THE ONLY HEALTHCARE BUSINESS NEWS WEEKLY | MARCH 5, 2018 | $5.

50

What’s holding the technology back? Page 16

Atrium, Tax law will

UNC Health be boon for
merger talks some for-profit
put on ice / providers,
Page 2 bust for others /
Page 10
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 News Opinions/Ideas
2 Late News 30 Editorial 31 Guest Expert
Atrium, UNC Health Hospital systems buying Dr. Jonathan Lewin of
suspend merger physician practices say Emory Healthcare and Dr.
talks after criticism vertical integration will Jeffrey Balser of Vanderbilt
from state officials. drive care coordination Medical Center on how to
16 Cover story
and lower costs. But fight the silent epidemic of
The slow upgrade to artificial intelligence 4 Week Ahead where’s the evidence? clinician burnout.
By Rachel Z. Arndt and Steven Ross Johnson AI and healthcare
Software powered by artificial intelligence and machine disruption are likely 34 Innovations
learning is supposed to transform healthcare. Alas, what to top the agenda
By Rachel Z. Arndt
was supposed to be isn’t—at least not yet. at HIMSS18.
Utah’s state health information exchange provides
What’s standing in the way? 6 Regional EMTs with feedback on their performance, helping to
News improve patient assessments on their calls.
Partners
HealthCare and “We don’t
Care New England discharge
add Lifespan to
people; we
merger talks.
recognize the
8 Politics treatment of
Lawsuit challenging
chronic illness
the ACA creates
new political as a lifetime
drama for red-state event.”
lawmakers.
36 Q&A
9 Providers Family First Health CEO Jenny Englerth discusses
Features New guidance from the many challenges facing community health
12 The road to recovery in Puerto Rico the CMS could centers like her organization.
By Steven Ross Johnson end rehab claims
In the wake of Hurricane Maria, a chance flickers that denials.
Puerto Rico’s health system could be revamped to address Data
residents’ most pressing health needs.
10 Providers
Tax law a boon 35 Data Points
to some for-profit Will artificial intelligence and
24 The 100 Top Hospitals hospitals, a drag machine learning revolutionize
By Maria Castellucci on others. healthcare? While that remains
With new data available, an unanswered question,
dedication to infection control 10 Providers spending projections indicate the
helped to determine which market is about to take off.
Court blocks
organizations made IBM Watson
CHS’ former
Health’s annual roster of the
100 Top Hospitals.
Fort Wayne exec 38 By the Numbers
from disclosing Largest security breaches of
confidential electronic health records.
@ModernHealthcare.com information.

Education and events

Opioid Crisis Symposium Diversions
Our first Critical Connections conference, set for April 25-26 40 Outliers
in Baltimore, will focus on strategies and tactics to combat
In the age-old battle of cats
the opioid-abuse epidemic. /CCOpioids
vs. dogs, when it comes to
Healthcare Transformation Summit biomedical research studies,
Join senior leaders from all sectors of healthcare June 7-8 canines win the race by far
in Austin, Texas, to share ideas on how to survive and thrive more than a whisker.
in a rapidly changing industry. /TransformationSummit

MODERN HEALTHCARE (ISSN 0160-7480). Vol. 48 No. 10 is published weekly by Crain Communications Inc., (except for combined issues the last week of June and the first week of July, the third week of November and
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March 5, 2018 | Modern Healthcare 1

 Briefs
n 
The worst of the nation’s nasty flu
Atrium Health suspends merger season is finally over. U.S. health
officials said last Friday that the flu
talks with UNC Health Care season apparently peaked in early
February and has been falling since
then. The number of people going to
Atrium Health and UNC Health Care suspended their merger the doctor with symptoms of the flu
talks. The proposed deal had received vocal criticism from has continued to decline. Deaths from
state officials, as well as the state’s largest insurer. the flu or pneumonia are dropping,
Charlotte, N.C.-based Atrium signed a letter of intent to too. The Centers for Disease Control
create a joint venture with UNC Health Care in August. and Prevention said 32 states reported
The resulting system would have had about $14 billion in heavy patient flu traffic last week, down
combined annual operating revenue, more than 50 hospi- from 43 a month ago. This flu season
tals and more than 90,000 employees. Atrium’s CEO, Gene started early and the intensity level was
Woods, and the chairman of its Board of Commissioners, the highest seen in a decade.
Gene Woods
Ed Brown, called off the deal in a letter to UNC Health
Care’s leadership March 2. n 
Chicago-based Health Care Service
An Atrium spokeswoman declined to say what caused the proposed deal, Corp., which operates Blue Cross
which was subject to regulatory review, to fall through. and Blue Shield plans in five states,
In a news release, UNC Health Care CEO William Roper and board Chairman announced plans last week to launch
Dale Jenkins said the two systems agreed that the best path forward is to iden- a program called Affordability Cures.
tify specific opportunities for collaboration, as they have previously, rather than Budgeted at $1.5 billion over the next
form a joint operating company. three years, the program will focus
State officials, who were openly skeptical of the deal fearing it would raise resources on collaborations with
prices for patients and taxpayers, put significant pressure on the systems to offer hospitals and doctors; partnerships
evidence to the contrary. The two systems never presented the proposed deal to with employers; the use of more
North Carolina’s Council of State, a prominent group that includes the attorney digitally driven data to assist in
general, treasurer and insurance commissioner. decisionmaking; and initiatives in
State Treasurer Dale Folwell wanted evidence that the deal would not raise expanding care beyond traditional
prices. Folwell said he asked UNC Health Care representatives to provide the State hospital settings. HCSC earned
Health Plan for Teachers and State Employees a $1 billion bond guaranteeing a $1.3 billion in 2017 while expanding
merger with Atrium would not increase medical costs for its members and taxpay- its membership by 5% to more than
ers. They declined. Similarly, North Carolina Attorney General Josh Stein wrote a 15 million people.
letter last month to the CEOs of both health systems asking for additional informa-
tion on how the deal would affect consumers, especially prices and access to care. n 
In his first State of the Clinic address,
Blue Cross and Blue Shield of North Carolina’s CEO came out against the pro- Cleveland Clinic’s new CEO,
posed merger in January, arguing it would drive up prices for patients. Dr. Tom Mihaljevic, praised the work
Atrium, which changed its name from Carolinas HealthCare System last of the health system’s past leader,
month, wrote in its news release that it remains committed to creating an orga- highlighted successes of 2017 and set
nization that can serve more people and address North Carolina’s most press- out a vision for the future. In 2017, the
ing issues, including rural care, behavioral health and affordability. Atrium’s clinic earned $328 million in operating
spokeswoman declined to say whether negotiations could reopen in the future. income—a significant 35% rebound
Last month, Atrium and Macon, Ga.-based Navicent Health signed a letter of from the year prior—on $8.4 billion in
intent to join forces. Ken Marlow, chair of the healthcare department at law firm operating revenue, up 5% from 2016.
Waller Lansden Dortch & Davis, said that deal may have rankled UNC executives. Mihaljevic attributed financial gains
“If a partner sees that your strategy and priorities are spread out and not concen- to both cost-cutting efforts and growth
trated in a way that aligns, that would be a real sticking point,” particularly for of the system. He said his goal for this
the conflicting business models of academic and non-academic institutions, he year is to maintain a similar operating
said. —Tara Bannow with Alex Kacik margin to 2017’s, which was 3.9%, up
from 3% in 2016. Mihaljevic credited
former CEO Dr. Toby Cosgrove,
Corrections & clarifications who attended the speech, with
Mario Garner is vice president of operations for Memorial Hermann Pearland transforming the clinic “in more ways
and Memorial Hermann Southeast Hospital. The Top 25 Minority Executives in than we can count.”
Healthcare “10 to Watch” feature gave an incorrect title (Feb. 26, p. 24).

