60,308 9.3
TOTALS 9,341.4 29.9 229,998 34
Sources: Companies’ first-quarter earnings news releases, Securities and Exchange Commision filings

10 Modern Healthcare | May 6, 2019

EXECUTIVE INSIGHT

Finally, an Answer to the Physician Burnout Epidemic

The Greeley Company’s breakthrough approach to diagnosing and treating physician burnout
Richard Sheff, MD
Chief Medical Officer
The Greeley Company

Physician burnout is an epidemic, and would cause a dramatic rise in burnout. Some of the answers
like most epidemics, there isn’t one simple were surprising and led to new and creative solutions.
solution. In recent years The Greeley Company has
been working on a realistic, practical approach to What can you share about Greeley’s diagnosis and
physician burnout. This effort, led by Dr. Rick Sheff, treatment for physician burnout?
Greeley’s Chief Medical Officer, has now produced a
RS: We have developed an action plan for organizations to
unique diagnosis and treatment plan for turning around
better understand and immediately address the multifactorial
the physician burnout epidemic. causes of physician burnout, and practical ways to help turn It
Why should hospitals, healthcare systems, and around. The diagnosis looks at what’s changed in recent years
physician groups invest in addressing physician that is causing epidemic rates of physician burnout through
burnout? five different diagnostic lenses. These led us to develop a
roadmap with eight interrelated work streams that are needed
RS: The imperatives to succeed in today’s healthcare to meaningfully impact burnout.
industry are to improve quality and reduce costs. These
goals can’t be achieved if physicians and clinicians are How can organizations start taking steps towards
burning out. A recent report in Medscape found that 44% resolving physician burnout?
of physicians reported at least one symptom of burnout in
2019. The proportion of physicians screening positive for RS: There is an overwhelming need to enhance integration and
depression continued to rise to almost 42%, and the rate connectedness among physicians. All too often finding a shared
of suicide and depression in doctors is more than twice purpose, or ‘Why’ is difficult due to a history of conflict and low
the general population. This equates to more than one levels of trust, especially between physicians and hospitals/
medical school graduating class a year dying from suicide, healthcare systems. If this describes your organization, I
a grim reminder of one of the most devastating impacts of encourage you to take active steps to build a foundation for
burnout. There is a return on investment for addressing collaboration going forward. Getting called into and turning
physician burnout, and it’s also the right thing to do. around these situations is some of the most gratifying work we
What are the leading drivers of physician do at Greeley.
burnout? If you are serious about moving the needle on physician
burnout, we are providing a free live webinar on May 23rd to
RS: First, there is emotional exhaustion that often leads to
share Greeley’s diagnosis and treatment for physician burnout.
depersonalization, when physicians are unable to connect
We are also hosting two, one-day educational programs later
with their patients and develop a negative attitude. The
this year as part of Greeley’s Physician and Hospital Leadership
added stress and unaccounted time required to integrate
national education seminar. Additional details can be found
the electronic health record (EHR) with patient care
under Resources at Greeley.com.
pulls physicians and clinicians away from the gratification
of direct patient interaction. Physicians feel their work
with patients is being reduced to a set of metrics, usually
metrics they feel don’t reflect the quality and value of their
work. Finally, physicians are experiencing a growing sense of
“dis-integration”, meaning they no longer feel connected to This Executive Insight was
their fellow physicians or organization. Ultimately, burnout is a produced and brought to you by:
symptom of a broken healthcare system.
How did Greeley develop a unique approach to
physician burnout?
RS: We began by using the medical model. You can’t
know how to treat a condition until you’ve made the
correct diagnosis. We used Greeley’s vast experience with
hundreds of hospitals and physician organizations as well
as our engagement with thousands of physicians to think To learn more about The Greeley Company,
outside the box. Knowing physicians have always worked
hard, we asked what’s really changed in recent years that
visit https://greeley.com/
 SPONSORED CONT ENT

A N EXEC U T IVE DISC U SSIO N

Making Your Health System Age-Friendly

How providers are innovating to address the
unique needs of older adults

PANELISTS
MODERATOR
MODERATOR

PANELISTS

Terry Fulmer, PhD, Gary Baker Natalya Faynboym, MD, CPE Kedar Mate, MD Brian Peters
RN, FAAN Regional Hospital Executive Director for Chief Innovation & Chief Executive Officer
President Senior VP/CEO Innovation – Affordability Education Officer Michigan Health &
The John A. Hartford HonorHealth and Medicare Advantage Institute for Healthcare Hospital Association
Foundation Banner Health Improvement

H
ealth systems must adopt evidence-based models and practices in delivering care that
meets the needs of our aging population across the continuum. Older adults want care
that is effective and affordable, and they increasingly expect that the healthcare they
receive will align with their own goals and preferences. They don’t want to break their
bank—or the nation’s—to get the care they expect.
Terry Fulmer, president of The John A. Hartford Foundation, sat down with four healthcare
leaders at Modern Healthcare’s 2019 Leadership Symposium to discuss how health systems are
finding new ways to care for older adults, exploring best practices, innovations and challenges.

TERRY FULMER: How big of an impact is the aging
population having on your institutional planning?
What are your challenges? Given that this population
will continue to grow, what changes are you currently
making in order to continue delivering high-quality care?
BRIAN PETERS: For us, we view the opportunity to
improve care for the aging population as perhaps our
greatest opportunity. In Michigan, two out of every 10
folks in our state is over the age of 65. That is a number
that is rapidly increasing. Several years ago, we looked at
the demographic reality in our state and understood that
the traditional model of care delivery wasn’t serving that
population very well.
One of the things we did was join AARP, AHA
and others in being a founding member of the Root
Cause Coalition — which recognizes that the social
determinants of health that affect a broad swath of our
population in Michigan impact the elderly population
much more significantly, especially in their ability to
follow up on their care.
Our hospitals have also tried to get away from using the
term “discharge,” because it implies that our job is done
when patients leave the hospital. Instead, we’re using the
term “handoff,” because we want to hand off that care to
navigators and organizations that can help.
 SPONSORED CONT ENT

NATALYA FAYNBOYM: We have created

independent innovation hubs to look
specifically at older adults’ care in Medicare
Advantage as well as in our ACO. We’re looking
at care transitions from a care management
perspective. Our healthcare navigators make
house visits, but we also look at behavioral
health and what mental health may mean for
older adults.
For example, our older patients usually
put their best clothes on when they go to the
physician and they usually don’t tell their
primary care doctor what’s going on in their
heads. And if they do, they’re not ‘depressed,’
they’re blue. So, we’ve enabled our providers to have
a more transparent conversation by allowing patients
to connect with a health coach, a psychologist or even
a psychiatrist as needed during their primary care
appointment. For a lot of our older patients, it has helped
to take the stigma away from mental and behavioral health
issues.
And we’re not just thinking of the patient; we’ve also
come to realize the role of family caregivers, especially
those who have challenging situations at home. Maybe
it’s Alzheimer’s, maybe it’s another kind of decline. We
as a healthcare system — and maybe even nationally
— have been dropping the ball on this silent, secondary
population. So, we’re also looking at how we can provide
care for the caregiver, as well.
GARY BAKER: We’re able to use focus groups of seniors
to understand their needs, and we’ve found that what
they need most is patient navigation. They need help
navigating this complex medical system and their day-to-
day challenges. So, we have health coaches that are very
proactive and reach out with home visits. They conduct
home evaluations and check for a safe environment
and really help educate people about things, such as
explaining that if you fall, you may not return to normal
activity. So, let’s do everything we can in your home.
Our model is a clinically integrated network. That has
allowed us to come together and develop care protocols
with independent practices for the best care of certain
disease states and populations. We integrate that into our
ACO strategy in terms of providing value to the insurance
market as well as providing opportunities for stickiness
within our patient population.
We’re also doing some work in the end-of-life space —
both inpatient and outpatient coordinated palliative care
services — and meeting patients’ unmet social needs.
KEDAR MATE: At IHI, we’re increasingly seeing interest
in the quality of care for older adults amongst the systems
we work with. And, what’s interesting about this work is
that I’ve yet to encounter someone who hasn’t had a family
member, a friend, a close colleague — who’s over the age
of 65 that’s had a challenging experience with the health
system. Some form of discoordination has occurred, and
that’s led them back to the hospital or to some unfortunate
outcome. I think we all recognize that we can do better.
The good news is that there’s good evidence around
how to improve care for older adults. But the translation
of that knowledge into practice to reach every older adult
reliably every time is a persistent, common challenge. We
have pockets of excellent programs that impact some older
adults, maybe a couple hundred thousand people. But
there are 46 million older adults in the country and many
are not getting that same level of attentive care.
So, together with The John A. Hartford Foundation,
we’ve been studying how to deliver better care for older
adults. We began by working with experts in geriatric care
and five major health systems. That effort resulted in the
creation of the Age-Friendly Health Systems initiative
which is guided by four primary principles: understanding
what matters to older adults and their families — that
has everything to do with navigation, goals of care, family
caregiving and many of the themes that you all raised —
“We’re not just thinking of the patient;
we’ve also come to realize the role of
family caregivers, especially those who
have challenging situations at home…
we as a healthcare system — and maybe
even nationally — have been dropping the
ball on this silent, secondary population.”
Natalya Faynboym, MD, CPE | Executive Director
for Innovation – Affordability and Medicare
Advantage, Banner Health
 SPONSORED CONT ENT
“Payment reform is going to drive more
innovation. We’ve seen it time and again.”
Gary Baker | Regional Hospital Senior VP/CEO,
HonorHealth
emphasizing mobility, focusing on medications, and paying
attention to mentation, including depression, dementia
and delirium.
For these four things, we’ve identified the practices that
would be really useful, and we’ve started to scale that
around the country to more than 100 systems.
TF: At The John A. Hartford Foundation, we look to
improve care for older adults by creating age-friendly health
systems, improving serious illness and end-of-life care,
and supporting family caregivers — things that you’ve all
touched on so far. For 30 years, we’ve curated experts
and models of care, but we also struggle with the issue of
reliability and appropriate dissemination of those evidence-
based models. Do our panelists have any thoughts on how
this can be better approached? In what areas do you seek
partners to help put evidence into practice?
GB: I think there’s great opportunity for partnership in the
space of medication management and raising awareness
in the general population of polypharmacy — the benefits
as well as potential risks of simultaneous use of multiple
drugs to treat a single ailment or condition. We see that as
an intervention we’ve been able to make.
NF: Proper medications and medication reconciliation
are incredibly important. For example, in care transitions,
medications may change from acute setting to post-acute
setting to home. Unless you know with 100% certainty
what they have at home, sometimes there may be
duplications or other challenges. We know that more often
than not readmissions happen around seven to 10 days
post-discharge because of medication errors. That makes
patient education and coordination crucial, as older adults
are also seeing multiple outpatient providers that need an
accurate medication list.
KM: These things build on each other. Medications can
inhibit mobility and precipitate falls or lead to problems
with mentation, like with delirium. One thing we’ve
thought a lot about is simplification — getting these
evidence-based models down to simpler principles that are
easier to follow.
BP: One challenge for an organization like ours is the
ability to get the word out about successful interventions
and scaling them for systems of different sizes. Another
challenge is that often providers don’t have the full picture
of the patient. Our members know what happens inside
the four walls of their institutions, but they may not have
the complete picture of what happens to that individual
out in the rest of the care continuum.
TF: We like to say that an age-friendly health system starts
and ends at your kitchen table as you transition through
primary care, the emergency department, the rehabilitation
facility, or a nursing home. We know we have tremendous
challenges in continuity of care across settings. Do you see
broader shifts happening that can help spread better care
and better practice to our older adults?
GB: Payment reform is going to drive more innovation.
We’ve seen it time and again. Investments in IT that offer
caregivers relevant information can also help disseminate
best practices.
NF: When you take full risk with a Medicare Advantage or
similar plan, it really allows you to concentrate more on
prevention and social determinants of health and allows
for better care coordination to happen.
 SPONSORED CONT ENT

