Kaiser Permanente waives tuition for first 5 medical school classes

https://www.beckershospitalreview.com/hospital-physician-relationships/kaiser-permanente-waives-tuition-for-first-5-medical-school-classes.html

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Oakland, Calif.-based Kaiser Permanente announced its intent Feb. 19 to waive all four years of tuition for the first five classes of students admitted to its new medical school.

Kaiser officials said in a news release obtained by Becker’s Hospital Review that its medical school has received preliminary accreditation from the Liaison Committee on Medical Education and will begin accepting applications from prospective students in June 2019 for its inaugural class in summer 2020. Each class will contain roughly 48 students, according to The New York Times.

Mark Schuster, MD, PhD, founding dean and CEO of the Pasadena, Calif.-based Kaiser Permanente School of Medicine, told The New York Times that while the institution only plans to cover the entire $55,000-per-year tuition for all of its first five classes of students, Kaiser will offer “very generous financial aid” based on need for future students.

Kaiser is the second institution to announce that it will waive tuition for students. Last August, the New York City-based NYU School of Medicine declared plans to cover its entire tuition costs for all students, which equates to more than 400 students across classes.

While NYU raised $600 million from donors to pay for its tuition plan, Kaiser is using a portion of its revenue set aside for “community benefits,” which all nonprofit hospitals have to provide to maintain their tax-exempt status, according to The New York Times. The health system, which has an operating revenue of nearly $73 billion, spent $2.3 billion on community benefits in 2017, including charity care for the uninsured and community health spending.

The medical school will be one of the only medical schools in the U.S. to be affiliated with a hospital or health system, not a university, The New York Times reports. Its curriculum will include a focus on small-group, case-based learning, and students will travel to the health system’s hospitals and clinics in the greater Los Angeles area for their clinical education.

“We’ve had the opportunity to build a medical school from the ground up and have drawn from evidence-based educational approaches to develop a state-of-the-art school on the forefront of medical education, committed to preparing students to provide outstanding patient care in our nation’s complex and evolving healthcare system,” said Dr. Schuster said in a news release.

In December, Kaiser added 11 executives to the medical school’s leadership team.

To access the full report, click here.

 

 

Kaiser Permanente just invested in a housing complex. Here’s what it’s doing with it

https://www.fiercehealthcare.com/hospitals-health-systems/kaiser-permanente-aims-to-address-homelessness-by-investing-affordable?mkt_tok=eyJpIjoiTlRnM1lUZGhNV1kzWXpjeSIsInQiOiI5UFUwa2VZSFwvMU0rSjZjcys5ZDdlWXB2dll2SlBPNTFXcVVvd3Y3ODA3S0hSMFZxZFVtbUd6TDV4bU9qSVpmTEljSUZOc3JsbWRmT3g1dGplaVhuSXJtYWhXUUtiSUlHNTRnTk1sU2VuSVdCYUF2SnZlbU03M1wvVks4N0U3TVJJIn0%3D&mrkid=959610&utm_medium=nl&utm_source=internal

Kaiser Permanente

Kaiser Permanente has gotten into the business of housing.

The health system announced in May that it would put $200 million toward initiatives targeting housing insecurity and homelessness in the communities it serves. On Tuesday night, it announced the first investment is the $5.2 million purchase of an affordable housing complex in Oakland, California, through a fund in partnership with Enterprise Community Partners and the East Bay Asian Local Development Corporation.

The 41-unit building is in an Oakland neighborhood “on the brink of gentrification” which puts the existing residents at risk for displacement. By purchasing the building, it will be blocked from redevelopment that prices out the existing residents, preventing displacement, Kaiser Permanente CEO Bernard Tyson said at a press event on Tuesday.

Preserving buildings like this is a “key component to addressing the national homelessness crisis,” he said. “We know that preserving affordable housing is more effective than building new units.”

It’s part of a comprehensive strategy, officials said, to invest in addressing the economic, social and environmental conditions that ultimately affect the health of their patients.

Kaiser also announced it is “adopting” 500 homeless individuals in the city, Tyson said. He said that several of the system’s employees focused for 12 weeks to expedite a strategy to partner with community groups to house older homeless patients with chronic conditions.

All 500 people identified by the system have at least one chronic condition. The system is working with local groups to secure housing and other needed services for this group.