2 Modern Healthcare | March 5, 2018

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 EDITORS
Aurora Aguilar Editor

AI, healthcare disruption 312-649-5218 aaguilar@modernhealthcare.com

Matthew Weinstock Managing Editor

312-397-7585 mweinstock@modernhealthcare.com
likely to top HIMSS18 agenda Paul Barr
312-649-5418
Features Editor
pbarr@modernhealthcare.com

In the past few weeks, Veterans Affairs Secretary Dr. David Erica Teichert News Editor
212-210-0209 eteichert@modernhealthcare.com
Shulkin has faced scathing criticism over a number of alleged
ethical lapses including accepting free tickets to Wimbledon. David May Assistant Managing Editor
312-649-5451 dmay@modernhealthcare.com
Late last week, two top Democrats on the Senate Veterans’
Affairs Committee said “chaos” within the department was Patricia Fanelli Art Director
312-649-5318 pfanelli@modernhealthcare.com
affecting care of the veterans the agency seeks to serve.
Shulkin this week will get a chance to distance himself
from D.C. as he joins healthcare executives, technology Merrill Goozner Editor Emeritus
VA Secretary mgoozner@modernhealthcare.com
Dr. David Shulkin vendors and others gathering in Las Vegas to talk shop
is expected to and hear about the latest and greatest in health IT. DIGITAL
discuss care Blair Chavis Web Producer
The Healthcare Information and Management Systems 312-649-5225 bchavis@modernhealthcare.com
coordination.
Society’s annual convention and trade show, which runs
Emily Olsen Web Producer
March 5-9, is expected to draw 45,000 people this year. About 42,287 312-649-5482 eolsen@modernhealthcare.com
attended in 2017.
Fan Fei Digital Graphics Producer
Shulkin is slated to speak Friday morning with Vice Adm. Raquel Bono of 312-280-3155 ffei@modernhealthcare.com
the Defense Health Agency and address coordinated care. Former executive
chairman of Alphabet (née Google) Eric Schmidt, who spoke at HIMSS in SENIOR REPORTER
Harris Meyer Chicago
2008 when Google launched its now defunct personal health record, will 312-649-5343 hmeyer@modernhealthcare.com
talk about how to implement technology effectively in healthcare and how to
REPORTERS
more quickly transform the industry. Rachel Z. Arndt Technology | Chicago
“You see a pattern here—there’s more of a ‘roll up your sleeves and 312-649-5314 rarndt@modernhealthcare.com
deliver’ mentality,” HIMSS CEO Harold Wolf said. Tara Bannow Finance | Chicago
To that end, Wolf expects conference attendees, speakers and exhibitors 312-649-5362 tbannow@modernhealthcare.com
to focus on using information technology in care delivery. “How do we put Maria Castellucci Safety & Quality | Chicago
into the hands of both the clinician and the administrator more tools that 312-397-5502 mcastellucci@modernhealthcare.com
help them understand end-to-end delivery and the value of it?” Wolf also Virgil Dickson Washington Bureau Chief
expects artificial intelligence to garner attention this year, as it has in the 202-434-4552 vdickson@modernhealthcare.com
past two or three years, as well as cybersecurity, which he called “more Steven Ross Johnson Public Health | Chicago
important than ever.” 312-649-5230 sjohnson@modernhealthcare.com
These topics all play into the goal of coming up with new ways to deliver Alex Kacik Operations | Chicago
care. “I think the biggest issue that everyone is facing right now is how do 312-280-3149 akacik@modernhealthcare.com

we use digital health effectively? How do we take care of individuals outside Shelby Livingston Insurance | Nashville
843-412-6857 slivingston@modernhealthcare.com
the walls of the encounter-based paradigm?” Wolf said. —Rachel Z. Arndt
Susannah Luthi Politics | Washington
202-434-8462 sluthi@modernhealthcare.com

RESEARCH
Megan Caruso Research Associate
Upcoming 312-649-5471 mcaruso@modernhealthcare.com
Modern Healthcare
lead the tranSformation COPY DESK
events Julie A. Johnson Copy Desk Chief
of health care delivery 312-649-5236 jajohnson@modernhealthcare.com
Healthcare Transformation
EDITORIAL SUPPORT
Summit: Partnering for Joanne Yj Kim News Intern
Success 312-649-5338 jykim@modernhealthcare.com

June 7-8, 2018 CUSTOMER SERVICE

877-812-1581 customerservice@modernhealthcare.com
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4 Modern Healthcare | March 5, 2018

 NORTHEAST

Partners, Care New England add Lifespan to talks

Providence, R.I.-based Lifespan has joined neighboring
system Care New England in proposed merger talks with
Boston’s Partners HealthCare.
The announcement added a new wrinkle to the potential
deal as Partners, the largest healthcare provider in
Massachusetts, looks to expand its reach into Rhode
Island. The news came about a month after Brown
University and California-based hospital company
Prospect Medical Holdings intervened by pitching an
unsolicited proposal to acquire Care New England if the
talks with Partners fall through.
Care New England and Partners approached Lifespan—
the owner of three hospitals including the state’s largest,
Rhode Island Hospital—to combine the resources of the
“like-minded” organizations to create a “national model
that fully leverages the integration and coordination of
care,” the organizations said in a joint statement that
offered minimal detail. Together, they said, the combined
entity could meet market challenges and mandates to
improve outcomes and lower costs.
Brown and Prospect had previously argued that
Rhode Island would suffer if the Partners and Care New
England deal went through. Specialty care would shift
to Massachusetts, reducing access for Rhode Island
consumers and increasing the cost of care.
Brown University President Christina Paxson said in
a statement that the university has advocated for this
kind of in-state dialogue for years to create an integrated
academic medical center. But “a business relationship
between Partners and Lifespan that further consolidates
market power could have additional adverse effects on
Rhode Islanders.” —Alex Kacik