BP: I think it’s critically important to keep in mind the

public policy domain as well. Medicare and Medicaid
policy will have so much to do with how successful we
can be going forward.
TF: Do you think there is a business case that could
be made for delivering more effective, higher quality
services to older adults, even within the four walls of an
institution?
“Our members know what happens inside
the four walls of their institutions, but they
may not have the complete picture of what
happens to that individual out in the rest of
the care continuum.”
Brian Peters | Chief Executive Officer,
Michigan Health & Hospital Association

GB: Well, it’s certainly a focus and a goal currently.

I influence more within my four walls than I do with
what’s happening in the community and patients’ homes.
We actually look to partner with practices that will help
us through the continuum, even to the point where groups
have now incorporated home visits into their model, which
is a throwback to the house calls of the past. We justify it
with the need to keep the patient safe and healthy, while
preventing avoidable readmissions. I’m encouraged by the
entrepreneurial spirit, and that typically is generated by
alignment with health plans willing to recognize and value
that kind of model for the practices.
KM: We all recognize that if we get to continuum-based
care, that would be terrific. The cost of coordination is
enormous, so the benefit has to overcome that cost. But
the hypothesis we have is that there’s probably sufficient
value that you can obtain even from a fairly narrowly
defined perspective around an institution getting better
value out of the services that they offer to older adults.
BP: We operate a federally certified patient safety
organization (PSO), so we’ve been in the business of
collecting adverse event data for the last eight, nine
years. Since the inception of our PSO, the number one
most frequently reported adverse event is patient falls,
and the overwhelming number of those patient falls
affect the elderly population. There’s a great opportunity
for improvement in that space, and there’s certainly
a business case, as falls have a significant impact on
providers from both a quality and financial perspective.
NF: From a hospital perspective, we’re putting resources
toward prevention of delirium. We’re also putting in
resources to encourage early mobility on general medicine
and telemetry floors — not just in the ICU — because it
has the potential to help you run a much more efficient
admission. That prevents readmissions and potentially
prevents the need for a post-acute stay and additional
complications, and that can potentially shorten length
of stay for that patient. Overall, that creates a better
experience for the patient as well as, I suspect, the
hospital.
KM: It’s hard to imagine that we won’t also be somewhat
motivated intrinsically. Even if there are external
motivators like incentive payments, or disincentives, or
certifications, I think we’ll always have some form of inner
motivation, because we can think about our parent, our
spouse, or ourselves who need age-friendly care.
TF: Thank you everyone for your perspectives on how to
drive improvement in care for older adults.

About The John A. Hartford Foundation

The John A. Hartford Foundation, based in New York City, is a private, nonpartisan, national philanthropy
dedicated to improving the care of older adults. The leader in the field of aging and health, the Foundation has
three priority areas: creating age-friendly health systems, supporting family caregivers, and improving serious
illness and end-of-life care. For more information, visit johnahartford.org.

Produced by
 InDepth Medical Education

Dr. Bonita
Stanton,
dean of the
Hackensack
Meridian
School of
Medicine at
Seton Hall
University, at
a community
event with
medical
students last
year.

Say goodbye to the old ways:

Medical schools overhaul curriculum
to better prepare future docs
By Maria Castellucci

B ROOKE WAGEN DIDN’T HAVE a typical third-

year medical school experience.
Instead of going through the clinical rotations
students usually are exposed to, Wagen spent the
year interviewing elderly residents who lived in the housing
developments close to her home in Austin, Texas.
Wagen talked to 30 residents over age 65 to try to under-
stand how they viewed their health and social situation.
“I always passed by these older adults who made me cu-
rious and made me want to know more and do more. Now
I have gotten the amazing privilege of getting to interview
some of them.”
Wagen’s yearlong qualitative research study was part of a
unique curriculum approach at Dell Medical School at the

16 Modern Healthcare | May 6, 2019

University of Texas at Austin that flips the traditional third-
year experience on its head.
The school, which welcomed its first class in 2016, encour-
ages students to spend a so-called growth year taking what
they have learned so far and pursuing a passion focused on
health. Students can pick research, population health, de-
sign, entrepreneurship or a dual degree like engineering or
business administration. The goal is to build a pipeline of
doctors who want to be agents for change.
“We try to emphasize there are major issues around
health and health systems,” said Dr. Clay Johnston, dean of
Dell Medical School. “We are trying to create a cadre that
is actually driving changes to ensure our health system is
better aligned with society’s interest and people’s interest.
Right now, that is missing. The changes are being done to
the system and not for the system.”
Wagen, who chose to pursue population health, said her
growth year experience taught her the importance of lis-
tening to patients’ needs and challenges.
“I’m going to have a voice as a physician to continue to
advocate for my patients,” she said.
Dell Medical School is one of a growing number of in-
stitutions reimagining the traditional medical education
curriculum. Leaders are throwing out
long-held practices in hopes of creating a
pipeline of doctors armed with skills typ-
ically not learned until years in the pro-
“We give the
fession, if ever. The end goal is to have a message to our
workforce of physicians who are innova- students that
tive and patient-centered, concepts that
traditional medical education doesn’t pro-
their mission is
mote very well. to serve.”
“When I was in medical school, I did
Dr. Steven Scheinman
10 weeks of obstetrics. I delivered six ba- Dean of the Geisinger
bies. It’s one of the highlights of medical Commonwealth School
school, but I never saw the women again. of Medicine
The message there wasn’t that I was here
to serve the patient, you were here to de-
liver the baby,” said Dr. Steven Scheinman, president and
dean of Geisinger Commonwealth School of Medicine,
Scranton, Pa.
Virtually all U.S. medical schools have modified their
curriculums, but the extent of changes vary, said Dr. Susan
Skochelak, group vice president of medical education at the
American Medical Association.
Generally, newer medical schools are more easily able to
take an entirely innovative approach to the curriculum, but
Skochelak said there are legacy schools that have done it too.
The AMA has been a vocal advocate for revamping med-
ical education through its Accelerating Change in Medical
Education Consortium. The initiative, which launched in
2013, currently involves 37 schools that have received a total
of $14.1 million in grants to develop new curricula at their in-
stitutions. (See p. 32 for a Q&A with the AMA’s CEO.)
That’s not to say there aren’t those resistant to changing
medical education. When leaders at Sidney Kimmel Medi-
cal College at Thomas Jefferson University in Philadelphia
started to consider overhauling the curriculum in 2015, the
faculty was skeptical.
“There was a lot of faculty who had cause to wonder, ‘Why
make a change if it’s working?’ ” said Dr. Steven Herrine, vice
dean for undergraduate medical education at the college.
The leadership did “a lot of ground work” with the faculty
to get their support, he said. Meetings were held to discuss
the plans and involve them in the changes.
“There has been tremendous buy-in from both the sci-
ence and clinical faculty; it’s extremely gratifying,” Herrine
said. The school officially changed its curriculum in 2017.
Modern Healthcare spoke with officials from six med-
ical schools to understand how they addressed some of
the shortcomings in traditional medical education that
ultimately leave future doctors ill-equipped for the rapidly
changing healthcare landscape. The schools—four rela-
tively new and two with long histories—took different ap-
proaches to their curriculum changes but share common
principles aimed at ensuring that today’s students will be-
come better doctors of tomorrow.
Addressing the social determinants of health
Ensuring students understand that patients face unique
personal and social challenges that influence their health
has become a key component of medical education for
some schools.
Geisinger Commonwealth School of
Medicine—which opened 10 years ago
as the Commonwealth Medical College
and was acquired in 2016 by Geisinger
Health—requires students to complete
100 hours of community service before
they graduate.
“We give the message to our students
that their mission is to serve,” Schein-
man said.
Cecelia Strauch, a second-year student
at Geisinger, has already completed her re-
quired hours of service but still volunteers
with the National Court Appointed Spe-
cial Advocate Association, an organization that advocates
for children who experienced abuse or neglect in foster care.
“Working so closely with a family that is going through
so much turmoil and socio-economic crisis, it’s a humbling
experience. It gives me a new perspective, a really in-depth
look at the kinds of challenges that people from these back-
grounds experience,” Strauch said.
Geisinger also sets up students during their first year
with a patient who has a chronic condition. The student,
along with another classmate, follow that patient to their
appointments and visit them at their home throughout
medical school.
The objective is for students to witness firsthand the
challenges of living with a chronic disease and how social
conditions impact following a care plan. It mirrors the em-
phasis many payers and providers are starting to put to-
ward addressing social determinants.
Hackensack Meridian School of Medicine at Seton Hall
University implemented a similar approach. The school,
which opened just last year in Nutley, N.J., with a class of 60,
introduces students to multiple families who they will fol-
May 6, 2019 | Modern Healthcare 17
The diversity challenge
From free tuition to a more holistic review of applicants,
medicals schools are looking for ways to boost the
diversity of their student populations. Read the whole story
at ModernHealthcare.com/MedSchoolDiversity.
U.S. medical school enrollment, 2018-19
Percentage listed as minority and/or Hispanic, Latino
low throughout their time at school. Students ask questions
about barriers the families face in healthy eating or going to
see their doctors.
Additionally, students need to advocate for ways to help
the family address those challenges.
“We want our students to recognize that whenever they
are seeing the patient they must be thinking of the commu-
nity from which the patient comes,” said Dr. Bonita Stan-
ton, founding dean of the school.

