Verity Health’s Deep-Pocketed Savior Failed. Here’s Why.

https://www.healthleadersmedia.com/strategy/verity-healths-deep-pocketed-savior-failed-heres-why

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An ambitious plan to save troubled Verity Health System ended in bankruptcy. Hospital CEOs should see Verity as confirming a trend.

The recent bankruptcy announcement by Verity Health System should worry CEOs and boards at hospitals all over the country that share some of the same characteristics, because they could be the next to fall, one analyst says.

The financial troubles of Verity are part of a trend in healthcare, and the health system’s experience shows that the dramatic arrival of a savior with deep pockets doesn’t guarantee organizational health and stability.

Verity operates six nonprofit hospitals in California, and citing growing losses and debts for the facilities, it filed for bankruptcy. The hospitals will remain open during the bankruptcy, Verity said.

The bankruptcy filing is a public failure for biotech billionaire Patrick Soon-Shiong, MD, a physician and entrepreneur whose privately owned umbrella company NantWorks in 2017 acquired Integrity Healthcare, the company that manages the Verity health system. Soon-Shiong said at the time that his goal was to revitalize the hospitals and improve the care they provided to mostly lower-income neighborhoods.


Though a surgeon and entrepreneur, Soon-Shiong had never operated hospitals before, as reported by STAT. The Verity system’s woes apparently were more than he could fix, with more than $1 billion of debt from bonds and unfunded pension liabilities.

The Verity CEO said at the time Soon-Shiong entered the picture that the system also needed cash to make seismic repairs to aging facilities and also needed hundreds of millions of dollars’  worth of new equipment such as imaging machines and neonatal intensive care units.

A Definite Trend

Verity’s overall experience is part of a trend in U.S. hospitals, says Ilyse Homer, JD, a partner at the Berger Singerman law firm with experience in hospital bankruptcies.

“There are hospitals all over the country that are not dissimilar in what happened to Verity—large debt, an aging infrastructure, an inability to negotiate contracts,” Homer says. “They have trouble with maintaining pensions and that is very typical in filings in other districts. There are some commonalities throughout the industry, and I can’t say I’m surprised that Verity came to this.”

Nantworks provided more than $300 million in unsecured and secured loans and investments, the Los Angeles Times reported. The money went to operational costs, pension obligations, and capital improvements, and only a third of it was secured by property.

The management company deferred most of the $60 million in management fees Verity was expected to pay over the last year.

Industry Ripe for Restructuring

Some criticism has been directed at financial decisions by Soon-Shiong’s team, such as providing millions of dollars to health IT vendor Allscripts rather than spending that money on capital improvements. Soon-Shiong has a financial stake in Allscripts. Fully implementing a new Allscripts health IT system could cost from $20 million to more than $100 million, according to estimates from different sources, as reported by POLITICO.

Even without any questions over Soon-Shiong’s strategy, saving Verity would have been a tall order for any investor, Homer says. The challenges were so great that it might have been too late to simply infuse cash and hope for the best, she says.

Once a hospital or system becomes weak in so many areas, it is hard to recover and gain strength again, Homer says.

“What happened to Verity is happening, to some extent, to a significant number of hospitals in the country. They have costs that are rising faster than revenues, and they’re being downgraded by financial analysts,” Homer says. Moody’s recently downgraded the entire hospital sector to negative, which suggests that there could be more bankruptcy in the future, she says.

“I absolutely expect to see more of this down the road,” Homer says.

Big Promises Are Tempting

The healthcare industry, in general, is in flux and the insurance industry uncertainty plays a part in that, Homer says. Struggling hospitals and systems are looking for ways to survive and the siren song of a billionaire like Soon-Shiong can be irresistible.

“I think this case shows that while you will have individuals and groups that want to come in and save or fix these hospitals, particularly nonprofits, it’s not necessarily as easy as adding a flush of cash when you have all these other issues that aren’t going away,” Homer says.

Healthcare CEOs should look at Verity for lessons in how much financial pressures can mount up, Homer says.

“My hope would be that they are looking at these issues as early as possible – renegotiating contracts, upgrading systems, ensuring pensions are funded – before they get to a crisis point,” Homer says. “Clearly this case is a reminder that this can happen, this can be the end result for your hospital system. [CEOS] need to be cautious and act on these issues before they get so far that even a huge influx of cash won’t solve their problems.”