SOUTH
Virginia governor voices
optimism for state
Medicaid expansion
Virginia Gov. Dr. Ralph Northam,
speaking at the National Governors
Association annual meeting, said he
is optimistic that ongoing negotiations
with the state Legislature will result
in a compromise to expand Medicaid,
even though there’s some opposition.
As the Washington Post report-
ed, state House lawmakers backed
Northam’s wish to expand coverage to
an estimated 400,000 low-income Vir-
ginians. But the Senate didn’t, and GOP
Senate Majority Leader Thomas Nor-
ment Jr. said the state may not be able to
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rely on the federal government continu-
ing to pay 90% of the tab for expansion,
according to the Post.
Former Democratic Gov. Terry
McAuliffe tried for years to push expan-
sion on a recalcitrant state Legislature,
but the blue wave in last November’s
elections that pushed many Republi-
cans out of their legislative seats man-
aged to stem the political winds on the
issue, at least in the House.
Tenet receives $550 million
on divestitures in first quarter
Tenet Healthcare Corp. has drawn
more than $550 million in the first
quarter of 2018 through a series of pre-
viously announced divestitures.
The Dallas-based hospital chain last
week completed the sale of MacNeal
Hospital, Berwyn, Ill., to Loyola Med-
icine, an affiliate of Trinity Health.
Terms of the agreement were not
disclosed. Tenet also completed the
sale on its minority interest in Bay-
lor Scott & White Medical Center—
White Rock, Dallas, to Pipeline Health.
Additionally, Tenet sold its minority in-
terest in Baylor Scott & White Medical
Center—Centennial and Baylor Scott
& White Medical Center—Lake Pointe,
also located in the Dallas area, to Baylor
Scott & White Health.
Tenet also transferred its minori-
ty interest in the Baylor Scott & White
Medical Center—Sunnyvale to Texas
Health Ventures Group, a joint venture
between Tenet’s United Surgical Part-
ners International subsidiary and Bay-
lor Scott & White Health.
The $550 million includes the sale
of its last two Philadelphia hospitals:
Hahnemann University Hospital and
St. Christopher’s Hospital for Children
to American Academic Health System.
MIDWEST
R1 RCM to acquire Intermedix
for $460 million
Chicago-based revenue cycle man-
agement company R1 RCM last week
signed a definitive agreement to ac-
quire competitor Intermedix Corp. for
about $460 million. The deal would
increase Intermedix’s healthcare divi-
sion, including its physician practice,
practice management and analytics
businesses.
The deal, subject to regulatory approv-
als, is expected to close in the second
quarter. It does not include Intermedix’s
emergency preparedness division. “We
believe the next chapter in healthcare
is one of revenue cycle transformation,
where an enterprisewide approach will
simplify and contribute to the way pa-
tients interact with the revenue cycle,”
R1 CEO Joseph Flanagan said.

6 Modern Healthcare | March 5, 2018

EXECUTIVE INSIGHT

Reimagining Healthcare through Practical Innovation

Change Healthcare: a catalyst in accelerating the journey to a value-based healthcare system

Neil de Crescenzo if the immediate reimbursement effects are unclear or

President and CEO, Change perhaps even negative. For example, patient and member
Healthcare engagement is essential due to increasing consumerism and
the drive toward population health, but it may take time to
Navigating the evolving healthcare see the financial benefits.
environment is challenging, and
An important part of being agile is fostering a culture
organizations often struggle with where to
that embraces new ideas and supports rapidly testing
prioritize limited resources. As one of the largest, independent
them. Every organization needs to learn how to “fail fast.”
healthcare IT companies, Change Healthcare is working with
Support for innovation at this level has not always existed
its customers and partners to pinpoint opportunities and make
in healthcare, yet it’s something we all need to develop
meaningful improvements for all stakeholders – physicians,
given the ongoing change, and speed of that change, in our
hospitals, and other providers as well as payers and consumers.
industry.
As Change Healthcare approaches the one-year
mark of its formation from the combination of Where is the company prioritizing and investing in
McKesson Technology Solutions and legacy technologies to advance healthcare?
Change Healthcare, how has it moved toward its NC: The evolution of healthcare drivers coupled with
goal of inspiring a better health system? revolutionary advancements in technology are creating
fertile ground for disruptive innovation. Many new entrants
NC: Change Healthcare was created at a transformational
are bringing fresh perspectives to longstanding challenges.
time in U.S. healthcare to bring together complementary
For instance, blockchain—and the work Change Healthcare
capabilities for the delivery of innovative solutions. We
is doing to apply this technology’s capabilities—has the
drive cost, quality, and member/patient satisfaction
potential to improve auditability and efficiency. When we
advancements for our customers, employing a breadth
started working with this technology, people were unsure
of solutions that support end-to-end improvements. Our
of its scalability. However, we have uncovered ways that
innovation, speed, and scope allow us to scale change
blockchain can handle billions of transactions and do so in
and impact the industry, whether by optimizing care
a manner that respects healthcare’s need for immutability,
through medical guidelines, enhancing the efficiency and
transparency, accuracy, and efficiency.
security of healthcare’s IT infrastructure, or leading the
way in exploring next-generation technologies like artificial When you look back five years from now, how will
intelligence and blockchain. Because of our work with you measure success?
both providers and payers, we are increasingly viewed as a
NC: We, the nearly 15,000 team members of Change
collaborative and trusted resource in helping the industry
Healthcare, will consider ourselves successful when, with
think through some of its challenges and knit together what
our help, our customers and partners are exceeding their
is often a fragmented ecosystem.
patients’, members’, and other customers’ needs while
What are the biggest hurdles your customers improving quality and moderating cost increases. Recently it
face, and how do you recommend organizations was estimated that healthcare costs in the United States will
focus their attention? increase 5.5% per year through 2026, reaching almost a fifth
of the U.S. GDP. As we help our customers achieve their
NC: There has been increasing uncertainty about the
goals, they and their customers will be able to take money
healthcare environment over the past year, which makes it
being spent on the administrative aspects of the delivery
challenging for customers to effectively make short- and long-
system and apply it to keeping people healthy or returning
term plans. The uncertainty around reimbursement models,
them to health.
constant regulatory developments, rise in consumerism, and
shift away from inpatient care all create pressure, but they
also create opportunities. At the same time, providers and This Executive Insight was
payers are using data and analytics to create an efficient and produced and brought to you by:
informed system that can not only respond to sick patients,
but also proactively partner with individuals to improve their
overall health.
To weather these dynamics, healthcare entities must be
agile and proactive during periods of uncertainty and take To learn more about Change Healthcare, please
both a short- and long-term view when investing. This may
visit www.changehealthcare.com
mean investing in capabilities needed for the future, even