AK ME
Exposing students to the clinic sooner
Some schools are exposing students to clinical experi-
VT NH ences earlier so they can better apply classroom teachings.
“Medical students learn best when they learn the basic
WA MT ND MN WI MI NY MA RI sciences along with the clinical approach. It’s hard to say
ID WY SD IA IL IN OH PA NJ CT you need to memorize this if you don’t know there is a clin-
ical application for it or a clinical need,” said Dr. Sue Cox,
OR NV CO NE MO KY WV MD DE DC executive vice dean of academics at Dell Medical School.
Students at Dell get introduced to their clinical clerkship
CA AZ UT KS AR TN VA NC in their second year at the school instead of the third year.
NM OK LA MS AL SC All of the clinical blocks last eight weeks except for primary
care, which goes on every week for two years.
TX GA Since there is a primary-care shortage in Austin, the
hope is more students will be interested in pursuing that as
HI FL
a specialty if they are given longer exposure to it, said Dr.
Elizabeth Jacobs, a professor of internal medicine and pop-
0 up to 25% 25% up to 50% 50% up to 75% ulation health at Dell.
“We wanted to make sure students could see the value of
75% or more No data
primary care, which is hard to see if you just spend a month
doing it,” she said.
Top five/bottom five diverse enrollments
Each student is set up in a local federally qualified health
For graduate medical schools, by 2018-19 enrollment
center or community clinic where a physician has agreed
Top five to mentor the student, allowing them to sit in on clinical
Percentage Percentage visits and ask questions.
School Enrollment white alone minority
Charles R. Drew/UCLA
For third-year Dell student Anatoli Berezovsky, the expe-
Medical Education Program 133 0.0% 100.0% rience has solidified his intent to pursue family medicine
Howard University instead of oncology, his initial choice for a specialty. “It was
College of Medicine 510 3.1 96.9 cool for me to see that family medicine is more than just
Meharry Medical College 476 4.8 95.2 diabetes and high blood pressure—you can help your pa-
Morehouse School tients in other ways,” he said.
of Medicine 387 9.3 90.7 Hackensack Meridian also hastened when students are
University of Hawaii, exposed to clinical experiences, but with a slightly different
John A. Burns School twist—offering an option to graduate in three years instead
of Medicine 290 12.4 87.6
of the traditional four.
Bottom five Like Dell, Hackensack Meridian students begin their
Percentage Percentage
School Enrollment white alone minority clinical clerkships in their second year.
University of South Stanton said the three-year graduation has a dual ben-
Dakota, Sanford efit: to reduce education debt and entice more students to
School of Medicine 275 92.0% 8.0% pursue residency at the affiliated health system, Hacken-
University of Minnesota sack Meridian Health. New Jersey, like many states, is fac-
Medical School, Duluth 70 81.4 18.6
ing a shortage of physicians.
University of Nebraska The idea is that the students will be interested in staying
College of Medicine 542 80.8 19.2
at Hackensack’s health system, which has 13 hospitals, for
Louisiana State University
School of Medicine residency because they are familiar with the organization.
in Shreveport 521 79.7 20.3 Third-year graduating students also won’t have as much
University of North time to seek out many other residency options. A big chunk
Dakota School of Medicine of the fourth year is usually dedicated to that time-con-
Health Sciences 310 79.4 20.6 suming, stressful process.
Source: Association of American Medical Colleges “We feel that the students who are going to do a residency

18 Modern Healthcare | May 6, 2019


Carla Van Den Berg, program here in New Jersey will be
standing center, more likely to stay in New Jersey to
co-director of the
developmental practice medicine,” Stanton added.
therapeutics lab at Some medical schools are offering
Dell Medical School, courses that go beyond medicine.
leads a physiology The doctors of the future will need
discussion group with
first-year students. “other tools” in their bag, said Dr.
Bon Ku, assistant dean at Sidney
Kimmel Medical College.
The medical school implemented a
component called the scholarly inqui-
ry track in which students select one of “We need
eight disciplines they are going to pursue
throughout the four years separate from doctors who not
medicine, such as population health re- only have the
search and digital health.
One of the disciplines, design, teaches
technical skills
students to flex a muscle they don’t usually but also who
get to in medical school: creativity. can be creative.”
“There is an under-representation for the
skill of creativity in medicine,” Ku said. “We Dr. Bon Ku
need doctors who not only have the techni- Assistant dean at the Sidney
Kimmel Medical College at
cal skills but also who can be creative.” Thomas Jefferson University
Students choose the track they want to
pursue in their first year and about 25 stu-
dents per class are in the design track. They learn design
principles like architecture and systems engineering and
then how to apply them to common problems in healthcare.
For Terry Gao, a third-year student at Sidney Kimmel,
involvement with the design program led her to the Phil-
adelphia neighborhood of Kensington where she—along
with other students—interviewed residents about the so-
cio-economic factors that affect their overall health.
Gao said it changed her view about interacting with pa-
tients, saying, “It’s not enough for me to say you need to eat
healthier. For me, that means something different than for
someone who comes from Kensington.”
She’s now working on a series of initiatives in the neigh-
borhood through the school including offering health
screenings and cooking classes for food-insecure residents.
Applied learning
At Rush Medical College at Rush University in Chicago,
students don’t sit in large halls with a professor lecturing
for hours. Instead, students watch lectures on their own
time—usually via video—and come to class prepared to
work with their peers on a clinical
case study that applies the lec-
ture’s concept.
The idea—dubbed a “flipped class-
room”—comes from literature that
shows lectures are usually an inef-
fective way to retain important con-
cepts, said Ranga Krishnan, dean of
the college.
“It has been shown in well-done
studies that lectures don’t work if
you don’t use the material,” Krish-
nan said. He led the conversion of
the school to a flipped-classroom model in 2017.
Some faculty were initially skeptical. It required them to
change how they spend time with students in the classroom
and to video-record their lectures. Rush brought in content
creation experts to help the professors redesign their lectures
so they would be engaging for students to watch at home.
Krishnan said faculty came around once they saw how
much it improved student engagement in the material.
Kaiser Permanente School of Medicine, which will open
to its first class of students in the summer
of 2020, will be using a similar approach.
Rather than lectures, classes will focus
on case studies designed by Kaiser that in-
tegrate many concepts like health systems
science, the role of the physician as an ad-
vocate, social determinants of health, and
costs along with the clinical concepts.
“They will understand the continuum
of what matters,” said Dr. Mark Schuster,
founding dean of the school.
Heading off burnout
Surveys show that burnout, which
affects roughly half of U.S. physicians,
starts in medical school. Institutions are
starting to give students the tools to handle it early on.
For example, at Kaiser Permanente School of Medicine,
each student will be assigned a physician mentor who will
check in with them every few weeks to see how they are
getting along with classes and the curriculum. The rela-
tionship is meant to prevent students from falling behind
academically.
“It can be emotionally challenging to be working with pa-
tients and brought into their lives so intimately,” Schuster
said. “So we want them to be well supported.”
Kaiser also plans to offer cooking and art classes to help
the students relieve stress.
In addition to providing counseling services like many
schools do, Sidney Kimmel Medical College has an aspect of
its new curriculum dedicated to practitioner wellness. First-
year students also engage in a week where the importance of
wellness is highlighted, Herrine said.
“Medical school is hard, the responsibility to take care of
people’s health is enormous, and that needs to be taken se-
riously; that said, we also need to look after our own health,”
he said. l
May 6, 2019 | Modern Healthcare 19
 InDepth Medical Education

Cost of graduate medical

education stifling ability to
bolster physician workforce

N
EMILY OLSE

Students at Rush Medical College

celebrate Match Day 2019.