 

 

Erlanger’s board faces overhaul if conflict of interest bill becomes law

https://www.beckershospitalreview.com/hospital-management-administration/erlanger-s-board-faces-overhaul-if-conflict-of-interest-bill-becomes-law.html

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Chattanooga, Tenn.-based Erlanger Health System may have to upend its board of trustees if a bill targeting ties between governing bodies and public hospitals is signed into Tennessee law, according to the Times Free Press.

The bill, which passed the state’s Senate and is moving through its House, aims to protect consumers who live near a county or publicly owned hospital. It would prevent hospital authority trustees and former trustees from signing an employment agreement with an authority until at least 12 months after the trustee’s tenure of service on the board. The bill would not affect private or nonprofit hospitals.

The Times Free Press reviewed a list of current and former trustees from Erlanger to see if anyone would be affected by the bill. A hospital spokesperson told the publication “it would be premature for Erlanger to speculate who this bill impacts at this point.”

After reviewing conflict of interest disclosures trustees have to complete, the Times Free Press found current physician board members could have to choose between ending any financial ties with Erlanger or staying on the 11-member board.

Erangler’s Board Chairman Mike Griffin told the publication having physicians on the board is “a tremendous asset.” He added, “I am hopeful that the bill, in its final form, will not impact physician participation on Erlanger’s board.” 

 

 

 

WILLIS-KNIGHTON CEO CONTRACT EXTENDED DESPITE RETIREMENT PLANS, ‘COUP ATTEMPT’

https://www.healthleadersmedia.com/strategy/willis-knighton-ceo-contract-extended-despite-retirement-plans-coup-attempt?utm_source=silverpop&utm_medium=email&utm_campaign=ENL_190410_LDR_BRIEFING%20(1)&spMailingID=15444335&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1620658993&spReportId=MTYyMDY1ODk5MwS2

The board gave James K. Elrod two more years at the health system’s helm, despite the 81-year-old CEO’s retirement plans announced amid controversy.


KEY TAKEAWAYS

The longtime CEO signaled in 2017, after a push for his ouster, that his likely successor would be recruited to the health system so he could retire.

The board decided keeping the same leader in place for another two years would be ‘our greatest advantage’ in the midst of change.

Eighteen months have passed since the medical executive committee of Willis-Knighton Health System in Shreveport, Louisiana, urged the board to force President and CEO James K. Elrod to either step out of his longtime leadership position voluntarily or be pushed.

The committee’s statement of no confidence in a letter to the trustees complained that Elrod failed to tolerate dissent and hadn’t responded appropriately to changes in the healthcare industry, as the Shreveport Times reported, describing the incident as “an attempted coup.”

Elrod was 80 at the time. He had worked for the organization more than 50 years and turned what was an 80-bed hospital into what became Louisiana’s largest health system. He weathered the criticism with backing from the board. Then he signaled in a letter to hospital staff that a succession planning process for his likely successor was underway.

Despite the controversy, the board announced Friday that it asked Elrod, now 81, to stay at his post for another two years.

“After taking some time to consider our vote, Mr. Elrod graciously agreed to delay his retirement plans,” board president Frank Hughes, MD, said in a statement describing Elrod as “our greatest advantage” in the face of uncertainty and change.

“This is a clear indication of his ongoing dedication and commitment to Willis-Knighton, and we are grateful for this decision,” Hughes added. “While we are pleased with the current senior leadership team assembled during the past 18 months, we felt that the greatest gift we could give them is additional time for mentoring and guidance. We made this decision in support of our physicians, our employees and the larger community.”

“WHILE WE ARE PLEASED WITH THE CURRENT SENIOR LEADERSHIP TEAM ASSEMBLED DURING THE PAST 18 MONTHS, WE FELT THAT THE GREATEST GIFT WE COULD GIVE THEM IS ADDITIONAL TIME FOR MENTORING AND GUIDANCE.”

 

 

 

 

Scale: blessing or burden for statewide ACOs?

https://www.healthcaredive.com/news/scale-blessing-or-burden-for-statewide-acos/551206/

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Scale can smooth out quality variation and assuage providers’ fears of taking on risk. But it’s not a catch-all solution.

A handful of accountable care organizations are moving to cover an entire state, but not everyone thinks bigger is better when it comes to population health management.