The plans unveiled by the system on Tuesday also expand beyond Oakland and the Bay Area, where Kaiser is headquartered. On top of the two initiatives focused in that region, Kaiser and Enterprise are teaming up to launch a $100 million loan fund to create or maintain affordable housing units in all of the communities Kaiser Permanente serves. 

Tyson said the health system will make future announcements about specific plans under that fund. Tackling this issue, he said, “ties into who we are and what we’re about as Kaiser Permanente.”

“This is the beginning of us being in traffic and backing our talk that we want to help to make a difference in Oakland, in the Bay Area, in this great country,” Tyson said.

 

 

 

Insurers blame specialty drug costs for rising premiums. This report from California shows why

https://www.fiercehealthcare.com/payer/report-prescription-drug-costs-driving-up-insurance-premiums?mkt_tok=eyJpIjoiWWpZNU4yTTROREExWlRsaSIsInQiOiJjZHh5VGpsWnhSN3RLQjNHbDNsWUROQkg0Y2EzOFZ3OFY2Z0Z1a1dFNVhwNkRXNTE3dTNMK0U2TloxUnFKT1RDU29cL3NEZ0gwMTdJbUptaTFxamFTbFg1cG1PbFRHbTQ2TmQzRHhYZERqcUZXQ1B0YVF1aW1QODBDb2g3aHA1cEwifQ%3D%3D&mrkid=959610&utm_medium=nl&utm_source=internal

Drugs and money sign

Specialty drugs made up about 3% of prescriptions in California in 2017 but accounted for more than half of the prescription drug spending that year, according to new report that compiled drug spending from nine insurers in that state.

According to the first Prescription Drug Cost Transparency Report released by the California Department of Insurance, there were about 270,000 specialty prescriptions compared to about 1.4 million brand-name prescriptions and about 8.9 million generic prescriptions in 2017.

Insurers—including Aetna, Anthem, Cigna, Kaiser Permanente and UnitedHealthcare—reported spending upwards of $606 million on specialty drugs, $271.3 million on brand-name drugs and $172.6 million on generics in 2017.

Among other findings, the report said:

  • In all, insurers reported that per member per month drug spending reached about $81 last year, or about 16.5% of premiums in 2017, comparable to per member per month spending of about $76 or 16.3% in 2016. Total health insurance premiums per member per month were about $491 in 2017, compared to about $470 in 2016.
  • Specialty prescriptions on average cost about $2,361 per prescription compared to about $236 for brand-name prescriptions and $29 for generics. Members typically pay about $113 per specialty prescription while insurers said they pay about $2,248 per specialty drug. They report members pay about $45 per brand-name drug, while insurers pick up $192 of the tab for brand names. And they report members typically pay about $10 for generics on average while insurers pay about $19.
  • The top 25 most frequently prescribed drugs in California represent about 40% of insurers’ overall spending. Specialty drugs make up about 1.3% of the 25 most frequently prescribed drugs and about 20% of insurers’ spending (resulting in a 3.7% impact on health insurance premiums.) In comparison, brand-name drugs make up about 6.8% of the most frequently prescribed drugs and about 11% of insurer spending (and a 1.2% impact on health insurance premiums). Generics represent about 32% of the most frequently prescribed drugs and 4% of the cost to insurers (and about .3% impact on premiums.)

The most frequently prescribed specialty drugs included HIV drug Truvada, immunosuppressant Humira, insulin therapeutic Humalog, diabetes drug Victoza and hormonal agent Androgel.

The most costly specialty drugs by total annual prescription drug spending included Humira, arthritis drug Enbrel, Truvada, psoriasis and psoriatic arthritis drug Stelara and multiple sclerosis drug Copaxone.

 

 

 

Dr. Toby Cosgrove: 2019 will be the year of telehealth

https://www.beckershospitalreview.com/telehealth/dr-toby-cosgrove-2019-will-be-the-year-of-telehealth.html?origin=bhre&utm_source=bhre

Image result for telehealth trends 2019

Toby Cosgrove, MD, former CEO of Cleveland Clinic, told CNBC he foresees 2019 as the year telehealth becomes ubiquitous.

Although telehealth has already permeated the healthcare space, many patients don’t know it exists, Dr. Cosgrove said. However, as awareness grows, patients are increasingly becoming interested in using video conferencing with their physician as a way to save a trip to a hospital. Telehealth also helps patients with chronic conditions, who may need regular monitoring.

“[Oakland, Calif.-based Kaiser Permanente] is seeing over 50 percent of their patients distantly,” Dr. Cosgrove told CNBC.