March 5, 2018 | Modern Healthcare 7

 Politics

Lawsuit challenging
ACA creates new
political drama for
red-state lawmakers The day after the lawsuit
AP PHOTO

was filed, Gov. Scott

By Susannah Luthi said this argument may very well stand. Walker of Wisconsin
However, she added, the case likely falls visited two hospitals to
Disappointed that the GOP-con- apart on a second point that the attor- hold ceremonial signings
trolled Congress failed to repeal and re- neys general are making, namely link- of a measure to spur a
place the Affordable Care Act, red-state ing the entire ACA to the mandate.
1332 waiver application
lawmakers continue to look for ways to Timothy Jost, a health law scholar and
take down the law. But many are finding ACA expert, said the fact the attorneys to stabilize the state’s
that they must balance that goal with the general want to repeal the entire law individual market.
need to shore up insurance exchanges regardless of the impact shows a lack of
and address persistent gaps in coverage. understanding. “Does that mean the do- ry focus remains replacing Obamacare
Twenty state attorneys general filed a nut hole comes back for Medicare?” Jost with a new healthcare policy that allows
lawsuit last week challenging the ACA, said. “Do 12 million to 14 million people Florida families to have access to quality
adding another twist to a political dra- lose Medicaid coverage? Do 10 million healthcare at an affordable price,” said
ma that shows no sign of abating and people lose exchange coverage?” McKinley Lewis, Scott’s deputy com-
will play a significant role in this year’s Those broader implications aren’t munications director.
midterm elections. lost on providers. “Our concern is more Legal experts see the Trump admin-
“It would be a decision to destabi- practical—what happens when hun- istration’s role as the wild card in the
lize the markets,” said George Horvath, dreds of thousands of marketplace case. Epstein said it’s unlikely that the
health law scholar at the University of enrollees would lose coverage?” said administration will defend the law,
California at Berkeley law school. “It is not Dave Dillon, spokesman for the Mis- even though HHS Secretary Alex Azar
just the individual market, it is Medicaid souri Hospital Association, whose state is named as a defendant, along with
expansion and insurance regulations.” joined the plaintiffs in the suit. David Kautter, acting commissioner
Texas Attorney General Ken Paxton Missouri’s hospitals said their un- of the Internal Revenue Service. That
led the group of state attorneys general compensated-care costs continue to could throw Democratic attorneys gen-
in the complaint filed in a north Texas rise despite the recent ACA coverage eral in the mix as proxy defendants, es-
federal court, where it will be heard gains, Dillon said. pecially given the precedence of their
by U.S. District Judge Reed O’Con- And this is where the politics get sticky. intervention in the lawsuit over ending
nor, who was appointed by President On one hand, plaintiff states are suing to cost-sharing reduction payments.
George W. Bush. end the ACA. On the other hand, gover- Horvath noted that the financial im-
The attorneys general are using the re- nors are publicly espousing the virtues of plications for stakeholders could moti-
cently enacted Tax Cuts and Jobs Act as health coverage for their citizens. vate private parties such as insurance
the basis for challenging the ACA. Since GOP Gov. Rick Scott of Florida, whose companies to intervene. Epstein found
the tax law zeroed-out the individual state is also among the plaintiffs, wants that unlikely since many of the provi-
mandate penalty, they argue the man- an immediate “repeal and replace,” sions that carriers would want to de-
date can no longer qualify his spokesperson said fend are gone. Yet the various scenarios
as a tax. The U.S. Supreme in response to a Modern and potential fallout of this case, even if
THE TAKEAWAY
Court upheld the ACA in Healthcare query about the states lose, point to ongoing turmoil
2012 as a tax penalty. Attorneys general whether Scott supported over the ACA.
Wendy Netter Epstein, from 20 states claim the lawsuit or would pre- “We’ve all known all along the ACA
professor of law and direc- the ACA is no longer fer lesser changes to some wasn’t the end of the process,” Horvath
tor of the Jaharis Health viable since the ACA provisions, such as said. “In so many ways it’s the beginning
Law Institute at the DePaul individual tax penalty insurance regulations. of the process, and I don’t see this radi-
University College of Law, has been zeroed-out. However, Scott’s “prima- cally ending any time soon.” l

8 Modern Healthcare | March 5, 2018

Providers
ance may be an effort by the CMS to
New CMS guidance could relieve the burden on providers in ap-
pealing denied claims, Snecinski said.
Claims denials weren’t the only con-
stop rehab claims denials sequence of the Medicare contractors’
actions. To avoid the possibility of non-
payment, some providers would direct
By Virgil Dickson patients in need of rehab services to
skilled-nursing facilities, where regula-
Pennsylvania-based Post Acute Med- tory standards are lower and the thera-
ical has lost hundreds of thousands of py is less intensive, Stein said.
dollars due to rejected Medicare claims, Stays at skilled-nursing facilities do
often because of a matter of minutes. tend to cost less than those at inpatient
Claims are rejected if patients fall short rehab facilities. Across all clinical con-
of their minimum time for daily inpa- ditions, Medicare payment for patients
tient rehabilitation therapy. treated in an IRF is on average about
Medicare pays for the therapy if bene- $6,000 higher than the payment for
ficiaries participate at least three hours a patients treated in a nursing facility,
day. But Post Acute Medical, an operator according to a study commissioned by

$7.4
of long-term acute-care facilities, sees Medicare spending the ARA Research Institute, an affiliate
Medicare deny 20% to 25% of its inpa- on fee-for- of the American Medical Rehabilitation
tient rehab claims when patients miss service inpatient Providers Association.
that threshold by just minutes. rehabilitation facility However, that study also found that
care in about 1,180

BILLION
“Claims denied solely on therapy clinical outcomes tended to be better
facilities nationwide
minutes don’t take into consideration in 2015. for patients who received care at an in-
the medical necessity or medical condi- patient rehabilitation facility versus a
GETTY IMAGES
tions that justify the need for the rehab skilled-nursing facility.
stay,” said Kristen Smith, an executive Patients missed their three-hour re- Stein worries that the CMS’ deci-
vice president at Post Acute Medical. hab threshold due to bathroom breaks, sion to let contractors use their clinical
Often when patients miss the time being too ill to continue the session or judgment in determining the benefit of
standard they make it up on a subse- receiving other medical screening or IRF may not totally address the claims
quent day, but Medicare contractors services during physical therapy times. denial issue. Contractors such as recov-
would deny claims anyway, Smith said. “The regulations have been inter- ery audit contractors have an incentive
But that denial trend should change preted in an absurdly rigid way,” said to deny claims, he said. “Inherently it’s
soon thanks to a recent CMS policy Dr. Joel Stein, who specializes in physi- a conflict of interest as (the CMS) has
move. The agency has issued a notice cal medicine and rehabilitation at Weill established a situation where they’re
that starting March 23, Medicare con- Cornell Medicine in New York City. benefiting from denying claims, and
tractors can no longer deny a claim Stakes are high when it comes to that worries me.”
solely because the three-hour thresh- claims denials, since the contractors Encompass Health, one of the nation’s
old is missed. Contractors will have would deny claims for a patient’s en- largest post-acute care providers, said
to use clinical judgment to determine tire stay at a facility rather than just the last week that it was pleased with the
if inpatient rehab facility services are session that fell short of the three-hour CMS’ “initial step” to resolve the denials.
covered based on a patient’s overall standard, according to Harriett Wall, “Since it was issued recently and will
needs and treatment. a principal at LW Consulting. At Post not become effective until later this
In 2015, Medicare spent $7.4 billion Acute Medical, Smith said, the average month, it is too early to say whether this
on fee-for-service inpatient rehabil- denied claim per patient is $20,000. change request guidance from CMS
itation facility care pro- Many of the denials that will sufficiently clarify and resolve
vided in about 1,180 such have occurred for a pa- the concerns,” said Casey Lassiter,
facilities nationwide, ac- THE TAKEAWAY tient missing a few min- Encompass’ director of communica-
cording to the Medicare Medicare contractors utes of therapy have been tions. “Like so many of these types of
Payment Advisory Com- have been denying overturned on appeal, ac- directives issued to CMS’ contractors,
mission. About 344,000 claims if patients cording to Jane Snecinski, whether the intended outcome is ac-
beneficiaries had more miss just a few president of consulting firm tually attained will be determined by
than 381,000 inpatient minutes of their Post-Acute Advisors. Giv- how the Medicare administrative con-
rehab facility stays. Medi- minimum time for en the repeal backlog now tractors interpret and apply it when
care accounts for about inpatient rehab plaguing administrative reviewing claims for rehabilitation
therapy.
60% of IRF discharges. law judges, the new guid- hospital care and services.” 