20 Modern Healthcare | May 6, 2019

By Steven Ross Johnson

F OR PROVIDERS like UMass Memorial Health

Care, the dearth of active physicians within the
workforce has forced the organization to increas-
ingly rely on physicians-in-training to address the
health needs of their patients. The Worcester, Mass.-based
system currently employs around 570 physician residents.
“We wouldn’t be able to take care of the patients that we
included in higher rates they pay to teaching hospitals,
making it difficult to quantify how much funding they ac-
tually provide. But recent signs indicate commercial insur-
ers are taking steps to avoid the higher prices that teaching
hospitals can charge by encouraging patients to seek care
in other clinical settings such as outpatient clinics.
Some of the measures payers have used include requir-
have” without residents, said Dr. Deborah DeMarco, senior ing prior authorization for certain services performed at
associate dean for clinical affairs and associate dean of hospitals, as well as negotiating lower prices and exclusive
graduate medical education at the University of Massachu- contracts with certain hospitals while excluding providers
setts Medical School. “The residents are whose costs for services are deemed too
a tremendous workforce, and you would high.
have to fill those positions with midlevel With limits Medicare provides teaching hospitals
providers that you can’t find, like nurse with two types of payments for GME. Direct
practitioners and physician assistants.” to how many graduate medical education payments cov-
Yet the number of physician residents GME slots er such things as residents’ salaries, while
at UMass has not substantially increased Medicare indirect medical education payments are
over the years despite growing demand for intended to cover the higher costs of treat-
their services. DeMarco said a major barri-
will cover, ing sicker patients who visit such facilities.
er has been the costs involved in training hospitals find Medicare GME funding is calculated
physicians, which she said have increased themselves through a formula based in part on the
over the years as the health system has had
to take on more of the cost of training resi-
taking on number of Medicare inpatients a teach-
ing hospital receives. The way Medicare
dents to meet workforce demands. a growing counts residency positions at a teaching
In 2018, total expenditures for GME cost percentage of hospital means a physician who begins a
UMass Memorial more than $215 million the burden. three-year residency takes up three resi-
to train 525 residents, according to figures dency slots to complete his or her training.
provided by the system. Medicare reim- To curtail Medicare spending, the Bal-
bursed more than $84 million of those costs, leaving a bud- anced Budget Act of 1997 kept the number of medical
get shortfall of $130 million. residents for existing teaching hospitals at 1996 levels. An ex-
With limits on how many GME slots Medicare will cover, ception was made in 1999 to fund more slots at rural teach-
hospitals find themselves taking on a growing percentage ing hospitals. But for the majority of the more than 1,100
of the burden to fund their GME programs. That has forced teaching hospitals in the U.S., residency positions have been
those providers to make some difficult business decisions. relatively unchanged for more than two decades.
Stakeholders say it’s time to revamp what they deem an out- Last year saw a record 19,553 students graduate from med-
dated governmental financing formula in order to meet the ical school, an 18% increase from 2009. Subsequently, there
steady rise in medical school enrollment and ease the bot- was a rise in graduates applying for residency positions in
tleneck in the doctor pipeline that’s limiting the number of 2019—38,300 compared with 33,167 in 2018. But due to lim-
physicians entering the workforce. itations in the number of available posts, more than 3,100 ap-
plicants were left without a residency slot in 2019.
Funding GME Still, 95% of residency positions were filled in 2019, about
Most costs that hospitals incur for training
physicians are reimbursed by the federal gov-
ernment through Medicare, which made up 71% GME positions not keeping pace
of GME government funding in 2015 at $10.3 bil-
lion, according to the most recent data from the Medicare spending overall and spending on graduate medical education
Government Accountability Office. have risen dramatically since 2001; the cap on GME residents has not.
Other sources include Medicaid, which paid Percentage change, 2001-16
approximately $2.4 billion, followed by $1.5 bil-
lion through the Veterans Affairs Department.
HHS earmarked another $248 million for GME Total FTE resident cap 5.79%
training in children’s hospitals and $76 million for direct GME
for community-based primary-care settings. Total Medicare payments 77.37%
Private insurers also support GME, but unlike for GME
Medicare and Medicaid, their contributions are Total Medicare spending 173.39%
not in the form of an explicit payment but instead Sources: Robert Graham Center; CMS

May 6, 2019 | Modern Healthcare 21

a 1.2% decline from the previous year. Various reasons ex-
plain why residency positions are left unfilled even with a
rise in the number of applicants, ranging from graduates
failing to gain high enough test scores to too much compe-
tition in a specialized field or training location.
Stakeholders contend that increasing the number of
available slots overall would expand the pool of opportu-
nity to allow more applicants to get their desired positions.
“We have medical students graduating who aren’t able
to get post-graduate training spots,” said Dr. Ana Maria
Lopez, president of the American College of Physicians.
“By limiting GME funds, that limits GME slots, which lim-
its care for people.”
Teaching hospitals have in recent years
taken it upon themselves to create more “There is coming
residency positions at their own expense.
The number of available first-year res- a point in which
idency positions increased by 1,962 to hospitals just
32,194 in 2019, a 6.5% rise over 2018, ac-
cording to figures from the National Res-
cannot incur the
ident Matching Program. costs anymore
Tim Johnson, senior vice president and without needing
executive director of the Center for GME
Policy & Services at the Greater New York
additional external
Hospital Association, said 62% of U.S. support from the
teaching hospitals now go above their Medicare program.”
Medicare caps for residency positions.
Between 15,000 and 21,000 of the na- Tim Johnson
tion’s 140,000 physician residents are Senior vice president and executive
director of the Center for GME
training in teaching hospitals without Policy & Services
Medicare support. Johnson estimated the Greater New York Hospital
decision to go over the cap costs each hos- Association
pital $150,000 to $200,000 annually per
resident, typically for salaries and other
overhead costs related to training residents.
At UMass Memorial Medical Center, Medicare provided
funding support for 442 of the more than 500 resident phy-
sicians who worked at the facility in 2016, according to data
from the Robert Graham Center, the policy research arm
of the American Academy of Family Physicians. Last year,
the total cost of GME at UMass was estimated at more than
$409,000 per resident, with about $160,000 reimbursed by
Medicare.
Staying under the cap would have been detrimental to
meeting demand, DeMarco said. UMass Memorial employs
more than 1,200 physicians and handled 135,000 emergency
department visits during the first three months of 2019.
“In some of our programs—like emergency medicine—
volume has gone up tremendously but we have not allowed
an increase in the number of residents in our program and
we limit the number of new programs,” DeMarco said. “We
have a really stringent process for looking at this, because
where is the money going to come from?”
For the remaining 38% of teaching hospitals that train
residents at or below their Medicare funding limit, Johnson
said the majority are nonacademic, medium-size rural facil-
ities. He said many of those providers simply don’t have other
resources to train residents beyond what they receive from
22 Modern Healthcare | May 6, 2019
Medicare. “There is coming a point in which hospitals just
cannot incur the costs anymore without needing additional
external support from the Medicare program,” Johnson said.
Funding shift
GME funding appears to be having a separate but equally
important impact on the physician pipeline, helping drive a
spike in specialists and a decline in primary-care doctors.
Primary care went from making up 44% of the doctor work-
force in 2005 to 37% by 2015, according to a 2017 report in the
Health Affairs Blog.
Some providers believe Medicare’s funding limits con-
tribute to that imbalance by creating
an incentive for hospitals to offer resi-
dency training slots in specialties that
can generate the most financial value.
“In a fee-for-service environment, I can
justify hiring an orthopedic resident
much easier than I can justify hiring an
additional primary resident,” said Dr.
David Hughes, executive vice president
and chief medical officer at Kaleida
Health, based in Buffalo, N.Y.
The decision on whether to train pri-
mary-care or other types of residents
can have long-term implications for
both patient care and the bottom line,
which can be a tricky balancing act.
With 420 physician residents, Kaleida
has for the past five years tried to avoid
going over its Medicare cap.
Hughes acknowledged the rising cost
burden on hospitals to train physician
residents has forced providers to look
at GME as more of a business decision than an academic or
altruistic choice. In terms of the best return on investment
to the hospital, it often makes more business sense to train
residents in medical specialties.
Dr. John Cullen, president of the American Academy of
Family Physicians, said while more graduates have be-
come interested in entering family medicine in recent
years, there has been relatively little increase in the number
of residency positions offered in the field. With hospitals
opting to select fewer primary-care specialists for residen-
cy positions, Cullen is concerned that it will lead to fewer
primary-care physicians in the workforce to lead the move
International graduates on the rise
Internal medicine offered Family medicine offered
7,500 positions in 2018 3,629 positions in 2018
with a 96% fill rate.
with a 97% fill rate.
Of those: Of those:
42% 45%
were were U.S.
U.S. medical medical
graduates graduates
Source: National Resident Matching Program
toward population health. Growth in reported graduate medical education
Nearly half of all first-year physician res- and residents/fellows
idents were offered a position in a prima-
ry-care specialty in 2019, a 7.8% increase over Total GME payments
the number offered in 2018, according to the
National Resident Matching Program. And Total FTE residents/fellows
Cullen noted that many medical graduates Source: Modern Healthcare Metrics, which are derived from analysis of Medicare cost reports
who complete their residency in primary
care end up moving into more specialized fields early in
their careers.
Earning potential coupled with the high amount of debt
many medical students accrue are common reasons medi-
cal graduates give for choosing to become specialists.
Cullen said the current Medicare GME funding structure
does little to give more medical graduates incentives to prac-
tice primary care given that the majority of the program’s
support is still concentrated in hospital-based training pro-
grams. And the trend continues even though an increasing
share of healthcare is being delivered in outpatient settings.
That decision has also had an impact on where doc-
tors decide to practice medicine once they complete their
training. Studies show physicians were more likely to stay
in areas where they do their residen-
cy programs, many of which are in the
Northeast and on the West Coast, leaving
shortages in many areas throughout the
middle of the country.
There’s some
concern that
Looking ahead continuing to
Hospitals have been calling for in-
creasing the Medicare GME cap for years focus so heavily
without much success, but recent signs on academic
indicate lawmakers in Washington are
beginning to listen with greater interest.
medical centers
Reports of the pending physician is as outdated
shortage—potentially reaching 122,000 as the Medicare
by 2032, according to the Association of
American Medical Colleges—has spurred GME caps.
congressional interest. An estimated 44%
of the more than 890,000 active doctors in
2017 were 55 and older, which means there will be an exo-
dus of professionals as they reach retirement age.
In February, a bipartisan group of senators that includ-
ed Democrats Bob Menendez of New Jersey, Minority
Leader Chuck Schumer of New York and Republican John
Boozman of Arkansas introduced the Resident Physician
Shortage Act, which aims to add up to 15,000 new resi-
dency positions over five years by allowing for increased
payments for direct GME costs, which would train an es-
timated 3,000 new physicians. A companion bill was intro-
duced in the House in March.
The bill would require participating hospitals to ensure
at least 50% of the new GME positions be used for a pro-
gram to address specialty shortages, which would include
adding more slots for primary-care specialists.
Yet there’s some concern that continuing to focus so
heavily on academic medical centers—which make up just
6% of all hospitals and provide roughly 20% of all hospital
2013 2014 2015 2016 2017
3.9% 2.2% -8.8% -3.1% 3.3%
2.5% 1.2% 2.2% 1.9% 0.6%
care—is as outdated as the Medicare GME caps.
“If you want to either shift something about the geo-
graphic distribution or the specialty choice, it would be
much more effective to have targeted loan forgiveness or
targeted subsidies to address the physicians you are trying
to get to change their minds,” said Gail Wilensky, a health-
care economist who was head of the predecessor agency to
the CMS from 1990 to 1992 under President George H.W.
Bush. “To do it through this very diffused, nonspecific
mechanism of making more money available to the hospi-
tals puts the decisionmaking at the wrong point.”
Wilensky co-chaired a panel of experts brought together
by the Institute of Medicine to examine the GME funding
structure. Its findings, published in 2014, recommended a
gradual phasing out of the current Medi-
care GME payment system and called for
the creation of one fund to pay for oper-
ational costs and another to develop new
innovative training programs.
She contended that if the ultimate aim
of providing more Medicare GME support
was to increase the primary-care physi-
cian workforce, providing more support
directly to doctors as well as to commu-
nity-based healthcare training programs,
such as federally qualified health centers,
would probably be a more effective means
of achieving that goal.
Several government agencies—most
notably the National Health Service
Corps—currently offer a number of loan
repayment programs for physicians to
provide certain services for two years in a designated
healthcare professional shortage area. Those services ad-
dress a number of needs, including primary-care, dental
and mental health services. The Corps added another pro-
gram at the end of last year to include addiction treatment
facilities to a list of eligible health sites for loan forgiveness.
Wilensky said those types of programs could be more ro-
bust. Any continued commitment toward Medicare GME
funding should include reforms that make hospitals more
accountable for how the money is spent and do a better job
of addressing disparities in both the types of medical spe-
cialists being trained and where the physicians are distrib-
uted throughout the country, she said.
“If you just do what you’ve been doing, you can expect
that you’ll get the same relative distribution that we’ve al-
ways been getting,” Wilensky said. “If you’re going to keep
$10 billion of Medicare money going there, at least have it
going into more sensible ways than what now occurs.” l
May 6, 2019 | Modern Healthcare 23
 Let’s start out with
long-term care for all
MERRILL GOOZNER Editor Emeritus