Dr. Cosgrove, who now serves as an executive advisor to Google Cloud’s healthcare and life sciences team, also said the cloud will serve as a way to make the tremendous amount of data available in healthcare actionable.

“There’s an enormous amount of data and it’s a problem for us to keep track of and that’s why I think the cloud is going to come in,” he said, noting data can be stored and analyzed in the cloud. “So now you can have huge data sets that you can begin to analyze, and now that’s where [artificial intelligence] and machine learning comes in.”

“As the data goes to the cloud all the major cloud providers have come to an agreement that they will share unidentified information,” he added.

 

Labor board will charge Kaiser for refusing to bargain, union says

https://www.healthcaredive.com/news/labor-board-will-charge-kaiser-for-refusing-to-bargain-union-says/544648/

Dive Brief:

  • The National Labor Relations Board (NLRB) is preparing to prosecute health system Kaiser Permanente for refusing bargain with SEIU United Healthcare Workers West, according to the union. SEIU-UHW, part of the Coalition of Kaiser Permanente Unions, filed a complaint with the NLRB in the spring charging Kaiser for refusing to negotiate a new contract that covers 85,000 employees across eight states and D.C. Hearings for case will likely begin in the spring.
  • In their complaint, SEIU-UHW and the Coalition of Kaiser Permanente Unions claimed Kaiser tried to set conditions on bargaining that would ban unions from engaging in political action that could affect the healthcare organization. Kaiser issued a statement last week arguing the delay was due to a split that occurred within the coalition earlier this year, and said it is “confident the NLRB will agree that Kaiser Permanente has acted lawfully and in good faith” in dealings with SEIU-UHW.
  • That may not be the case. SEIU-UHW is planning on proposing a new arrangement. If Kaiser doesn’t agree to enter into that settlement proposed by the union, the NLRB is expected to issue charges by the end of the month — if not sooner, according to an email obtained by Healthcare Dive.

Dive Insight:

Kaiser has been wracked with labor woes this year. The health system reached an agreement with the Alliance of Health Care Unions — the 21 unions that broke off from the Coalition of Kaiser Permanente Unions — earlier this year. That split occurred the day before bargaining was scheduled to begin, and negotiations with the coalition did not move forward.

That contract, according to SEIU-UHW, included a condition prohibiting those unions from taking any kind of political action against Kaiser, including ballot initiatives, legislation or public policy campaigns. That’s the same condition that led SEIU-UHW to file its complaint earlier this year.

“The Coalition of Kaiser Permanente Unions strongly opposes such a proposal,” SEIU-UHW said in a statement, “and believes this condition violates their free speech rights.”

Healthcare Dive reached out to the NLRB for confirmation on its reported decision to prosecute Kaiser, but did not receive a response in time for publishing.

“The decision confirms what has been clear to workers for months now: Kaiser isn’t the labor friendly employer it claims to be, nor is it as committed to patient care as it claims to be,” Lanette Griffin, a laboratory assistant at Kaiser Permanente, said in a statement. “If Kaiser was committed to improving patient care, you would expect it to want to negotiate a contract to retain and attract the outstanding caregivers who have driven the corporation’s success. But Kaiser is showing its true colors when it avoids bargaining and wants to silence our voices.”

Last week, 4,000 mental health workers represented by National United Healthcare Workers engaged in a five-day strike against Kaiser, causing the system to postpone some surgeries. Kaiser has attributed the cancellations to California Nurses Association nurses joined the picket line in an authorized sympathy strike.

“The determination by the district 32 office of the National Labor Relations Board is not a verdict. It is the beginning of the NLRB’s process to hold evidentiary hearings to fully understand this complicated case,” Kaiser said in its statement.

 

 

Healthcare as a zero-sum game: 7 key points

https://www.beckershospitalreview.com/hospital-management-administration/healthcare-as-a-zero-sum-game-7-key-points.html?origin=cfoe&utm_source=cfoe

This article sets out seven thoughts on healthcare systems.

The article discusses:

  1. Types of Healthcare Systems
  2. Mergers and Key Questions to Assess Mergers
  3. Headwinds Facing Systems
  4. The Great Fear of Systems
  5. What has Worked the Last 10 Years
  6. What is Likely to Work the Next 10 Years
  7. A Few Other Issues

Before starting the core of the article, we note two thoughts. First, we view a core strategy of systems to spend a great percentage of their time on those things that currently work and bring in profits and revenues. As a general rule, we advise systems to spend 70 to 80 percent of their time doubling down on what works (i.e., their core strengths) and 20 to 30 percent of their time on new efforts.

