CMS gives $2.4 billion boost to inpatient hospitals for fiscal year 2018 with final uncompensated care rule

http://www.healthcarefinancenews.com/news/cms-gives-24-billion-boost-inpatient-hospitals-fiscal-year-2018-final-uncompensated-care-rule?mkt_tok=eyJpIjoiTXpOa01qUXhaVGd5TnpkaiIsInQiOiJudFozOHVLS1VVNXZZRE42Y0RmTWdIZHpkOU0yNERUSmlXU0VCMlJDMEFyMmVTUUc4aVwvcXRVc0gzXC9ndUdJVjhHT1drZkkzdDhBVFhHZ3BHVjI1NmhIVHY1RmNXSENVdWtwb3RVVnVtaFNWbXNFdnBzb0JVenRcL1ZuR1p0MW0zRyJ9

Inpatient hospitals will see increase of $800 million over the previous year, but long-term care facilities face $110 million cut in payments.

CMS Final Rule for the 2018 Medicare Inpatient Prospective Payment System will give hospitals an overall $2.4 billion raise in fiscal year 2018, the agency said.

Due to the combination of payment rate increases, other policy changes and adjustments acute care hospitals will see $6.8 billion in payments for uncompensated care, an increase of $800 million over the previous year, CMS said.

Medicare payments to inpatient psychiatric facilities will rise by $45 million, or roughly one percent. However, long-term care hospitals will decrease by $110 million in fiscal year 2018.

The changes will affect 3,330 acute care facilities and roughly 420 long-term care hospitals for discharges happening after October 1, 2017. The new rule incorporates CMS’ finalized proposal to use data from its National Health Expenditure Accounts in its estimate of the rate of uninsurance, which is used in calculating the total amount of uncompensated care payments available.

Long-term care hospitals will be facing a cut. Under the 2018 final rule, CMS projected payments will drop roughly 2.4 percent, or $110 million in FY 2018, which is “due in large part to the continued phase in of the dual payment rate system.” However, this amount is actually smaller than the previously projected cut of 3.75 percent, which was first proposed back in April.

CMS has also finalized its proposal for a one-year regulatory moratorium on the payment reduction threshold for patient admissions for long-term care hospitals in FY 2018 while they continue to evaluate the policy, CMS said.

Court complicates Trump’s threat to cut ‘Obamacare’ funds

https://www.washingtonpost.com/politics/federal_government/trump-on-tricky-legal-ground-with-obamacare-threat/2017/08/01/436cfc8e-771e-11e7-8c17-533c52b2f014_story.html?utm_term=.35d0bd8ec053

Image result for us court of appeals circuits

President Donald Trump’s bold threat to push “Obamacare” into collapse may get harder to carry out after a new court ruling.

The procedural decision late Tuesday by a federal appeals panel in Washington has implications for millions of consumers. The judges said that a group of states can defend the legality of government “cost-sharing” subsidies for copays and deductibles under the Affordable Care Act if the Trump administration decides to stop paying the money.

Trump has been threatening to do just that for months, and he amped up his warnings after the GOP’s drive to repeal and replace “Obamacare” fell apart in the Senate last week. The subsidies help keep premiums in check, but they are under a legal cloud because of a dispute over the wording of the ACA. Trump has speculated that he could force Democrats to make a deal on health care by stopping the payments.

The court’s decision is “a check on the ability of the president to sabotage the Affordable Care Act in one very important way,” said Tim Jost, professor emeritus at Washington and Lee University School of Law in Virginia, a supporter of the ACA who has followed the issue closely.

Because of the ruling, legal experts said, states can now sue if the administration cuts off the subsidies. Also, they said, the president won’t be able to claim he’s merely following the will of a lower court that found Congress had not properly approved the money.

“We’re not going to wait to find out what Donald Trump wants to do,” said California Attorney General Xavier Becerra, who is helping steer the states’ involvement. “My team is ready to defend these subsidies in court.”

The Justice Department had no comment. The White House re-issued an earlier statement saying, “the president is working with his staff and his Cabinet to consider the issues raised by the … payments.”