March 5, 2018 | Modern Healthcare 9

Providers
Tax law a boon to some for-profit
chains, a drag on others
By Tara Bannow
The new tax law could widen the
distance between healthcare’s haves
and have-nots. It’ll be a boon to the
balance sheets of for-profit health sys-
tems that are faring well, giving them
more resources. But it could make life
more difficult for their cash-strapped
peers in 2018 and beyond.
“It increasingly bifurcates the win-
ners and the losers in the for-profit
hospital industry,” Jessica Gladstone,
a senior vice president with Moody’s
Investors Service, said of the Tax Cuts
and Jobs Act, which was enacted in
late December.
Large for-profit hospital chains that
have thrived in recent years, such as
HCA, Universal Health Services and
LifePoint Health, highlighted huge ex-
pected tax breaks on investor calls in
recent weeks. Nashville-based HCA,
which posted more than $2 billion in net
income on nearly $44 billion in revenue
last year, expects to pay $500 million less
in cash taxes under the law’s lower cor-
porate tax rate beginning in 2018.
But healthcare companies carry-
ing high debt loads like Community
Health Systems and Tenet Healthcare
Corp. aren’t as vocal about the tax law’s
Effects of lower corporate tax rate under Tax Cuts and Jobs Act
2018 expected 2018
Company cash tax impact tax rate
Acadia Health $21 million in savings 21%
Community Health Systems Declined to provide expectations
for impact or rate.
Encompass Health $10 million -$40 million in additional payments 28%
HCA $500 million in savings 25%
LifePoint Health $30 million in savings 24.5%
Tenet Healthcare Corp. Not provided 28-29%
Universal Health Services $140 million-$150 million in savings 21.4%
Source: The companies and Modern Healthcare reporting.
effects. These companies, while shar- ing, “whereas the companies that have
ing in the benefits of a lower tax rate already been struggling with invest-
and ability to immediately deduct cap- ments like Community or Quorum are
ital expenses, are now limited in how probably going to be doubly at a disad-
much interest they can deduct. vantage because they’ll have less free
Moody’s studied 11 for-profit health cash flow to invest in their markets.”
systems and determined they would CHS reported other financial set-
see $700 million to $800 million in tax backs last week, primarily that it was
savings in 2018 compared with what recording a $2 billion fourth-quarter
they would have paid under previous net loss, mostly from nearly $1.8 billion
rules. The vast majority of the savings in impairments and reduced assets
will go to HCA and UHS. related to the company’s hospitals,
Gladstone, an author of the Moody’s including those it sold or plans to sell.
report, said health systems that are do- The Franklin, Tenn.-based chain also
ing well will reinvest in their markets to reported a roughly $400 million in-
become even more competitive, add- crease in its provision for bad debt and

employees to work for IU Health and

Court blocks CHS’ former Fort Wayne exec
from sharing confidential information
A Tennessee court last week ruled
that a former CEO of Lutheran Health
Network disclosed confidential
information, but is allowing him to still
work with competitor IU Health to
create a new primary-care practice in
Fort Wayne, Ind.
Judge Joseph Woodruff of the
Circuit Court of Williamson County,
Tenn., said Lutheran Health, a
subsidiary of Community Health
Systems, will likely prevail in its suit
accusing Brian Bauer of sharing
information with third parties, and he
cannot create a competing healthcare
network with anyone who received
that information. That doesn’t include
IU Health. Bauer admitted he shared
confidential and proprietary information
with a venture capital firm and others.
The judge also prevented Bauer
from soliciting Lutheran Health’s
ordered him to recover the private
information he gave out.
The temporary injunction is part of
a lawsuit Franklin, Tenn.-based CHS
and Lutheran Health filed in November
against Bauer for allegedly breaching
his contract by disparaging the hospital
system, sharing confidential information
to harm the system, and ultimately luring
IU Health to Fort Wayne.
“The court rulings not only
demonstrate that the litigation has
merit, they also ensure that the litigation
will proceed and prohibit Bauer

10 Modern Healthcare | March 5, 2018

 an increase of about $200 million in THIS IS AN ADVERTISEMENT
contractual allowances, both of which
it said are due to switching to a new Fi-
nancial Accounting Standards Board
principle that narrows what hospitals THE INDUSTRY IS CHANGING.
can categorize as revenue.
But Universal Health’s outlook is LET OUR HEALTH LAWYERS
stronger. The King of Prussia, Pa.-
based company whose net income in- HELP YOU UNDERSTAND THE
creased to $752 million on more than
$10 billion in net revenue last year, ex-
IMPACT ON YOUR ORGANIZATION.
pects to save up to $150 million in cash
taxes this year.
Steve Filton, the company’s chief Put our singular health care focus to work
financial officer, expects UHS could for you. Visit hallrender.com.
save an additional $50 million under
the provision of the law that allows for
accelerated depreciation, which could HEALTH LAW IS OUR BUSINESS.
prompt more capital expenditures.
UHS projects a capital budget of up to
$625 million.
“We feel like there are some projects
and opportunities we think are com-
pelling today that we didn’t necessar-
ily think were compelling two months
ago,” Filton said.
The new law limits the amount of in-
terest expense companies can deduct
to 30% of their earnings before interest,
taxes, depreciation and amortization
through 2021.
But since companies that have gen-
erated losses in the past can still use
those to shield income from taxes in
future years, a function called net op-
erating loss carryforwards, companies
that are hit by the new deductibility
cap can still offset their tax burdens in
future years.
Dallas-based Tenet expects 80% of
its capital expenditures will qualify for
immediate deduction in 2018. l

from continuing to use Lutheran’s

confidential information for his
personal gain,” a CHS spokesperson
said in a statement.
Bauer was fired as Lutheran’s CEO
in June 2017 after a failed bid to find
a buyer for CHS’ eight area hospitals.
He started working with IU Health in
October as an independent contractor
to build out a new primary-care practice.
“I’m excited to move forward with
IU Health expanding access to high-
quality healthcare in Fort Wayne,”
Bauer said in a statement.
—Shelby Livingston