Second, when we talk about healthcare as a zero-sum game, we mean the total increases in healthcare spend are slowing down and there are greater threats to the hospital portion of that spend. I.e., the pie is growing at a slower pace and profits in the hospital sector are decreasing.

I. Types of Healthcare Systems

We generally see six to eight types of healthcare systems. There is some overlap, with some organizations falling into several types.

1. Elite Systems. These systems generally make U.S. News & World Report’s annual “Best Hospitals” ranking. These are systems like Mayo Clinic, Cleveland Clinic, Johns Hopkins Hospital, NewYork-Presbyterian, Massachusetts General, UPMC and a number of others. These systems are often academic medical centers or teaching hospitals.

2. Regionally Dominant Systems. These systems are very strong in their geographic area. The core concept behind these systems has been to make them so good and so important that payers and patients can’t easily go around them. Generally, this market position allows systems to generate slightly higher prices, which are important to their longevity and profitability.

3. Kaiser Permanente. A third type of system is Oakland-based Kaiser Permanente itself. We view Kaiser as a type in and of itself since it is both so large and completely vertically integrated with Kaiser Foundation Health Plan, Kaiser Foundation Hospitals and Permanente Medical Groups. Kaiser was established as a company looking to control healthcare costs for construction, shipyard and steel mill workers for the Kaiser industrial companies in the late 1930s and 1940s. As companies like Amazon, Berkshire Hathaway and JPMorgan Chase try to reduce costs, it is worth noting that they are copying Kaiser’s purpose but not building hospitals. However, they are after the same goal that Kaiser originally sought. Making Kaiser even more interesting is its ability to take advantage of remote and virtual care as a mechanism to lower costs and expand access to care.

4. Community Hospitals. Community hospitals is an umbrella term for smaller hospital systems or hospitals. They can be suburban, rural or urban. Community hospitals are often associated with rural or suburban markets, but large cities can contain community hospitals if they serve a market segment distinct from a major tertiary care center. Community hospitals are typically one- to three-hospital systems often characterized by relatively limited resources. For purposes of this article, community hospitals are not classified as teaching hospitals — meaning they have minimal intern- and resident-per-bed ratios and involvement in GME programs.

5. Safety-Net Hospitals. When we think of safety-net hospitals, we typically recall hospitals that truly function as safety nets in their communities by treating the most medically vulnerable populations, including Medicaid enrollees and the uninsured. These organizations receive a great percentage of revenue from Medicaid, supplemental government payments and self-paying patients. Overall, they have very little commercial business. Safety-net hospitals exist in different areas, urban or rural. Many of the other types of systems noted in this article may also be considered safety-net systems.

6. National Chains. We divide national chains largely based on how their market position has developed. National chains that have developed markets and are dominant in them tend to be more successful. Chains tend to be less successful when they are largely developed out of disparate health systems and don’t possess a lot of market clout in certain areas.

7. Specialty Hospitals. These are typically orthopedic hospitals, psychiatric hospitals, women’s hospitals, children’s hospital or other types of hospitals that specialize in a field of medicine or have a very specific purpose.

II. Mergers and Acquisitions

There have seen several large mergers over the last few years, including those of Aurora-Advocate, Baylor Scott & White-Memorial Hermann, CHI-Dignity and Mercy-Bon Secours, among others.

In evaluating a merger, the No. 1 question we ask is, “Is there a clear and compelling reason or purpose for the merger?” This is the quintessential discussion piece around a merger. The types of compelling reasons often come in one of several varieties. First: Is the merger intended to double down and create greater market strength? In other words, will the merger make a system regionally dominant or more dominant?

Second: Does the merger make the system better capitalized and able to make more investments that it otherwise could not make? For example, a large number of community hospitals don’t have the finances to invest in the health IT they need, the business and practices they need, the labor they need or other initiatives.

Third: Does the merger allow the amortization of central costs? Due to a variety of political reasons, many systems have a hard time taking advantage of the amortization of costs that would otherwise come from either reducing numbers of locations or reducing some of the administrative leadership.

Finally, fourth: Does the merger make the system less fragile?

Each of these four questions tie back to the core query: Does the merger have a compelling reason or not?