A
dy Barkan, a 35-year-old Yale Law School graduate who is dying from ALS,
made a poignant plea for Medicare for All at Congress’ first hearing on a
single-payer proposal in more than a decade.

His testimony touched on the myriad
flaws of private insurance: high admin-
istrative costs, growing out-of-pocket
expenses, endless bureaucratic hassles,
and the restrictions even adequately in-
sured patient like himself face in obtain-
ing necessary care.
Yet his young family’s biggest prob-
lem, other than the sad fact that there
is no cure or treatment for his debili-
tating disease, is the nation’s lack of a
long-term care program. “ALS means
paying out of pocket for almost 24-
hour home care,” he said. “It costs us
$9,000 a month.”
How can he afford it? “GoFundMe is
a terrible substitute for smart congres-
sional action,” he said. “We have so little
time left.”
GoFundMe for the long-term care of
this fatally stricken person in the few re-
maining years of his life. In the richest
country on earth.
The event was held in the tiny hear-
ing room of the House Rules Com-
mittee, which, as Kaiser Health News
pointed out, can’t advance healthcare
legislation. House Speaker Nancy Pelo-
si has tipped her hand. M4A legislation
isn’t going anywhere in this Congress
and probably won’t in the next, even if
Democrats win control of both the Sen-
ate and White House and retain control
of the House.
One can imagine advancing signif-
icant healthcare legislation over the
objections of one or two industry stake-
holders. But given the united opposition
of most providers, all insurers, the drug
and device industries, and most em-
ployers—not to mention significant sec-
tions of the Democratic Party—it’s not
going to happen.
But that doesn’t mean the debate is
a waste of time. The Medicare for All
bills advanced in the Senate by presi-
dential candidate Sen. Bernie Sanders
(I-Vt.) and in the House by Reps. Pra-
mila Jayapal (D-Wash.) and Debbie
Dingell (D-Mich.) include coverage of
long-term care. With 10% of the pop-
ulation suffering from disabilities and
half the baby boom generation entering
retirement without significant assets,
coming up with a national plan that
works is long overdue.
Detractors say the cost would be
enormous, with estimates ranging as
high as several hundred billion dollars
a year. Some of that would relieve states
of their Medicaid obligations to help
the destitute. But, as the Congressional
Budget Office noted in a new review of
single-payer options, “public spending
would increase substantially … if ev-
eryone received long-term services and
supports benefits.”
Still, an Associated Press-NORC Cen-
ter for Public Affairs Research poll last
year showed 76% of Democrats and
56% of Republicans favor a government
long-term care program. No wonder.
The private market for long-term care
insurance has largely collapsed.
Most of the people who sign up wind
up using the benefits while the rela-
tively healthy and the well-to-do, who
can self-insure, avoid its huge premi-
ums. Private insurance for long-term
care inevitably breeds a massive ad-
verse-selection problem.
The Legislature in Washington, whose
governor, Jay Inslee, is running for pres-
ident, recently passed a universal long-
term care plan financed with a payroll
tax of about 0.5%. Its benefits would
provide up to $36,000 a year for personal
assistance, whether at home, in nursing
homes or at assisted-living facilities.
Today, less than 10 million people
have long-term care insurance, which
is very expensive. The rest of the pop-
ulation relies on unpaid family care-
givers or liquidating assets until they
qualify for Medicaid. Talk about a
death tax.
If single-payer advocates were smart,
they’d break off the long-term care sec-
tion of their bills, come up with a pro-
gressive, adequate tax to pay for it, and
pursue it in this Congress. Why not show
that single-payer can work for this cru-
cial but missing benefit before trying it
on the entire system? l

24 Modern Healthcare | May 6, 2019

Look before you leap—what primary-care doctors
should know if private equity comes calling
By Dr. Halee Fischer-Wright
D
octors, deep-pocketed investors are coming for your primary-care practice,
whether you’re prepared or not. Until recently, private equity investment in U.S.
healthcare had mostly flowed to physician groups in high-end specialty fields.
Since 2016, though, private equity
has begun spreading its net to target
primary-care physician groups. The
basic model is the same—the firms
provide an infusion of cash and busi-
ness expertise while setting clear
performance targets leading up to
a sale. Physicians get two seductive
bites at the apple: the initial cash in-
jection and another potential wind-
fall from the sale.
I meet with a lot of private equity
people, and they generally are not shy
about touting their success stories. So
it may be telling that I have yet to hear
of an exit from such a primary-care
deal considered successful by both
investors and physicians. The truth is
there’s a big gap between the fantasy
and reality of private equity involve-
ment when it comes to primary care.
Even with a cash infusion and an
efficient operation, the economics
of primary care make it very hard for
practices to make the multiples these
firms demand. The other key misalign-
ment is timing. Primary care’s long-
term prospects are heavily dependent
on the shift from the fee-for-service
payment model to a value-based mod-
el. But that is going to take five to 10
years to bear fruit, whereas private eq-
uity firms usually have an exit horizon
of about three years.
If their multiples aren’t hit, private
equity firms may be able to take an
“enhanced ownership position,” i.e.,
a lot more than initially agreed upon,
leaving physicians with far less control
than they expected. For this reason,
Dr. Halee
Fischer-Wright
is president
and CEO of the
Medical Group
Management
Association.
doctors must go into these deals with
their eyes wide open. Physicians are
inherently some of the smartest peo-
ple around and don’t tend to lack con-
fidence. When dealing with private
equity, though, they are effectively op-
erating in a foreign land and speaking
a new language, one they need to ad-
mit they can’t speak with any fluency.
Too often they focus only on the
upside. One of the most important
things they can do is to take emotion
out of the decisions by bringing in a
third-party expert that can assess the
offer on its true merits.
Physician groups should also
know that private equity capital is not
the only way to grow their business.
There are other options, especially for
groups that have an entrepreneurial
DNA and want to remain independent
because they believe they can do bet-
ter on their own.
In the end, all private equity is
really offering is capital and some
business expertise, and doctors rare-
ly consider the true cost of that cap-
ital. If physicians are savvy enough
to work out these solutions on their
own, then they may be able to live
without private equity and retain a
lot more control over their business.
After all, if they have three-quar-
ters of the cookie recipe and all that
they’re missing is chocolate chips,
why not just go get their own?
Fortunately, we are seeing some
creative capital-raising alternatives
emerge.
One option is for physician groups
to enter into joint ventures with larger
healthcare systems, such as hospital
groups or insurers. The hospital groups
can become a subordinated joint ven-
ture partner rather than ending up
owning the whole practice. For big
health systems, such arrangements
can also be a useful physician-align-
ment tool and help them to expand
market share.
There are also steps that practices
can take by themselves to enhance
their efficiency, revenue and opera-
tions. All it really takes is the will to
make changes. How can your process
flow be improved? Are your doctors
spending too much time on the com-
puter rather than seeing patients?
And if a practice has already hired
able people on the business side, then
the doctors need to listen and pay heed
before wading into a private equity
deal. The consequences of getting it
wrong could be significant. l
Interested in submitting a Guest Expert op-ed?
View guidelines at modernhealthcare.com/op-ed.
Send drafts to Assistant Managing Editor David May
at dmay@modernhealthcare.com.
May 6, 2019 | Modern Healthcare 25
 family, our broader Scripps family and is sick or has a change in health wants
our country, which is experiencing a someone who will listen and work
rise in hate-fueled violence. with them, not dictate what they think
But I also felt a sense of pride in they should do. There are a lot of good
the diversity we have in the world of things about our healthcare system;
‘This violence must end, healthcare—religion, race, gender, however, we must learn to listen so we
and it starts with us’ sexual orientation, ethnicity and more. can change with the times.
Diversity in all forms makes us stronger. Dr. Janice Brown
As healthcare professionals, This violence must end, and it Lakeland, Fla.
we come to work each day with a starts with us.
dedication to improve the human Chris Van Gorder
condition, and that includes standing President and CEO Alternatives to the ED often
up to reject all forms of hatred. Scripps Health not where they’re needed most
We must take a stand and reject San Diego
negative comments about any group The article “ACA has not
or individual. We should be telling reduced ED visits, study finds”
everyone, “We accept you, we will Focus on personalized care (ModernHealthcare.com, April 19)
care for you—you are an extension can help fix a fractured notes the availability of urgent care
of our family, and we will surround and retail clinics, but patients are still
consumer experience
you with our protection and care and choosing the emergency department.
compassion.” Regarding the article While I do see this as an issue, I can
On April 27, I received a phone alert “Healthcare CEOs debate impact also chime in to say urgent-care
about a multicasualty shooting at the of consumer-focused approach” facilities are frequently not located
Chabad of Poway synagogue near (ModernHealthcare.com, April where they’re needed most.
San Diego. 24), the discussion over the An urgent-care site near an ED
It wasn’t long before I learned the “Amazonification” of healthcare is does little good if the urgent-care
shooting had involved two of our own taking place across the country as site operates the same as an ED and
at Scripps Health—Dr. Howard Kaye healthcare organizations try to mend therefore patients are charged rates
of the Scripps Coastal Medical Group a fractured consumer experience. similar to an ED. When looking at
and his wife, Lori—and that Lori had As a physician in the field of physical costs, it would be a better choice to
been killed. medicine and rehabilitation, I see go to the ED and get their full services
I felt rage over the hatred of the patients who have had life-altering rather than visit an urgent-care facility
19-year-old suspect who attacked events, whether from an acute illness and not have a full workup. Also,
strangers in such a violent way at the or trauma. Two things that we need to where are the urgent-care centers that
same time he was being trained to focus on in healthcare are personalized do not operate as EDs located? We
save lives as a nursing student. And care and prevention; neither was know the elderly and those with low
I felt profound sadness for the Kaye mentioned in the article. Anyone who incomes are frequent ED users, so why
not have more urgent-care facilities
in neighborhoods with higher
concentrations of these populations?
Educating these communities
by showing how the step-by-step
Nominations sought process of care works would help
for healthcare innovators remove the burden on the EDs. The
flow of care should be retail clinics/
primary care, urgent care and the ED
Innovation is driving change across the healthcare industry, leading to as a last resort. When an ambulance
gains in quality, affordability, accessibility and sustainability. We’re looking is called, do EMTs determine urgent
for the people who are initiating and leading the transformation. care is an option instead of an ED
Modern Healthcare is now accepting entries for its inaugural Top 25 visit? Also, let’s not forget wait times.
Innovators recognition program. Nominations are open to leaders at When clinicians at an urgent-care
provider and payer organizations. Researchers and public policy officials or primary-care facility cannot see
are also eligible but entries must reflect the real-world impact of their work. the patient in a timely manner, the
The nomination categories are population health, consumerism, quality patients are likely to opt for the ED.
and safety, and cost reduction. Hopefully a change in the way we
For details on the criteria and documentation requirements and to set up care and operate these sites
submit an entry, please visit ModernHealthcare.com/Top25Innovators. will get the results needed.
The deadline is June 3. Chico Grimes
Dallas