March 5, 2018 | Modern Healthcare 11

The road to recovery:
Prospect of federal funding could
reshape Puerto Rico’s health system
other area providers. The hospital’s in-
“The most tensive-care and telemetry units have
important need been severely damaged, and key equip-
we have right ment such as the MRI machine and
supplies for its catheterization labora-
now is the tory have been completely lost.
payment from “We have capacity for 40 beds right
the insurance now, and we are full,” Feliciano said.
company.” Before the storm, Ryder had 165 inpa-
tient beds. “My principal responsibility
Jose R. Feliciano right now is to open beds.”
Executive director The storm damage forced Ryder to
Ryder Memorial Hospital close its doors for the first time in its
104-year history, with a one-month
shutdown starting in October.
Feliciano estimated the cost of re-
pairs at around $24 million, and that the work at its current
STEVEN ROSS JOHNSON
pace could take years to complete. Plá Cortes said Ryder’s
By Steven Ross Johnson impact on the community could not be overstated. Before
the hurricane, Ryder averaged more than 300 surgeries a
HUMACAO, Puerto Rico—Recovery has been slow in month, and the facility was one of the only providers in the
Puerto Rico since Hurricane Maria struck the U.S. territory area to offer comprehensive obstetric and gynecological
Sept. 20, particularly in the island’s southeast region, where services; those services are now limited.
Ryder Memorial Hospital is located. “They are the premier hospital on this side of the island,”
For Ryder Memorial, the area’s largest healthcare provider, Plá Cortes said. “So, with the hospital having difficulties,
addressing patients’ health needs has been a daunting task patients are having trouble getting access to services like
because of how severely the hospital was damaged. they used to.”
Only about half of Humacao’s 50,000 residents have Plans are on track to re-open the hospital’s second and
electricity, while in the neighboring town of Yabucoa, as third floors soon, Feliciano said, but he acknowledged prog-
many as 80% of residents remain without power. “Things ress has been slower than planned. Part of the problem has
are bad,” said Jose R. Feliciano, executive director of Ryder been delayed insurance payments that the hospital is ex-
Memorial. “We are probably the hospital that suffered the pecting to cover property damage and disruptions in ser-
worst from the hurricane.” vices. The hospital had received $2 million of its $30 million
As with the rest of the region, the effects of Hurricane claim as of Feb. 18. Feliciano said
Maria were both swift and long-lasting at Ryder. Three the payment delay has kept the hos- THE TAKEAWAY
days of powerful winds followed by heavy rainfall caused pital from bringing back to work
extensive flooding to offices, floors with inpatient beds more than 200 employees who have While Puerto Rico’s
and laboratories. been suspended since the closure. hospitals have gone
“Once the hurricane entered here it was a Category 5,” “We do not know when to expect months without
significant aid or
said Jaime Plá Cortes, executive president of the Puerto payments, as this has been a com-
support, the way
Rico Hospital Association. “One notch (higher in storm cat- pletely random process,” Feliciano forward seems to
egory) is good enough to kill you.” said. “The most important need provide a ray of
More than five months after the storm, four of Ryder’s five we have right now is the payment hope that could lead
floors remain closed. Feliciano said the hospital currently from the insurance company.” to revamping the
is operating at 25% of its normal capacity, with many of its Ryder’s issues regarding reim- health system to
health services limited to primary care and the emergency bursement are indicative of the address residents’
department. Almost all of the hospital’s more specialized lack of needed support that other most pressing
services, such as surgery, have had to be outsourced to providers on the island say they health needs.

12 Modern Healthcare | March 5, 2018

 A makeshift sign at Ryder
Memorial Hospital warns of
mold. Much of the hospital
remains closed as officials
work to repair damage from
the hurricane.

status as a U.S. territory. Cou-

pled with the lower rate, that
puts the actual rate at which
federal funds cover costs at
roughly 23%, according to a
2017 Urban Institute report.
By contrast, states with the
same poverty rate as Puerto
Rico, 44%, would have 83% of
their Medicaid costs matched
by federal dollars.
“We are underpaid, and that
makes it more difficult for us to
perform the type of improve-
ments that need to be done for
the long term,” Plá Cortes said.
As was the case when
Hurricane Katrina hit New
Orleans in 2005, the federal
government will pay 100%
of Medicaid health costs in
Puerto Rico for the next two
STEVEN ROSS JOHNSON years thanks to the budget
deal that passed. Plá Cortes
have faced since the hurricane hit. said that will help providers begin making longer-term in-
As the island braces for the next hurricane season in frastructure improvements, but he argued a more perma-
just a few months, some fear delays in support will hinder nent funding change is needed.
preparation efforts, and worsen a public health system that “In many cases, we need to look at how do we do bet-
was arguably in crisis even before Hurricane Maria. “Folks ter infrastructure for some of the hospitals to make sure
are racing to prepare for the next hurricane season,” said that they can withstand any catastrophe,” Plá Cortes said.
Maria Levis, CEO of San Juan-based healthcare consul- “From that point of view, I think one of the issues we have is
tancy Impactivo. “There is an issue of time and there is an how do we get reimbursement from the government here,
issue of resources; they are not separate from one another.” and how do we get a permanent source of reimbursement
from the U.S. government.”
Funding challenges Despite a blackout in San Juan last week, there has been
On Feb. 26, Puerto Rico Gov. Ricardo Rosello sent a let- some progress toward recovery. Around 84% of the island
ter asking congressional leaders to help reverse the U.S. has electrical power, not taking into account the temporary
Treasury Department’s decision to reduce a $4.7 billion di- blackout; 97% of residents have access to drinking water,
saster relief loan to $2 billion. Congress approved the loan and all 68 of the island’s hospitals are open, according to
in October. The Treasury has yet to allocate any portion of figures posted on the Puerto Rican government’s site.
the loan. On Feb. 8, Congress approved $6.8 billion in di- Aside from Medicaid reimbursement parity, Levis said
saster relief for Puerto Rico as part of a budget deal, includ- a crucial component to Puerto Rico’s recovery will be if it
ing $4.9 billion to the island’s Medicaid program. gets the kind of investments New Orleans got after Katrina
Currently 61% of the island’s population is insured by ei- to strengthen its primary-care infrastructure. Federal sup-
ther Medicaid, the Children’s Health Insurance Program, port brought more than 50 neighborhood health clinics to
a Medicare Advantage plan or traditional Medicare, com- areas of that city that were without primary-care access
pared with 31% who are covered by a commercial insurer. before the storm. Mental health services were among the
The rate at which Medicaid reimburses providers in new offerings, a big need in New Orleans as residents dealt
Puerto Rico has historically been much lower than in the 50 with the stress of recovery.
states, averaging about 50% of health costs. The island also As was seen in New Orleans, depression has become a
has a federal cap on total Medicaid funding because of its growing problem among Puerto Rico residents. A recent

March 5, 2018 | Modern Healthcare 13

report found the number of suicides there increased by 18%
in 2017 compared with 2016.
“That kind of funding vehicle for transformation will be
vital,” Levis said.