III. Headwinds

Hospitals face many different headwinds. This goes into the concept of healthcare as a zero-sum game. There is only so much pie to be shared, and the hospital slice of pie is being attacked or threatened in various areas. Certain headwinds include:

1. Pharma Costs. The increasing cost of pharmaceuticals and the inability to control this cost particularly in the non-generic area. Here, increasingly the one cost area that payers are trying to merge with relates to pharma/PBM the one cost that hospitals can’t seem to control is pharma costs. There is little wonder there is so much attention paid to pharma costs in D.C.

2. Labor Costs. Notwithstanding all the discussions of technology and saving healthcare through technology, healthcare is often a labor-intensive business. Human care, especially as the population ages, requires lots of people — and people are expensive.

3. Bricks and Mortar. Most systems have extensive real estate costs. Hospitals that have tried to win the competitive game by owning more sites on the map find it is very expensive to maintain lots of sites.

4. Slowing Rises in Reimbursement – Federal and Commercial. Increasingly, due to federal and state financial issues, governments (and interest by employers) have less ability to keep raising healthcare prices. Instead, there is greater movement toward softer increases or reduced reimbursement.

5. Lower Commercial Mix. Most hospitals and health systems do better when their payer mix contains a higher percentage of commercial business versus Medicare or Medicaid. In essence, the greater percentage of commercial business, the better a health system does. Hospital executives have traditionally talked about their commercial business subsidizing the Medicare/Medicaid business. As the population ages and as companies get more aggressive about managing their own healthcare costs, you see a shift — even if just a few percentage points — to a higher percentage of Medicare/Medicaid business. There is serious potential for this to impact the long-term profitability of hospitals and health systems. Big companies like JPMorgan, Amazon, Berkshire Hathaway and some other giants like Google and Apple are first and foremost seeking to control their own healthcare costs. This often means steering certain types of business toward narrow networks, which can translate to less commercial business for hospitals.

6. Cybersecurity and Health IT Costs. Most systems could spend their entire budgets on cybersecurity if they wanted to. That’s impossible, of course, but the potential costs of a security breach or incident loom large and there are only so many dollars to cover these costs.

7. The Loss of Ancillary Income. Health systems traditionally relied on a handful of key specialties —cardiology, orthopedics, spine and oncology, for example — and ancillaries like imaging, labs, radiation therapy and others to make a good deal of their profits. Now ancillaries are increasingly shifted away from systems toward for-profits and other providers. For example, Quest Diagnostics and Laboratory Corporation of America have aggressively expanded their market share in the diagnostic lab industry by acquiring labs from health systems or striking management partnerships for diagnostic services.

8. Payers Less Reliant on Systems. Payers have signaled less reliance on hospitals and health systems. This headwind is indicated in a couple of trends. One is payers increasingly buying outpatient providers and investing in many other types of providers. Another is payers looking to merge with pharmaceutical providers or pharmacy and benefit managers.

9. Supergroups. Increasingly in certain specialties and multispecialty groups, especially orthopedics and a couple other specialties, there is an effort to develop strong “super groups.” The idea of some of these super groups is to work toward managing the top line of costs, then dole out and subcontract the other costs. Again, this could potentially move hospitals further and further downstream as cost centers instead of leaders.

IV. The Great Fear

The great fear of health systems is really twofold. First: that more and more systems end up in bankruptcy because they just can’t make the margins they need. We usually see this unfold with smaller hospitals, but over the last 20 years, we have seen bankruptcies periodically affect big hospital systems as well. (Here are 14 hospitals that have filed for bankruptcy in 2018 to date. According to data compiled by Bloomberg, at least 26 nonprofit hospitals across the nation are already in default or distress.)

Second, and more likely, is that hospitals in general become more like mid-level safety net systems for certain types of care — with the best business moving away. I.e., as margins slide, hospitals will handle more and more of the essential types of care. This is problematic, in that many hospitals and health systems have infrastructures that were built to provide care for a wide range of patient needs. The counterpoint to these two great fears is that there is a massive need for healthcare and healthcare is expensive. In essence, there are 325,700,000 people in the United States, and it’s not easy to provide care for an aging population.

V. The Last 10 Years – What Worked

What has worked over the last five to 10 years is some mix of the following:

  1. Being an elite system has remained a recipe for financial success.
  1. Being regionally dominant has been a recipe for success.
  1. Being very special at something or being very great at something has been a recipe for success.
  1. Being great in high paying specialties like orthopedics, oncology, and spine has been a recipe for success.
  1. Systems have benefited where they provide extensive ancillaries to make great profits.