26 Modern Healthcare | May 6, 2019

EXECUTIVE INSIGHT
Improving a State and Nation through Community Crowdsourcing
Fastest-Moving Population Health Genetics Study Serves as National Model
Anthony D. Slonim, M.D.,
Dr.PH., FACHE
President and CEO
Renown Health, Reno, NV
The Healthy Nevada Project® is one of the
first, fastest-moving, community-based population health
studies in the U.S.
The team is now returning medically-actionable results to
participants. In three months, 24,000 study volunteers
were notified of their genetic health risks tied from
CDC Tier 1 conditions (Hereditary Breast and Ovarian
Cancer Syndrome, Lynch Syndrome and Familial
Hypercholesterolemia). This is potentially life-saving
information that more than 60 percent who tested
positive may not have received otherwise.
What is the strategic impact of population health
studies like the Healthy Nevada Project®?
AS: Research is pointing to the importance of genetic
testing on the individual level to help people discover
and mitigate their genetic risks. Initiatives like the Healthy
Nevada Project® and the Healthy USA Project® take that a
step further by emphasizing the impact of population level
screening. Health systems can use this information to guide
workforce planning, align health care services to the need
and improve the health of their communities.
Healthcare organizations must be aware of the factors
driving each community’s overall health status. A major
focus of strategic planning is healthcare programming to
serve the needs of the sick and injured, but many problems
stem from social, environmental and genetic determinants
that underlie a community’s overall health outcomes. These
issues must be addressed.
Through the Healthy Nevada Project®, we are using data
to address the most frequent inherited conditions in our
population and assuring people have access to screening
and intervention. We are providing early identification
of chronic conditions. Because the genomic sequencing
(spit) tests are offered at no cost, we are enhancing
participant engagement regardless of socioeconomic status
by democratizing the availability of genetic testing. Our
health “report card” for diseases such as heart disease and
respiratory disease is poor, and collectively these conditions
among local residents stand at 33% above the national rate.
This is important because, despite leading the country in
growth and innovation, Nevada ranks 47th in the nation in
terms of health.
What’s next for the Healthy Nevada Project®?
AS: Since launching in Sept. 2016, the Project is one of the
largest community-based population health studies with
38,000 Nevadans already enrolled. Ultimately, we aspire to
offer genetic testing to any Nevadan interested in learning
more about their health and genetic risks.
Behind each of those numbers is a story. Some study
volunteers have discovered half-siblings and unexpected
ancestry results. Hundreds are discovering life-changing
results. In October, we become one of the first studies to
return clinical results for CDC Tier 1 conditions including
familial hypercholesterolemia, hereditary breast and
ovarian cancer syndrome, and Lynch syndrome. In just three
months, more than 24,000 study volunteers were notified
of their risks for these conditions. Even more remarkable,
more than 60% of those who tested positive did not have
a family history and would not have been diagnosed using
national standards of care. The Project is saving lives here in
Nevada and we hope soon – will be saving lives nationwide.
What’s your goal for the Healthy USA Project®?
AS: We want the Healthy USA Project® to improve health
from the individual, to the community and the state, and
beyond. By understanding how genetics, environment, social
factors and health care interact we can help predict who
may be at greater risk for certain conditions – allowing for
quicker diagnoses and the development of more precise
treatments.
For us at Renown Health, the Healthy Nevada Project®
started out of a need for a data road map. In 2015, our
strategic plan emphasized the distinction between health
and healthcare but we weren’t able to improve health
outcomes for priority populations without robust data.
Today, we are engaging with other premier healthcare
systems around the country to improve health in their
local communities by joining this landmark, crowd-sourced
genetic study. The more data we can collect, and the more
people we can engage, the greater impact we can have.
This Executive Insight was
produced and brought to you by:
To learn more about joining the Healthy USA
Project®, visit HealthyUSA.org
 NEW to the
Top 25 awards
program!
Healthcare’s innovators
are those leading
transformative programs
that improve care.
Does this sound like
someone you know?

Modern Healthcare’s Top 25 Innovators

recognizes executives who are:
n Implementing initiatives from the vice president level or above
n Achieving measurable results within one or more of the four key areas
n Using innovation to contribute to the clinical and financial goals of their
health organization

Areas for nomination:

Population Health | Addressed a community
health need previously lacking attention and
developed partnerships with community
organizations
Consumerism | Implemented a patient-
centered program or technology and improved
organizational quality or financial performance
Quality and Safety | Devised initiatives that
addressed one or more of the Institute of Medicine’s
six domains of healthcare: safe, effective, patient-
centered, timely, efficient and equitable
Cost Reduction | Identified opportunities
for efficiencies and cost reduction without
compromising quality of care or workplace numbers

Who should be in this group of bright minds?