Providers aiding providers

With the lack of federal support, hospitals in Puerto Rico
have had to move forward in their recovery efforts either on
their own or with help from other entities. “There’s still a lot
of need in the long term in the areas of energy, communi-
cations, specialty services and infrastructure,” said Ryan
Frazier, senior vice president of member relations for the
American Hospital Association.
In mid-February, Frazier took his third trip to the island
since Hurricane Maria as part of the organization’s effort to
identify Puerto Rican hospitals’ long-term needs. He said
the goal is to help coordinate with mainland providers to
offer resources and technical assistance.
“One thing that has to happen is for the system to be able
to stand up by itself,” Levis said. “More than people com-
STEVEN ROSS JOHNSON
ing to provide direct support, I think that providing tech-
nical support that will help enable our transformation is pend somewhat on receiving Mennonite Hospital of
Caguas was able to remain
more important.” reimbursement from its insur- open during and after
One of the places Frazier visited during his last trip was ance carrier for the damage it the hurricane. Its parent
Mennonite Hospital of Caguas, a 400-bed acute-care fa- sustained, estimated at around system’s six sites on the
cility and one of six sites for the Mennonite Health System, $40 million for the entire sys- island suffered about
$40 million in damage.
one of Puerto Rico’s largest networks. The Caguas hospital tem, as well as from the federal
sustained less damage during Hurricane Maria than Ryder government in the form of rate
and was able to stay open throughout the storm and the increases for Medicare and Medicaid.
days that followed, according But he felt the hospital was well-positioned to recover.
to Eric Grafals Medina, the Over the past few months the system has brought in experts
Ashford Presbyterian hospital’s administrator. from the mainland to provide expertise on strengthening
Community Hospital, San “We are more or less areas of weakness that were found during the storm to bet-
Juan, suffered less severe
damage than many other self-sustained,” Grafals Me- ter prepare for the next emergency.
island hospitals and has dina said. “We got very lim-
remained open, despite ited response from FEMA or The way forward
initial concerns about
staffing vital tertiary-care
any other federal agency.” Levis acknowledged there was a need for more aid to ad-
departments, such as its Grafals Medina acknowl- dress the island’s more immediate health needs, but said re-
busy neonatal intensive- edged a part of the hospital’s cent conversations among stakeholders have focused on how
care and OB-GYN units. long-term recovery will de- the health system’s recovery should look for the long term.
She said what has been discussed is whether the recov-
ery effort should focus more on rebuilding existing health-
care facilities, or whether the opportunity should be taken
to redesign the health system to better address prevention
and chronic disease management.
Compared to 18% of mainland adults, 34% of adults in
Puerto Rico in 2016 reported being in fair to poor health,
according to a report by the Kaiser Family Foundation.
Puerto Rico also had higher rates of diabetes, heart dis-
ease, HIV and infant mortality than the 50 states.
Signs seem to indicate that the island’s leaders are lean-
ing toward redesigning the system to focus more on popu-
lation health. Two weeks ago, the Puerto Rican government
launched a request for proposals for its Medicaid man-
aged-care program from contractors who focus on pre-
vention and chronic disease management. That program
covers 1.3 million Puerto Rican residents.
“It should not just be about rebuilding, it should be about
redesigning,” Levis said. “And there’s still a lot to do.” l
STEVEN ROSS JOHNSON

14 Modern Healthcare | March 5, 2018

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healthcare
 In Depth

By Rachel Z. Arndt

The hospital of the future was supposed to be staffed

by robots and disembodied voices. You were never even
supposed to step foot in it, because long before you got sick, a chatbot
would rise from one of your many screens to coach you through better
health decisions. And if you didn’t listen and ended up in the hospital,
another computer would diagnose you after a few tests.

On the web: To see AI in action, including how neural networks

recognize the lung, go to Modernhealthcare.com/InDepthAI

16 Modern Healthcare | March 5, 2018

Alas, what was supposed to be isn’t. Artificial intelligence has yet to transform
healthcare, cutting costs by making providers more efficient and improving Chatbot
the health of patients. Though there are inklings of AI here and there, A conversational
interface that draws
the necessary resources—data, namely—are lacking. So the dream has on natural language
shifted from one of medically proficient AI doctors to a more realistic one of processing and other
techniques to mimic
bureaucratically proficient AI note-takers, coders and pattern-finders. human dialogue

Computer vision
“AI is processing more and more data Starting small How computers
faster. It’s an efficiency play, because time As people across industries begin to comprehend and
is money,” said Dr. William Morris, asso- acknowledge that AI, as a panacea, is un- analyze images,
ciate chief medical information officer at realistic, they’re also starting to be more as with facial
recognition
Cleveland Clinic. realistic about what AI actually can do.
The promise of AI to do just that—by Artificial intelligence is, in a nutshell, Deep learning
augmenting human activities, not re- a machine that can perform tasks—and A type of machine-
placing them—is real. It may one day often learn—like a human does. It’s be- learning algorithm
help physicians with diagnoses, guiding yond simple data analytics, which is, that is supposed
them rather than dictating. “We are not nevertheless, necessary for AI. “Machine to ape the neural
looking for robots to do work for us,” said learning,” a part of AI, is sometimes used networks of human
Manu Tandon, chief information officer interchangeably, though technically it’s brains, learning
of Beth Israel Deaconess Medical Center more of a subset or tool for AI. on their own to
in Boston. “We are looking to make better So far, this kind of software has been recognize patterns
decisions by benefiting from ma- particularly useful in imaging,
Machine learning
chine learning and AI.” where algorithms can rela-
A subset of AI,
How quickly and successfully tively easily pick out and clas- algorithms are
AI gets there depends on clini- sify anomalies. Physicians can trained on large
cal knowledge. It also depends feed images into apps made sets of data so
on funding and on the risks that “Computer vision by companies like Arterys and they can learn from
health systems are willing to take imaging is an Zebra Medical Vision and re- those data, perform
to try out services that haven’t been early harbinger.” ceive diagnosis suggestions or tasks, and continue
validated by the market. Adam Culbertson health predictions. learning as they go
But in the end, it depends pri- Innovator in “Computer vision imaging
marily on one thing: data. It’s not residence is an early harbinger,” said Natural language
Healthcare processing
just that AI algorithms require Information and Adam Culbertson, innovator
Software in this
trustworthy data to be fed into Management in residence at the Healthcare subset of AI can
them—they also require trust- Systems Society Information and Management understand human
worthy data as they’re forming, Systems Society. language, pulling
learning how to deliver insights. Just But even in radiology and imaging, AI meaning from texts
as humans are better equipped to un- is rare. Just 14% of those surveyed by Re- both spoken and
derstand the world when they take in action Data said they’ve been “using ma- written
high-quality facts, so too are algorithms. chine learning for a while,” and 27%—the
This is a special problem in healthcare, largest portion—said they’re one or two Turing test
where data are often fragmented, siloed years away from adopting the technology. A test in which
and held in a form designed for humans, There are also more proactive AI appli- a human tries to
figure out whether he
not computers, to understand. cations. In China, tech giants have already
or she is interacting
“There’s probably very little use of AI in taken the plunge into AI in healthcare. Al- with a machine or a
healthcare today,” said Theresa Meadows, ibaba offers software that gives doctors a human; if the human
CIO of Cook Children’s Health Care Sys- hand interpreting images, for instance, thinks the machine
tem, Fort Worth Texas. “People have ideas and Tencent software helps doctors find is a human, then that
of how it could be used, but we still need harbingers of cancer. machine has passed
to get to that point and have things devel- Stateside, at the University of Pennsylva- the Turing test
oped that would support it.” nia, researchers created a machine-learn-