Caravan Health, a company that works with ACOs, last week announced the launch of its second statewide program, this time in Florida. In the model, any of the 200-some Florida Hospital Association facilities that want to participate can join together to provide coordinated care.

The bid is meant to bolster care quality for Medicare beneficiaries while lowering costs and risk for participating facilities. But some experts say the larger scale, like rampant consolidation, could be more like an anchor weighing down an ACO instead of a beam propping it up.

“At the end of the day, success or failure is based on success in managing the quality of care,” Michael Abrams, partner at Numerof & Associates told Healthcare Dive. “While there may be some bigger numbers involved, I think the safety angle that they’re selling may not be all it’s cracked up to be.”

Caravan has no plans to back down on the model, however, and plans to roll out two more statewide ACOs in the next couple of weeks.

ACOs existed before the Affordable Care Act, but in 2011 HHS released new rules under the landmark law aimed at helping providers coordinate care through the population health management programs. Since then, the number of ACOs have grown dramatically, from an estimated 32 to more than 1,000 in 2018, according to Leavitt Partners.

A statewide all-payer ACO in Vermont has seen some success, but Caravan’s model and its efforts are some of the first to leverage the programs over a much larger population.

The business model

The Florida ACO, created in partnership with the FHA, is the second from Kansas City-based Caravan. The first, in Mississippi, was launched in January. Under the program, hospitals have access to Caravan’s population health management model to build primary care capacity and monitor quality results.

Mississippi currently has 29 providers participating in the program, managing care for roughly 130,000 Medicare patients in 22 locations. Its operations include hiring and training population health nurses throughout the state, annual wellness visits, chronic care management and more.

It’s potentially a good business playbook for both parties. The hospital association captures a revenue stream that’s not dependent on their membership — increasingly important in these days of sharp provider headwinds — and Caravan is granted access to the Medicare lives of a couple hundred hospitals in the state.

The need for population health management is especially acute in Mississippi, which ranks last or close to last in every leading health outcome, according to the state Department of Health. Florida and Mississippi couldn’t be farther apart when it comes to their primary care infrastructure, a factor linked to ACO success. According to the NCQA database, Florida has 894 patient-centered medical homes. Mississippi has 74.

“With population health, we improve the health of our state so it’s a win-win all the way around,” Paul Gardner, the director of rural health at the Mississippi Hospital Association told Healthcare Dive.

And Caravan, which currently works with more than 225 health systems and 14,000 providers, touts its track record with its programs. In 2017, its ACOs beat nationwide ACO performance with savings of $54 million and quality scores of 94%, a spokesperson said.

By comparison, studies have yielded mixed results when it comes to ACO success elsewhere.

An April report from Avalere found the Medicare Shared Savings Program, a CMS model to foster ACOs in Medicare, missed federal cost-savings projections from 2010 by a wide margin and raised federal spend by $384 million.

But a National Association of ACOs analysis retorted that MSSP ACOs saved $849 million in 2016 alone, and a whopping $2.66 billion since 2013 (higher than CMS’ $1.6 billion estimate). And an early 2017 JAMA Internal Medicine analysis found ACO savings only increase with time.

Scale: protection or illusion?

The threat of financial loss is a leading obstacle to participation in ACOs. Smaller ACOs are more likely to experience widely variable savings and losses simply due to change, Caravan representatives say, while larger ACOs deliver more predictable and sustainable results.

“The only way we can create certainty around our income is to have processes and accountability and the infrastructure, but you’ve also got to have to scale,” Caravan CEO Lynn Barr told Healthcare Dive. Barr said that since Caravan’s 2014 inception, the company has found having 100,000 Medicare lives or more in an ACO yields larger savings than the roughly 80-85% of ACOs with only 20,000 lives or fewer.

As the owner of the ACOs, Caravan assumes 75% of the financial risk for providers. Barr said that evens out to a maximum risk of $100 per patient.

By comparison, in the basic track of the Medicare Shared Savings Program, the maximum risk for providers is $400 per patient. In the enhanced model it’s $1,500. “With our model, if people follow it and have 100,000 lives, there’s no reason they would ever write a check,” Barr said.

That is one of the selling features of the statewide ACO: It can be a mitigating factor for hospitals that might feel too exposed on their own, Abrams said.