Visit ModernHealthcare.com/Innovators
to nominate today.
Nominations close June 3!
 Waging a relentless
Dr. Gary Kaplan
war on waste
CEO
Virginia
Mason
Health
System
In an industry that’s constantly evolving, managing
change should not be a risky move. Dr. Gary Kaplan,
chairman and CEO of Virginia Mason Health System in
Seattle, has led his organization through an exercise in
continuous improvement for the past 18 years. And that can
be exhausting or energizing.
Adopting the Toyota
W H AT WAS YO U R R I S K I E S T D EC I S I O N?
production system as the foundation of our management
system, what we call the Virginia Mason Production System,
which is all about a relentless war on waste.
W H Y WAS TH AT M OV E R I S K Y? Back in 2001, the notion of
looking to a management system for healthcare that was
developed and refined in manufacturing was unheard of.
There were people talking about principles of (W. Edwards)
Deming back then, but the notion that we would spend
time in factories that make air conditioners, automobiles,
airplanes? People thought we had lost our mind. I
remember Paul O’Neill (the former Treasury secretary
and Alcoa CEO who became active in the Institute for
Healthcare Improvement) saying, “Virginia Mason is
engaged in a bet-the-farm strategy on quality.” He knew at
that time that we were embracing this management system
because of what it meant to quality and safety, which was
what it was really all about.
W H AT WAS TH E R E S P O N S E F RO M TH O S E I N VO LV E D?
The board was very curious and they were part of this
journey from day one. There were many early champions.
There were also those who were basically in the over-my-
dead-body camp, wake me when it’s over. And then the
great majority I think was in the middle, either this too
will pass and let’s just put our heads down and do our jobs,
or time will tell. Thus began a major large-scale change
Culture change involves everybody,
but it has to start at the top.”
management endeavor, which has been, I think, quite
successful. Today people embrace it. It’s a magnet. People
want to work in a place that’s working on their work, where
continuous improvement is embedded in the foundation.
But it wasn’t always that way.
Make sure
A DV I C E TO E X EC S I N S I M I L A R P O S ITI O N S
there’s a shared vision so that the dots are connected,
the so-called “why” is understood—so that it’s not just
somebody’s leadership whim but a deeply embedded
rationale for getting to a better place. With that comes
organizational focus, so people need to understand that
it’s going to take prioritization relative to other things.
Sometimes we ask people to do things, but we don’t
recognize that we have to take things off their plates.
Culture change involves everybody, but it has to start
at the top. Leaders by their own behavior help to drive
culture. I don’t want to come across as saying we’ve
figured out how to ease the workload, because healthcare
today is a lot about drinking from the fire hose. But with
our management system we’re realizing that a lot of what
we do is waste and adds no value.
I work hard on
D E S C R I B E YO U R LE A D E R S H I P S T Y LE
communication. Transparency is really important. We
present regular reports about our improvement work and
all of our executives are there, I’m there. Then it’s my turn
to comment on what I’ve listened to and engage several
hundred people in a dialogue about what we’ve learned and
how it connects to their work. It’s those kinds of things that I
spend a lot of time on and hope to share with my leadership
team so that those things cascade across the organization.
H OW WO U LD OTH E R S D E SC R I B E YO U R LE A D E R S H I P
S T Y LE?I think they would say I’m inclusive, I’m engaged.
I’m very mission- or patient-driven but recognize that by
working in this industry it requires a lot of willingness to
embrace adaptive change, to engage in humble inquiry,
to care about the loss that people feel as the industry and
professions evolve. l
SPONSORED BY
Bold Moves is a Modern Healthcare editorial feature. Sponsor is
not involved in development of content or selection of authors.
May 6, 2019 | Modern Healthcare 29
Analytics speeds drug-diversion
discovery from weeks to hours
By Jessica Kim Cohen
IT USED TO TAKE Piedmont Athens
Regional Medical Center weeks, if not
months, to discover a possible instance
of drug diversion. That’s not uncom-
mon for hospitals—but with mount-
ing deaths across the nation from drug
overdoses, in particular from controlled
substances, the Georgia facility decided
to add a new technique to its discovery
process: analytics.
Nearly 50,000 people died from over-
doses involving opioids across the U.S. in
2017, the most recent year tracked by the
National Institute on Drug Abuse. Drug
diversion plays a role in the epidemic.
In the first six months of 2018 alone,
healthcare organizations lost more than
18.7 million pills from employee misuse
and theft, according to a report from
healthcare analytics vendor Protenus.
That diversion costs public and private
medical insurers $72.5 billion each year,
the Justice Department’s National Drug
Intelligence Center estimated.
Five years ago, Piedmont Athens Re-
gional addressed drug diversion by rely-
ing on medication dispensation reports,
which track the number of drugs with-
drawn from dispensing cabinets. These
reports were compiled every 30 days,
but reviewing abnormal dispensing pat-
terns and matching them to a potential
perpetrator was time-consuming.
It’s “very, very difficult to backtrack
retrospectively and to figure out who
was on that unit at the time, what
personnel was there (and) who had
access to those medications” after dis-
covering a suspicious activity, said Dr.
Eric Bour, executive sponsor of par-
ent system’s Piedmont Healthcare’s
drug-diversion program.
So, Piedmont Athens Regional began
using an analytics tool developed by
software company Invistics. The hospital
kicked off the program in 2014, when it
was known as Athens Regional Medical
30 Modern Healthcare | May 6, 2019
“It’s very, very difficult to
backtrack retrospectively
and to figure out who was
on that unit at the time,
what personnel was there
(and) who had access to
those medications.”
Dr. Eric Bour
Executive sponsor
Piedmont Healthcare’s
drug-diversion program
Center—two years before it was acquired in for a full investigation. The hospital’s
by Piedmont Healthcare in 2016. Now, drug-diversion specialist still needed to
it’s helping to scale the program. evaluate whether the abnormality was
The tool constantly monitors drug-dis- in response to patient need, a documen-
pensation, timekeeping and electronic tation error or was in fact drug diversion.
health record systems to flag any sus- A comprehensive plan to mitigate
picious activity, such as if a nurse dis- drug diversion might include analyt-
penses two tablets of hydrocodone, but ics, manual chart reviews, random
only documents giving one tablet to a audits of syringes and even teaching
patient. It then matches which employ- staff how to detect behavioral changes
ees were working at that time and which associated with drug diversion among
patients were in the associated unit. peers, said Robert Campbell, the Joint
From there, the program alerts designat- Commission’s director of clinical stan-
ed staff—at Piedmont Athens Regional, dards interpretation for hospital and
that means a drug-diversion specialist— ambulatory programs.
about any abnormal patterns, so they Piedmont Athens Regional now
can begin investigating as soon as possi- plans to expand the analytics program
ble—often within hours after the suspi- across the three other hospitals in
cious event occurs, Bour said. Piedmont Healthcare’s eastern hub by
A National Institutes of Health-fund- fiscal 2020.
ed study of the analytics tool found However, use of the tool is on hold
that it took Piedmont Athens Regional while Piedmont Athens Regional builds
anywhere from three weeks to sever- up functionality on the system’s EHR,
al months to discover a drug-diversion which it transitioned to late last year.
event before implementing the tool. Af- Bour, who also serves as CEO of Pied-
ter the hospital began using the tool in mont Newton Hospital, said that ex-
2014, it flagged roughly 200 instances of panding the analytics program fits into
possible drug diversion, with nearly half Piedmont Healthcare’s larger opioid-re-
leading to full investigations. About 25 duction strategy. “As we’re looking to
care providers faced disciplinary actions prescribe less opioids, use less opioids
as a result of these investigations. and spare patients from the wrath of
Bour stressed that the tool is meant to opioids, this is just another piece of that
be used as a first step, and not as a stand- whole puzzle,” he said. l
 Workplace violence persists
as a threat in healthcare
Fear is mounting that healthcare workers are increasingly subject to violence in the workplace.
So much so that Congress ordered HHS and the Occupational Safety and Health Administration
to produce an interagency report on the topic. As of deadline, that report, which was due in
March, had yet to materialize.

47% 71%
of emergency department said
physicians report that they’ve they had
been physically assaulted in witnessed
the ED an assault

70%
Who committed the assault?
of respondents said their hospital administration 97%
or security responded to the assault
Patient
97%
28%
How did the hospital respond? Patient family member or friend

Physician advised to 7%
Behavioral flag added to
the patient’s chart press charges Another visitor
1%
28% 21% 6% 42% Colleague
(Survey respondents who reported being
assaulted; could select more than one response)
Security or law 3% Security
enforcement pressed charges Other*
arrested the patient
*Included removing patient from the ED or restraining the patient.

$428.5 MILLION
Estimated annual costs of in-facility violence,
according to the American Hospital Association,
including $234.2 million for staff turnover and $42.3
million for medical care and indemnity

For healthcare, assaults account for

10%-11%
of workplace injuries involving days
away from work compared with 3% for all
private-sector employees

Sources: American College of Emergency Physicians,

American Hospital Association, Occupational Safety
and Health Administration

May 6, 2019 | Modern Healthcare 31

‘We have to recognize
it’s all a big system’

Dr. James Madara, executive vice president and CEO of the American Medical that are big enough that
Association, says momentum is building for reimagining medical education, as evidenced it doesn’t matter what
by the nearly 40 schools that are part of the association’s Accelerating Change in healthcare system we
Medical Education. The AMA is now setting its sights on residency programs. Modern have in 10 years. It doesn’t
Healthcare’s editorial board met with Madara to talk about the need to revamp how matter if we’re single-payer,
doctors are trained. The following is an edited transcript. if we’re pluralistic, if we’re
all-private, it just doesn’t
MH: What policy are you exposure is still largely in expanding this into the matter. But you cannot
working on in regard to on the inpatient side. residency program. We put imagine a healthcare
medical education? The outpatient side is out a request for proposals system of any type where
like a strobe light. Given to get about six or seven, physicians don’t have to
Madara: There have been the new ways that we do or maybe eight integrated be retrained for the 21st
opinions on what’s wrong analytics, we had to create areas where we could work century, where you don’t
with the current educational a third science in medical on this transition from a need better data and data
structure for more than schools. There’s clinical competency-based medical liquidity, where you don’t
a decade. Everyone’s in science, basic science, school to a competency- have to take the physician
agreement but no one was and the third science we based measured residency. hours and actually have
doing anything about it. So introduced was health We had the same reaction— those focused on patients
we decided we would try system science. So team- over 200 responses for rather than computers.
to do experiments with a based care, coordination of the RFP—which means We’re also creating a
group of medical schools. care, analytics, information everyone recognizes the medical education hub.
We hoped we’d get four, technology, all these things problem we have. The early form of that has
five or six schools. We put have not been embedded in been launched. The idea
out a request for proposals established curricula. MH: What’s the makeup of the there is to take all the
under which we were going We were also weak participating hospitals and assets of the AMA in the
to financially support this in having our students what are you looking for? first instance, and whether
work. Eighty-five percent of understand the economic they be JAMA or non-JAMA
the 140 (allopathic) schools underpinnings of Madara: About all, except related, they’re related to
responded. We selected 11 healthcare and how policy maybe three or four of education. Put that in a
initially and gave $14 million affected healthcare. If we’re our consortium schools form that’s attractive in this
toward the development. going to produce physicians responded, but mostly current digital age, which
Now there are 37 schools in who can act and contribute from teaching hospitals also means mobile, and be
the consortium. to solving the problem, how almost by definition, but able in an Amazon-like way
In the last half of the can you do that without not necessarily the core to start wrapping around
century, we’ve gone from knowing the economic academic medical centers. physicians the type of
largely an episodic disease wiring of the healthcare Some outside of that as well. education that they need.
burden to a chronic disease system or how policy works? We’ll be announcing
burden in the U.S. But if The Accreditation Council schools in June. We’re MH: Is one of the goals of your
you look at the way medical for Graduate Medical looking for innovation and efforts in medical education
school is structured, the Education approached us transformative (work). to increase the physician
intensity of the clinical to see if we had an interest We should pick problems workforce?