Trump has made his feelings clear on Twitter. “If ObamaCare is hurting people, & it is, why shouldn’t it hurt the insurance companies,” he tweeted early Monday.

He elaborated in an earlier tweet, “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies…will end very soon!”

In a twist, the appeals court panel seemed to take such statements into account in granting 17 states and the District of Columbia the ability to intervene on behalf of consumers.

The judges’ decision said states’ doubts that the administration could adequately defend their interests in court were fanned by “accumulating public statements by high-level officials…about a potential change in position.”

“He’s really a terrible client, President Trump is,” University of Michigan law professor Nicholas Bagley said. “The states point to his public statements and say, ‘Are you kidding me? We know the president is poised to throw us under the bus and we know because he said so.’”

The health law requires insurers to help low-income consumers with their copays and deductibles. Nearly 3 in 5 HealthCare.gov customers qualify for the assistance, which can reduce a deductible of $3,500 to several hundred dollars. The annual cost to the government is about $7 billion.

The law also specifies that the government shall reimburse insurers for the cost-sharing assistance that they provide.

Nonetheless, the payments remain under a cloud because of a disagreement over whether they were properly approved in the health law, by providing a congressional “appropriation.”

House Republicans trying to thwart the ACA sued the Obama administration, arguing that the law lacked specific language appropriating the cost-sharing subsidies.

A district court judge agreed with House Republicans, and now the case is before the U.S. appeals court in Washington

If Trump makes good on his threat, experts estimate that premiums for a standard “silver” plan would increase by about 19 percent. And more insurers might decide to leave already shaky markets.

In Congress, some prominent lawmakers in both parties are saying they hope to provide at least a temporary guarantee for the subsidies before open enrollment season for 2018 starts Nov. 1.

CHS expects $137M net loss in Q2, says divestitures will continue

http://www.beckershospitalreview.com/finance/chs-expects-137m-net-loss-in-q2-says-divestitures-will-continue.html

Image result for all that glitters is not gold

Franklin, Tenn.-based Community Health Systems ended the second quarter of 2017 with a net loss of $137 million, marking the fifth consecutive quarter the company has posted a loss, according to a preliminary earnings statement released Wednesday.

CHS recorded revenues of $4.14 billion in the second quarter of this year, down 9.7 percent from revenues of $4.59 billion in the same period of 2016. The drop was attributable, in part, to lower patient volumes. Total admissions were down 10.8 percent in the second quarter of 2017 compared to the same quarter of last year. On a same-facility basis, admissions were down 2.5 percent year over year.

In addition to a drop in patient volume, CHS said the lower than anticipated results in the second quarter were attributable to higher expenses related to purchased services, medical specialist fees and information systems. The company’s financial results also included one-time expenses related to its hospital divestitures.

The company ended the period with an operating loss of $131 million. That’s compared to the $1.43 billion operating loss CHS reported in the second quarter of 2016, when it recorded a noncash impairment charge of $1.4 billion.

To improve its finances and reduce its nearly $15 billion debt load, CHS put a turnaround plan into place last year. As part of the plan, the company announced earlier this year that it intended to sell off 30 hospitals.

CHS completed the sale of nine hospitals on June 30 and July 1, bringing its total completed divestitures to 20 out of the 30 it intends to sell off. The company said it expects to complete the divestiture of the remaining 10 hospitals by Sept. 30.

In its preliminary earnings release, CHS said it plans to continue to unload more hospitals.

“In addition to the previously announced divestiture of 30 hospitals, the company continues to receive interest from acquirers for certain of its hospitals. The company is pursuing this interest for sale transactions involving hospitals with a combined total of at least $1.5 billion in annual net revenue and combined mid-single digit adjusted EBITDA margins,” CHS said.

CHS will release its formal numbers for the second quarter and the first half of 2017 on Aug. 1.

CMS moves forward with $43B in DSH payment cuts

http://www.beckershospitalreview.com/finance/cms-moves-forward-with-43b-in-dsh-payment-cuts.html

Image result for cutting currency

CMS issued a proposed rule Thursday that lays out a methodology for implementing cuts to Medicaid Disproportionate Share Hospital allotments under the ACA beginning in fiscal year 2018.