But the threat of risk could still prove too much. CMS finalized new rules for shared savings ACOs in December, shaving down the amount of time they had before they were forced to assume downside risk from six year to two years for new ACO participants or three years for new, low-revenue ACOs.

And some critics say it’s a safe bet that the losses incurred by any one organization are not going to be spread across the other parties in the ACO, especially given the shortened timeline. As the deadline for assuming more risk approaches, Caravan could see attrition among providers who don’t feel ready.

“I think this is very, very, very challenging,” nonprofit primary care advocacy Patient-Centered Primary Care Collaborative Director Ann Greiner told Healthcare Dive. “Most of the hospital leadership has not been working under these kinds of conditions.”

And ACOs are all about a connection to the community, which might prove difficult to foster across an entire state.

“You’ve got to leverage people at the community level and have those relationships with the patient and, in the ideal world, know where to refer,” Greiner said. “At the state level, that’s pretty far removed.”

Unified governance, heterogeneity pose problems

The scale of large ACOs makes them much more difficult to manage, experts say. ACOs have a single set of policies that, in an organization involving more parties, needs to be adopted in one form or another that’s acceptable to all participating providers.

That’s done by majority, Barr said. Each participating provider has a single vote and the overall vote binds the ACO board’s decision on waiver approval, discharge standards, shared savings distribution plans and more.

But in an ACO with a lot of differently cultured and structured providers — academic hospitals, teaching hospitals, acute care, research, small, medium, large etc. — it can get a lot more complicated, Abrams said. For example, if 100 FHA hospitals opt into the new Caravan Health model, that’s 100 variations in acute care policy, physician compensation and all else involved in managing cost and quality operations, and 100 different voices strongly advocating to keep doing things the way they’ve always done them.

“Some issues are just working through the details,” Gardner from the Mississippi Hospital Association said. “In some of your larger systems, that’s getting the medical staff all pulled together and singing off the same sheet of music.”

The more homogeneous the ACO organizations are, the easier it will be to get them to buy in to the various policies and procedures that need to be put in place for operations to flow smoothly. “You can’t outsource that,” Abrams said. “The most you can do is get guidance from someone who’s perhaps been around this block about how to handle it.”

Barr maintains Caravan standardizes the most important factors.

“Nurses are critical to this model,” Barr said. “That’s what everyone’s doing the same.” Caravan has found that after nurses are trained in population health management over three to six months, each dollar the company spends on that provider produces two dollars in savings.

And, after Caravan puts the population health management infrastructure in place, the providers themselves helm the ship with a steering committee, leveraging data to see what differentiates them from the next community and making slight adjustments to course-correct.

Challenges for hospitals

Hospitals will face two challenges: taking in the coordinated framework given to them by Caravan and translating it into behavioral change, Abrams said. The success of the overall ACO will depend on the latter as “those who can’t do that successfully will probably self-select out when it comes time to take on risk.”

The question is whether Caravan can really deliver on some of the promises it’s explicitly making.

“The truth is that hospitals who haven’t had the infrastructure to manage their cost and quality are not better off in terms of consolidation and a position in a larger ACO,” Abrams said. “So an ACO comprised of multiple small hospitals and independent hospitals can’t expect savings proportionate to their aggregate size.”

With more statewide ACOs on the way, it’s important Caravan (and partnering providers) work out any kinks in the model sooner rather than later.

“This is not like bringing in a plumber to fix your faucet,” Abrams said. “At the end of the day, an organization stands on its own.”

 

 

CEO of U of Maryland Medical System to take leave of absence amid scandal

https://www.beckershospitalreview.com/hospital-management-administration/ceo-of-u-of-maryland-medical-system-to-take-leave-of-absence-amid-scandal.html

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The president and CEO of Baltimore-based University of Maryland Medical System agreed to take a leave of absence, effective March 25, amid a scandal involving business deals between the system and several of its board members, according to The Washington Post.

Six things to know:

1. UMMS Board Chairman Stephen Burch announced the board’s unanimous decision March 21 to have President and CEO Robert Chrencik take a leave of absence. The system will also hire an independent accounting and legal firm to audit the board’s contracts, and the search for an independent third party will begin immediately.

“Over the past week, I’ve had the proper time to listen to concerns and reflect. The board and I am firmly committed to evolving our governance principles and operating with even more transparency,” Mr. Burch said.