32 Modern Healthcare | May 6, 2019

“You cannot imagine a healthcare system of any type where
physicians don’t have to be retrained for the 21st century.”
Madara: The Association of
American Medical Colleges
has estimated that there will
be a substantial shortage
of physicians in the next
10 years relative to what’s
needed. We have the same
calculation, though it is
done largely on the premise
of how things exist today.
We know for example
that for every hour face to
face with a patient today,
a physician spends two
hours in data entry and
administration. We need to
think of a different way of
looking at that workforce.
Six years ago, we did a
collaborative study with
the RAND Corp. It was
multimarket, with a lot of
different kinds of physician
practices defining what was
satisfying and what was
dissatisfying for physicians.
Hands down the top satisfier
was face time with patients.
Nothing else came close.
So when we think about
the workforce, we think
about the numbers of people
we need, the types of fields
they’ll have to be in, but
also how we use the current
workforce. What we’re doing
currently is crazy.
MH: What role does
entrepreneurship have in the
medical school of the future?
Madara: It has to be at least
connected. Fifty percent
of medical schools—at
least this was the case two
or three years ago—did
not allow their medical
students to touch their
electronic health records
in their institutions. That’s
one of the reasons why
we co-created an EHR in
our consortium. It wasn’t
parroting any of the
existing vendors, but it was
showing what was possible
in the general pathways.
If you went to an
institution, and you were
unable to talk to the EHR
and you were to ask, “Well,
I don’t see how we do
population health on this
platform,” and the answer
was, “Well, you can’t do
population health,” you
know that’s wrong.
Another broad
disconnect that I saw
personally when I was at
the University of Chicago
is, we had two degrees:
MDs with MBAs. I began
to ask all of our students
who were graduating, “So
you’re MD MBA, you’re
interested in business and
economics as part of your
career in medicine, right?”
They said yes. “Can you tell
me the name of the CFO
of the health system of
the university?” “No.” The
degree wasn’t specified in
any way that differentiated
it from other MBAs. In
medical school, the way
we run the healthcare
processes and the way we
connect to communities,
we have to recognize it’s all
a big system. l

How is the CMS dealing with a booming

Medicare Advantage population?

By expanding coverage of telehealth

benefits.
Read the full story at ModernHealthcare.com/Hub12. Transformation Hub provides
resources, inspiration and real-life solutions from the cutting edge of healthcare.
The pace of innovation in healthcare is staggering. Keep up. Then get ahead.

May 6, 2019 | Modern Healthcare 33

Largest healthcare outsourcing vendors
Ranked by 2018 healthcare revenue

2018 REVENUE
RANK OUTSOURCING VENDOR LOCATION ($ IN MILLIONS) OUTSOURCING SERVICES OFFERED

1 Optum Eden Prairie, Minn. $8,087.0 Revenue cycle management

2 Cognizant Teaneck, N.J. 4,263.4 Information technology

3 Change Healthcare Nashville 3,305.1 Information technology

4 Dell EMC Hopkinton, Mass. 2,350.0 Information technology

5 Conduent Florham Park, N.J. 1,834.7 Business transactions

6 Conifer Health Solutions Frisco, Texas 1,600.0 Revenue cycle management

7 Wipro Bengaluru, India 1,200.0 Information technology

8 Tata Consultancy Services Mumbai, India 1,000.5 Information technology

9 Nuance Burlington, Mass. 899.0 Coding and data management

10 3M Healthcare St. Paul, Minn. 721.0 Coding and data management

11 Ciox Health Alpharetta, Ga. 631.0 Coding and data management

12 IBM Corp. Armonk, N.Y. 560.0 Information technology

13 Oracle Redwood Shores, Calif. 555.7 Information technology

14 NetApp Sunnyvale, Calif. 531.6 Information technology

15 R1 RCM Chicago 449.8 Revenue cycle management

16 Infosys Bengaluru, India 422.3 Information technology

17 Experian Dublin 331.0 Revenue cycle management

18 West Corp. Omaha, Neb. 325.0 Call center/revenue cycle management

19 M*Modal Franklin, Tenn. 320.2 Transcription

20 Availity Jacksonville, Fla. 250.0 Revenue cycle management

Source: Black Book Market Research

For more information on the data used to compile this chart, contact Black Book Market Research,
3030 N. Rocky Point Drive, Suite 150, Tampa, FL 33607; blackbookmarketresearch.com; Doug.Brown@Brown-Wilson.com; 800-863-7590

Information in this chart may be subsequently revised at the discretion of the editor.
For more information on our research, contact Megan Caruso at 312-649-5471 or mcaruso@modernhealthcare.com.
FOR MORE charts, lists, rankings and surveys, please visit modernhealthcare.com/data.

34 Modern Healthcare | May 6, 2019

 Announce your Promotions, New Responsibilities, Retirements or New Hires
To place your ad contact Kathleen Cavalieri l kcavalieri@modernhealthcare.com

HOSPITAL

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PUBLISHER AUDIENCE DEVELOPMENT

Fawn Lopez Vice President/ 312-649-5491 flopez@modernhealthcare.com Jennifer Mosley Group Director, 312-649-5312 jmosley@crain.com
Publisher Audience Development
OPERATIONS Lauren Melesio Reprint sales 212-210-0707 lmelesio@modernhealthcare.com
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Ilana Klein National Advertising 312-649-5311 iklein@modernhealthcare.com Jodi Sniegocki Education and Events 312-649-5459 jsniegocki@modernhealthcare.com
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To place an advertisement: Call 312.649.5311 or send a fax to 312-397-5510 877-812-1581 www.modernhealthcare/subscriptions
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PRODUCTION
Nicole Dionne Production Manager 312-649-5337 ndionne@modernhealthcare.com
CRAIN COMMUNICATIONS INC
MARKETING
Keith E. Crain Mary Kay Crain KC Crain Chris Crain
Katie Driscoll Integrated Brand 312-649-7849 kdriscoll@modernhealthcare.com Chairman Vice Chairman President Senior Executive
Development Director Vice President
Nadiia Dibrova Marketing Coordinator 312-280-3163 ndibrova@modernhealthcare.com *** ***
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CREATIVE SERVICES G.D. Crain Jr. Mrs. G.D. Crain Jr.
Patricia Fanelli Creative Services 312-649-5318 pfanelli@modernhealthcare.com Founder (1885-1973) Chairman (1911-1996)
Director
Joanne Yj Kim Graphic Designer 312-649-5338 jykim@@modernhealthcare.com WHO WE ARE AND HOW TO REACH US - Modern Healthcare is the only weekly business news
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May 6, 2019 | Modern Healthcare 35

‘Game of Thrones’ fan
gets her final wish The Facebook video shows Claire Walton
with family members and caregivers.

er dying wish was to watch the epic battle on the

H April 28 episode of “Game of Thrones,” when the
forces of the living went up against the Night King and his
as his allegiance shifted from claimant
to the throne Stannis Baratheon to
the “mother of dragons,” Daenerys
undead army of wights and White Walkers. Caregivers at Targaryen.
HopeHealth Hulitar Hospice Center in Providence, R.I., “How are you doing, Claire?”
were able to make that come true—with some surprises. Cunningham asks in the video. “It’s
Hospice patient Claire Walton also got some video Liam here … I hope you’re well enough
greetings from 10 actors in the HBO series, now in its to watch the battle, which is tonight. I
eighth and final season. Walton, 88, died the next day, Miltos “Syrio Forel” wish you the very best … take care.”
spokeswoman Victoria Vichroski Yerolemou Another actor—who fanboys and
said in an email. girls of the series will remember as
Among the actors who portraying Syrio Forel, who began Arya Stark’s training
sent their regards were Liam in sword-fighting—had a message for Walton. Miltos
Cunningham, who portrays Ser Yerolemou, whose character met a bad end in season
Davos Seaworth, also known one, said, “I just wanted to say hello and that you are with
as the “Onion Knight,” whose us in spirit, and that we’re thinking of you and sending you
character has played a big part all our love.”
in the tale of the battle for the Liam “Ser Davos” HopeHealth shared the story in a Facebook video,
Iron Throne since season two Cunningham showing Walton watching the video with her loved ones. 

Getting students engaged with

their health by going retro
hen the New Jersey Hospital
W Association wanted to engage
college students in some health-related
Students grapple with oversized
Jenga pieces at the event.
PAM BROWN-VILLARUZ
activities, it went retro. As in “put down
their phones, take out their earbuds
and connect with others and their own
well-being,” according to the NJHA.
The association and several of its
members hosted the “Retro-Activity”
event at the College of St. Elizabeth in
Morristown recently, the second such
gathering it’s staged to reach students.
About 200 attended the event, which
was moved inside because of rain. It
featured smoothie and salad stations;
stress-busting tips; a giant ‘Operation’
game; horticulture therapy, oversized
Jenga and checkers games, a
drumming circle and pet therapy.
Local systems involved in the
event were Atlantic Health System,
Hackensack Meridian Health Carrier
Clinic, Hackensack Meridian Health
Mountainside Medical Center, The
Valley Hospital and Trinitas Regional
Medical Center.
“Good health begins in the
community or, in this case, on
campus,” said NJHA CEO Cathy
Bennett. “If our goal is to create
healthier communities, we need to
reach individuals early and promote
healthy behaviors. And in today’s
culture, when it’s all too easy to plug
in and tune out, a key part of wellness
is to promote fun activities that urge
students to get moving and connect
with others.”
A third event is planned for the fall. 

36 Modern Healthcare | May 6, 2019

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Have a question about the event? Interested in sponsorship?

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