With the expectation of lower uninsured rates and lower levels of hospital uncompensated care, the ACA adjusted the amounts of funding available to states under the Medicaid program for hospitals that serve a disproportionate share of low-income patients. The ACA calls for aggregate reductions to Medicaid DSH payments annually from FY 2014 through FY 2020. Subsequent legislation delayed the start of the reductions until FY 2018 and pushed the end date back to FY 2025.

Medicaid DSH allotments are slated to be reduced by $2 billion in FY 2018. The reductions will grow by $1 billion per year through FY 2024, when payments will be cut by $8 billion. DSH allotments will be reduced by another $8 billion in FY 2025.

CMS proposed a methodology that would account for new data sources, some of which were unavailable during prior rulemaking. Those sources include DSH Medicaid Inpatient Utilization Rate data, U.S. Census Bureau data and existing state DSH allotments. “We are proposing to utilize the most recent year available for all data sources and are proposing to align data sources whenever possible,” said CMS.

The proposed methodology would help ensure DSH payments reach hospitals with the most need for financial assistance due to high volumes of Medicaid inpatients and high levels of uncompensated care, according to CMS.

CMS will accept comments on the proposed rule until Aug. 28 at 5:00 p.m.

More examples of what not to do AKA how to stay in the frying pan and not fall into the fire.

More examples of what not to do AKA how to stay in the frying pan and not fall into the fire.

Image result for interimcfo.wordpress.com

This is the second article in the series about what not to do.  The person suggesting this article asked for examples of things that might help you save yourself from yourself.  Please send me your examples and stories of things not to do.  Your confidentiality will be protected unless you want credit for the idea.  Sharing this experience, especially with younger executives is one of the best ways to serve the industry.  I have an outline of a third article and depending upon response, I could probably keep this going for a while since like a consultant friend of mine used to say, “One idiot can keep three consultants busy forever.”

Project planning

Ben Franklin’s adage goes, “Failing to plan is planning to fail.”  I have found this profound simple statement to be true time and again.

After being appointed interim CFO in a hospital, I learned that there was a major construction project under way.  The project and the rate at which the hospital was burning money on the project did not make sense to me.  To make a long, complicated story short, no one could produce a feasibility study to support the project’s value proposition or pro-forma analysis to support the project’s underlying  financing.  When no one could produce a sources and uses of funds analysis, I spent a couple of weeks creating my own from scratch.  When I was finished, it was clear that the project was underfunded by over $20 million and the hospital did not have sufficient reserves to cover the shortfall.  When this information was provided to the Board, after they recovered from the shock and horror, they decided to stop the project that would have resulted in a default in the bonds by drawing reserves below bond covenant minimum requirements triggering a technical default.  The entire organization was oblivious to this looming disaster.

Ole Abe said that, “You should spend twice as much time sharpening your axe as you spend cutting with it.”  The implication of this admonition is obvious to anyone that has ever cut wood with an axe.  Still and yet, executives let distractions and competition for their time lead them to allow ill-conceived initiatives to go forward then they are surprised when the projects blow up on them.  If you want to entertain yourself, pick any executive out at a cocktail party and ask them if they have ever seen a project go bad.  The war stories you will hear are spectacular. Better yet, ask the ‘expert’ if they have ever seen a peer do something stupid.  Apparently, they have not heard or have disregarded the advice of Einstein, “Doing the same thing and expecting a different outcome is the beginning of insanity.”

Project control

Oh boy!  The easy part of a project is the planing and approval.  The hard part is execution.  There are a lot of challenges with project execution.  One is that other unanticipated confounding priorities arise in the organization that bleed capacity from the organization’s leadership to remain focused on a critical project.  Another commonly seen problem with project execution is the loss of key leaders during the course of the project.  All too frequently, critical assumptions underlying the project’s rationalization are proven inaccurate or incomplete once execution begins.  Sometimes, a project’s success is largely dependent upon one person and if that person leaves or is incapacitated, the entire project goes into jeopardy.