2. John Ashworth, senior vice president of network development at UMMS and associate dean at the Baltimore-based University of Maryland School of Medicine, will serve as interim president and CEO of the 13-hospital system.

3. The leadership changes follow the resignations of three UMMS board members, including Baltimore Mayor Catherine Pugh. At least four other board members have taken a leave of absence. The deals have been sharply criticized by state lawmakers, including Gov. Larry Hogan.

4. Ms. Pugh resigned from the board after facing criticism for a $500,000 book deal she made with UMMS. A spokesperson for the mayor’s office said March 20 Ms. Pugh has returned $100,000 in profit to the health system because production on the books was delayed and they were not actually delivered to UMMS, which had planned to distribute the books to city schools.

5. Hours before Mr. Burch notified the public of Mr. Chrencik’s leave of absence, the Maryland House of Delegates unanimously fast-tracked a bill to overhaul UMMS’ 27-member board of directors, The Washington Post reports.

6. Amid the scandal at UMMS, The Baltimore Sun reviewed state disclosure and tax forms for several other health systems in the state and found at least five other systems have engaged in business deals with members of their board. The American Hospital Association’s guidance on the issue does not prevent such deals from taking place, but asks that leadership ensure “certain preconditions … to make sure that the organization’s interests prevail in the board’s decision-making.

 

CEOs shouldn’t pick their replacements

https://www.beckershospitalreview.com/hospital-management-administration/viewpoint-ceos-shouldn-t-pick-their-replacements.html?origin=ceo&utm_source=ceoe

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While CEOs may be intimately familiar with their companies, their opinion should take a backseat to the organization’s board of directors, according to Stanford (Calif.) University business school professor David Larcker, PhD, and researcher Brian Tayan.

In an op-ed for The Wall Street Journal, the authors note that while it was once general practice for CEOs to pick their successors, changes to corporate governance in recent years have shifted the balance of power to a company’s “independent, professional, outside directors.”

The authors claim that allowing a company’s CEO outsize influence on the hiring of their successor is a mistake because the CEO may not have the right perspective on evaluating candidates and may intentionally or unintentionally control the information presented to the board about candidates, shaping the board’s decision about those individuals.

“At the end of a long career, many CEOs are concerned about their legacy. This can bias them toward favoring candidates who will guide the company in the same direction — and in the same manner — that they themselves led it,” they write.

Instead, the authors argue that a company’s board should be responsible for the final hiring decision and use the CEO’s input to help come to that conclusion.

“Hiring the CEO is a fiduciary duty. The board owes it to the shareholders … to get it right. A subcommittee of independent directors with previous experience in succession at other companies should manage the process, with an open invitation to all board members to participate. If the board doesn’t have depth of experience in place, it can bring in an outside adviser to help,” they write.

To access the full report, click here.

 

The noble aim of being a great subcontractor

https://gisthealthcare.com/weekly-gist/

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Earlier this month I was at a health system board meeting in which we were discussing the transition from volume to value, and the shift to a population health model. One board member had the courage to ask a tough question: “What if we never get there?” Covering just a small slice of a large metropolitan area, this system has consistently ranked third in market share behind two larger competitors—and now they feel they are lagging those systems in moving toward risk. The most recent challenge: a large—and until recently, loyal—independent primary care group had just been acquired by one of their competitors. Yet the system prides itself, justifiably, on delivering low-cost hospital care and outstanding quality.

I raised a heretical notion: suppose the system pursued a strategy focused solely on being the highest-performing inpatient and specialty care provider in the market, and abandoned the goal of bearing population risk? Could the system shift their focus to simply being the best “subcontractor” to other risk-bearing networks in the market?

The ensuing conversation was uncomfortable, to say the least. The notion challenged the system’s assumptions of the role they wanted to play in the market, and whether they could be a leader in population health. I encouraged them to think of being a “subcontractor” to other risk-bearing organizations not as a defeat, but as fulfillment of a vital role—healthcare in their community would be better if more hospital care were delivered at their level of cost and quality.

Our view: for many smaller systems who are driven by a desire to remain independent, becoming a high-performing care subcontractor may be the best path forward, and the most realistic. (It will be interesting to watch the successful investor-owned chains on this front—organizations whose strategic advantage lies in running highly-efficient, low-cost hospitals.) It’s not as sexy as “population health”, but as any builder will tell you, there’s no substitute for a great subcontractor.