VI. The Next 10 Years

Over the next 10 years, we advise systems to consider the following.

  1. Double down on what works.
  1. Do not give up dominance where they have it. Although it may be politically unpopular and expensive to maintain, dominance remains important.
  1. Systems will need a new level of cost control. For years hospitals focused on expanding patient volume, expanding revenue and enlarging their footprint. Now cost control has surpassed revenue growth as the top priority for hospital and health system CEOs in 2018.
  1. Systems will have to be great at remote and virtual care. More and more patients want care where and when they want it.
  1. Because there will be so much change, systems must continue to have great leadership and great teams to adjust and remain successful.
  1. As systems become more consumer-centric, hospitals will have to lead with great patient experience and great patient navigation. These two competencies have to become systemwide strengths for organizations to excel over the next decade.

VII. Other Issues

Other issues we find fascinating today are as follows.

1. First, payers are more likely to look at pharma and pharma benefit companies as merger partners than health systems. We think this is a fascinating change that reflects a few things, including the role and costs of pharmaceuticals in our country, the slowly lessening importance of health systems, and payers’ disinterest in carrying the costs of hospitals.

2. Second, for many years everyone wanted to be Kaiser. What’s fascinating today is how Kaiser now worries about Amazon, Apple and other companies that are doing what Kaiser did 50 to 100 years ago. In essence, large companies’ strategies to design their own health systems, networks or clinics to reduce healthcare costs and provide better care is a force that once created legacy systems like Kaiser and now threatens those same systems.

3. Third, we find politicians are largely tone deaf. On one side of the table is a call for a national single payer system, which at least in other countries of large size has not been a great answer and is very expensive. On the other hand, you still have politicians on the right saying just “let the free market work.” This reminds me of people who held up posters saying, “Get the government out of my Medicare.” We seem to be past a true and pure free market in healthcare. There is some place between these two extremes that probably works, and there is probably a need for some sort of public option.

4. Fourth, care navigation in many elite systems is still a debacle. There is still a lot of room for improvement in this area, but unfortunately, it is not an area that payers directly tend to pay for.

5. Fifth, we periodically hear speakers say “this app is the answer” to every problem. I contrast that by watching care given to elderly patients, and I think the app is unlikely to solve that much. It is not that there is not room for lots of apps and changes in healthcare — because there is. However, healthcare remains as a great mix of technology and a labor- and care-intensive business.

 

Financial updates from Banner, Kaiser, Mayo + 3 other health systems

https://www.beckershospitalreview.com/finance/financial-updates-from-banner-kaiser-mayo-3-other-health-systems.html?origin=cfoe&utm_source=cfoe

The following six health systems recently released their financial statements for the nine-month period ended Sept. 30:

1. Phoenix-based Banner Health’s revenue climbed 7.2 percent year over year to $6.3 billion in the first nine months of 2018. The system ended the first nine months of this year with operating income of $122.1 million, down 37 percent from $192.9 million in the same period a year earlier.

2. Oakland, Calif.-based Kaiser Permanente’s revenue climbed to $59.7 billion in the first nine months of 2018, up 9.6 percent from revenue of $54.5 billion in the same period of 2017. Kaiser ended the first nine months of this year with operating income of $2.03 billion, compared to $2.33 billion in the same period of 2017.

3. Rochester, Minn.-based Mayo Clinic ended the first nine months of 2018 with revenue of $9.5 billion, compared to $8.8 billion in the same period of 2017. The system reported operating income of $601 million in the nine months ended Sept. 30, up 32 percent from the same period of 2017.

4. Bronx, N.Y.-based Montefiore Health System recorded revenue of $4.4 billion in the nine months ended Sept. 30, up from $4.1 billion in the same period a year earlier. The system ended the first nine months of this year with operating income of $59.6 million, up from $37.7 million in the same period of the year prior.

5. Arlington-based Texas Health Resources recorded revenue of $3.5 billion in the first nine months of 2018, up from $3.4 billion in the same period a year earlier. The system ended the first nine months of this year with operating income of $168.7 million, down from $174.5 million in the same period of 2017.

6. Pittsburgh-based UPMC reported revenue of $13.9 billion in the first nine months of this year, up from $11.4 billion in the same period of 2017. The system ended the first nine months of 2018 with operating income of $190 million, down from $196 million in the same period of 2017.