To some degree, a project is analogous to a marriage.  In order for it to succeed, more than 100% commitment is required from all sides.  Every effort you make to manage your risk can be thwarted by uncontrollable changes in your business partner(s).  There is no guarantee that the people that sold a deal and made commitments on behalf of your business partner will be around to honor those commitments.  If they made commitments that were not in the contract, they may not be allowed to honor them.  More than once before a project was completed, I have found myself dealing with an entirely different cast of characters.  What about a business partner that gets acquired during implementation and none of the commitments made before the acquisition are honored?  A business failure or overcommitment by a business partner can move into your life like bad in-laws.  This is why business partner selection is so important.  Too often, a decision maker will chose a business partner based on cost alone and in the process buy himself a set of problems that turn out to be exponentially more expensive than the most expensive option that was under consideration at the time the decision was made.

A project does not have to fail to become a disaster.  Delays in a project can be as damaging.  I do not know of a delayed project that resulted in a better outcome.  Sometimes, delays cause cascading problems.  Take a construction project for example where the electrical contractor is contracted to start on a date certain and the project is not far along enough for them to begin work.  This kind of a delay can rapidly spread throughout an organization and create enough problems to overwhelm the ability of the leadership team to address them.  This is the reason you were required to study PERT in school.  How often do you see it applied in practice?

If a mistake is to be made in project management, it should be biased in favor of overcompensation for potential problems.  I am regularly criticized for being too conservative and too hard on pro-forma analysis assumptions. Never the less, time after time I see projected revenues and time lines being overstated and projected expenses understated.

Waiting too long to intervene

I have watched executives demur from engaging an issue in hopes that it would go away.  I have rarely seen this strategy work.  More often than not, a problem in an organization will get worse the longer intervention is delayed.  There are a lot of reasons that this occurs not the least of which is that addressing operational problems most often involves dealing with a personnel problem.  I do not know many executives that enjoy taking on a personnel problem.  Vince Lombardi said, “Hope is not a strategy.”  Failing or refusing to intervene can allow a problem to become exponentially more damaging until it reaches the point that the organization’s financial statements are impacted.  Time and again as an interim, I have been asked, why it was going to take so long and cost so much to address a problem?  I have seen ten or more interim executives committed to address what had been allowed to become a major business problem on more than one occasion.  My answer to this question is always the same.  Cutting costs after an organization finally decides to address a problem only prolongs the time and cost necessary for the mitigation.  All too frequently, organizations create a problem by under-resourcing an area or initiative.  When this leads to a melt-down, the leaders charged with the mitigation are frequently frustrated by the cost and time associated with fixing the resulting mess.  Sometimes, I have to tell them for their future reference that the cost associated with keeping a process or function under control is always a small fraction of the time and resources necessary to straighten it out after it goes catawaumpus.  Every executive I know can relate one or more horror stories to prove this point.  More often than not, the fiasco is related to an I/T implementation where the costs and operational consequences associated with a failed project can exceed the original budgeted cost of the project.

Fire fighters are known for over-commiting resources to a fire.  This strategy is designed to err on the side of having more resource than is needed to address the fire as opposed to running the risk that a growing fire will overwhelm the resources that are available on site.  Once, I asked an interim CEO how it was going relatively early into his engagement in a very troubled large hospital.  His answer that I have never forgotten was, “The platform is on fire.”  A platform is like a ship.  When it catches fire, getting off is rarely an option.  You must fight the fire where it is and failure is not an option.  Remember the USS Forestall?  Skimping on resources when dealing with a problem like this can lead to figurative death in the form of an unplanned career transition.  A business problem is analogous to a fire in the organization.  If you are going to make a mistake addressing a problem, your personal risk will be much lower if you respond aggressively to a problem and err on the side of over-commiting resources until the problem is resolved and the situation stabalized.  The alternative is a potential conflagration.

Non-evidence based decisions

The mantra of UAB’s Doctorate of Administration in Health Sciences program is, “Evidence based practice in Healthcare Administration.”  I have commented before on what appears to be a paradox in healthcare.  On the clinical side, most of what is done is based on evidence gained from objective, peer reviewed research.  The purpose of the research is to yield better outcomes and safer facilities for patient care.  In the administrative suites of too many healthcare organizations, decisions are routinely made based on seat-of-the-pants hunches, little or no analysis, ridiculous assumptions, no assumptions, flawed analysis, systematic ignorance or reckless disregard of applicable evidence and research.  More often than not, harried administrators do not even bother to see if any applicable research is available.  In other cases, decisions are made for political expediency or to appease Dr. Huff-and-Puff.  I got into trouble in a Catholic hospital for suggesting the leadership team’s decision making ranged from magic eight ball to Ouija board.  I now keep a magic eight ball on my desk as a reminder to not fall into this trap.  It is funny to have younger people ask me what the magic eight ball is. They’re not old enough in some cases to have ever heard of the magic eight ball and they are fascinated to see how it works. It is a wonder some organizations get along as well as they do.

Indecisiveness
I was perusing novelty signs in a gift shop in Indiana when a sign captured my attention.  It said, “Decision making around here is like a squirrel crossing the road.”  Indecisiveness can be dangerous when it is practiced in the front office.  At its least, indecisiveness can lead to project and initiave delays.  At worst, it can wreck not only projects but the credibility of executives with their Boards.  There’s a one liner that says, “The road to failure is littered with run over squirrels.”  In an earlier article I said, “If you are a decision maker, make a decision.”  Not making a decision is making a decision.
As before, I would like to thank Dr. Christy Lemak Professor and Chair of the UAB Department of Health Services Administration for the inspiration or should I say assignment that resulted in this article. I am looking forward to seeing my grade.
Please feel free to contact me to discuss any questions or observations you might have about these blogs or interim executive services in general.  As the only practicing Interim Executive that has done a dissertation on Interim Executive Services in healthcare in the US, I might have an idea or two that might be valuable to you.  I can also help with career transitions or career planning.
The easiest way to keep abreast of this blog is to become a follower.  You will be notified of all updates as they occur.  To become a follower, just click the “Following” link that usually appears as a bubble near the bottom this web page.
There is a comment section at the bottom of each blog page.  Please provide input and feedback that will help me to improve the quality of this work.
This is original work.  This material is copyrighted by me with reproduction prohibited without prior permission.  I note and  provide links to supporting documentation for non-original material.
If you would like to discuss any of this content or ask questions, I may be reached at ras2@me.com. I look forward to engaging in productive discussion with anyone that is a practicing interim executive or a decision maker with experience engaging interim executives in healthcare.

The Latest Motion In House v. Price Has A Significant Impact On The Future Of CSR Payments

http://healthaffairs.org/blog/2017/08/01/the-latest-motion-in-house-v-price-has-a-significant-impact-on-the-future-of-csr-payments/

On August 1, 2017, the United States Court of Appeals for the District of Columbia granted the motion of the attorneys general of 17 states and the District of Columbia to intervene in House v. PriceHouse v. Price is before the D.C. Circuit on appeal from the ruling of a district court judge in favor of the House of Representatives in its lawsuit claiming that the reimbursement of insurers for reducing cost sharing for low-income qualified health plan enrollees is illegal because Congress had not appropriated funding for the payments. The judge enjoined the payments but stayed her order pending an appeal and the Obama administration in fact appealed. The states had moved to intervene, claiming that they had an interest in the action and that the Trump administration was not adequately defending their interest.

The three-judge appellate panel held first that the states had demonstrated that they had standing to intervene because they “would suffer concrete injury if the court were to grant the relief the plaintiffs seek.” The states established that a judgment for the House terminating the payments would “lead directly and imminently to an increase in insurance prices, which in turn will increase the number of uninsured individuals for whom the States will have to provide health care.” This would in turn result in state-funded hospitals suffering financially when they have to cover emergency care for uninsured individuals.

The court further held that the states had established a right to intervene in the action. First, the states had established an interest in the subject matter of the lawsuit.

Second, the court held that allowing the injunction of the court below would impair the states’ rights. The court observed that the administration’s “claim that it could unilaterally suspend payments is a debated legal question, not an answer to the injury the States have evidenced. The injunction sought, which would forbid the payments at issue, would erect a roadblock to the States’ goal of either persuading or compelling the Department to make the payments.”

Third, the court held that the states had raised a sufficient doubt concerning the adequacy of the administration’s representation of their interest. The court noted that the administration had nowhere argued that it would protect the states’ interest or continue to pursue the appeal.

Fourth, the court held that the motion to intervene was timely. The states, the court held, “had filed within a reasonable time from when their doubts about adequate representation arose due to accumulating public statements by high-level officials both about a potential change in position and the Department’s joinder with the House in an effort to terminate the appeal.” The court, in short, took President Trump’s threats to terminate the cost-sharing reduction (CSR) payments seriously.

Finally, the court held that permissive intervention was also warranted in the case.

The court further ordered that the case would continue to be held in abeyance, with status reports at 90-day intervals and the next one due on October 30, 2017. With their status as parties to the case, however, the states may well next seek to get the case moving again.

The decision does not mean that the Trump administration is barred from ending the cost-sharing reduction payments. It does mean, however, that the administration cannot unilaterally stop the CSR payments, dismiss the appeal, and claim judicial imprimatur for its doing so. If the administration does stop making the payments, the states—or insurers, or possibly consumers—would be able to sue to require the payments to be made and the injunction entered by the lower court would not be as much of a “roadblock” to their prevailing. Finally, if the states ultimately convince the appellate court that the CSR funding has in fact been appropriated, the administration would be required to pay it. The decision is, therefore, a major development in the ongoing CSR saga.

29 hospital, health system outlook and credit rating actions in July

http://www.beckershospitalreview.com/finance/29-hospital-health-system-outlook-and-credit-rating-actions-in-july.html

Image result for credit ratings

 

Brigham and Women’s may extend buyout offer beyond initial 1,600 employees

http://www.beckershospitalreview.com/hospital-management-administration/brigham-and-women-s-may-extend-buyout-offer-beyond-initial-1-600-employees.html

Image result for employee layoffs

Boston-based Brigham and Women’s Hospital may ask more employees to voluntarily leave their jobs just three months after offering buyouts to 1,600 employees, according to The Boston Globe.

“We are considering a respectful way to minimize any potential involuntary reduction in force by inviting some employees who may wish to leave the Brigham to voluntarily separate from the organization,” the hospital said in a statement to The Boston Globe. “When we announced the voluntary retirement opportunity in April, we indicated that additional reductions in force would likely be necessary.”

When Brigham and Women’s announced the buyout offer in April, the organization said it is profitable but facing pressure amid shrinking payments from government and commercial insurers and growing labor costs. Buyouts were only offered to employees age 60 or older. The offer includes one year of base pay and health insurance for up to 20 months.

About 45 percent of those eligible have applied for the buyout, according to The Boston Globe.

A hospital spokesperson told The Boston Globe the hospital hasn’t decided how many and which employees to extend the buyout offer to.

Brigham and Women’s is owned by Boston-based Partners HealthCare and has approximately 18,000 employees.

Fitch: Failed ACA replacement efforts add to healthcare sector uncertainty

http://www.beckershospitalreview.com/finance/fitch-failed-aca-replacement-efforts-add-to-healthcare-sector-uncertainty.html

Image result for negative credit outlook fitch

As ACA repeal and replace efforts stall, significant uncertainty remains surrounding how federal policy will affect nonprofit healthcare organizations, leading to a negative sector outlook for healthcare, according to Fitch Ratings.

The uncertainty and negative outlook comes as the Trump administration looks for ways to weaken the ACA even if the health reform law is not repealed.

Nonprofit hospitals experienced declines in uncompensated care under the ACA because of an increase in healthcare coverage due to Medicaid expansion, rollout of healthcare exchanges and allowing children to stay on their parent’s health insurance plan until age 26.

While repeal efforts cause uncertainty for hospitals, current discussions regarding a bipartisan healthcare bill could be beneficial for nonprofit hospitals. A bipartisan effort could potentially reduce the insurance premium price hikes, according to Fitch.

55 hospital transactions and partnerships in July

http://www.beckershospitalreview.com/hospital-transactions-and-valuation/55-hospital-transactions-and-partnerships-in-july.html

Image result for m&a hospital