March 5, 2018 | Modern Healthcare 17

ing system that can predict which
patients are at risk of sepsis. The al- Joe Marks, executive director of the Center for
gorithm translates that risk into an Machine Learning and Health at Carnegie Mellon
alert in the electronic health record. University, tells Modern Healthcare whether some AI
The UPMC health system has had in pop culture is realistic or possible today.
success controlling chronic condi-
tions using AI.
But aside from imaging and some
Joe Marks: If you take a What about HAL from
broad view of AI, it’s been “2001: A Space Odyssey”?
rare predictions, there are not yet around a long time. There Marks: The sentient computer HAL and all that it
many clinical uses of AI. “The best uses are many subdisciplines does—that’s still a long way away. Take the fact
of AI come from those implementing it in addition to machine that it’s interacting with speech: The things that do
in a thoughtful approach to make de- learning, and they work, for example, are simple Q&A with speech
terminations about discrete circum- have had a number of where you’re asking it to retrieve a fact. It’s still
stances where it can lower costs and successes over the years amazingly impressive what you can do on Google
improve outcomes, like imaging, and to the point where people on your smartphone and just ask a question in
those using AI in operations,” said maybe don’t even think of English and it comes back with an answer, often
them as AI anymore and a Wikipedia answer. There’s a very, very long way
Daniel Farris, co-chair of the technol-
they’re using them all the between that and the conversational and cognitive
ogy group at law firm Fox Rothschild. time. The combination and thinking capabilities that HAL had. They are far
Today, the healthcare industry is of genomic data and beyond what we can do.
turning to AI for back-office work, machine learning might be
automating tasks to make them less the big trend of the next “Minority Report”?
tedious and more efficient. decade or two. You’re Marks: We have some intelligent interfaces. They’re
“These are probably some of the going to see incremental on your smartphone, if you think about it—maybe
best applications of AI,” Morris said. results coming out and not the gestural stuff but certainty the speech stuff.
“Usually back-office functions are then mushrooming as The idea that it knows your consumption habits
highly inefficient and costly and mea- more data are available. and can provide recommendations—that already
surable. There’s a clear ROI.” A health exists. Amazon and Netflix do that decently.
system might, for instance, treat its
supply chain in a more anticipato-
ry rather than reactive way. Or it might automate bill and doesn’t help us, I don’t know how we’ll deal with all the in-
claims processing and eligibility checks. formation,” said Dr. Thomas Lee, chief medical officer for
Because AI can now run on Amazon and Google cloud Press Ganey Associates. “My expectation is that the orga-
platforms, the barriers to entry in terms of cost and access nizations that are more organized will have an increasing-
are lower, Tandon said. “They have democratized the avail- ly important competitive advantage in not only affording
ability of these technologies, which earlier were confined to the information technology to have machine learning and
research labs or academic institutions.” AI, but the ability to use it without people having nervous
At Beth Israel Deaconess Medical Center, technologists are breakdowns.”
developing a machine-learning One way to better deal with all that information might be
model to predict which patients speech, which, like imaging, is one of the types of AI that’s
are most likely to be no-shows. been most widely adopted. As Amazon’s Alexa, Google
Using that information, Tandon Home, and other virtual assistants have popped up in homes
said, Beth Israel could intervene across the country, virtual assistants have also been creep-
ahead of time, so it gets higher ing into healthcare, where adoption is a bit slower thanks to
utilization. The health system HIPAA rules and healthcare’s general pace of change.
is also developing a model to In the coming months, Nuance and Epic Systems Corp.
predict each patient’s discharge will introduce an AI-powered, voice-enabled virtual assis-
“Usually date. “It’s almost like the Waze tant in the EHR that could make accessing data easier.
back-office
functions are model, where when you leave “Speech-to-text is accurate, fast and mainstream,” said
highly inefficient home it predicts how long it will Mayo Clinic CIO Cris Ross, citing it as an example of a
and costly take and then evolves.” smaller-scale innovation that, when paired with others,
and measurable. These kinds of applications will lead to important change.
There’s a stand to improve patient out-
clear ROI. ” comes, make providers more Investing in the unknown
Dr. William Morris, productive, and relieve some of In terms of what’s actually in use today, that’s about it.
associate chief medical
information officer at the great bureaucratic weight There are no magical algorithms than can read a patient’s
Cleveland Clinic on everyone in healthcare. chart and tell doctors with certainty what’s wrong and
“If AI and machine learning what the treatment should be. IBM’s Watson hasn’t yet be-

18 Modern Healthcare | March 5, 2018

 A scene from the film “2001:
A Space Odyssey.”

thing that makes these robots in

movies compelling and exciting
and interesting, and that’s what
we don’t know how to do.

“Blade Runner”? gins, so they can’t make a lot of speculative

GETTY IMAGES
R2-D2 and C-3PO from
“Star Wars”?
Marks: That’s still very, very hard
AI. And there are also the power
requirements holding it back. The
hero has to solve some task and
consults with the robot, and that’s
hard. There’s a multistep process
that needs to be done to solve
some task, and the human and
computer together are going to
work, reason through that, and
then follow the steps perceiving
the changes to the environment
and everything else. Collaborative,
complex problem-solving is very
different from fact retrieval and
simple perception. That’s the
Marks: We’re so far away from
that kind of a robot that’s so
convincingly human that it could
fool us. That’s an unlikely one.
Killer robot dogs in the
“Black Mirror” episode
“Metalhead”?
Marks: Tragically, that kind of
thing might actually be closer to
reality. With something like killer
drones, you want much more
sophistication. When they have
military robots that are as clever
as a patrol leader, yes, then I’ll
feel safe having them deployed,
but just simple-minded drones
with simple-minded commands
like “kill everything in this zone”—
that’s doable but really not what
humanity needs or wants.
R&D developments. That makes them need
AI solutions that have a nearly instanta-
neous payback and are very short-term fo-
cused and work very well. They want proof
that these things are going to work and go-
ing to pay back.”
It’s a tough assignment for a technology that,
relatively speaking, isn’t widely adopted, espe-
cially in an industry that’s notoriously slow to
use new technologies, and especially in an in-
dustry that’s just gone through a major—and
expensive—upheaval with the implementa-
tion of massive EHR systems. “Now that we’ve
implemented the EHR, healthcare is trying to
determine how to go after the next frontier,”
Meadows said. “There’s definitely a concern
about costs, because it’s in its infancy. Every-
thing costs more when it’s not a fully vetted
product or process. These early adopters will be
investing a lot of money to potentially fail.”

Harnessing the data

come all it was cracked up to be. The machine is supposed
to recommend cancer treatments (among other tasks),
but the system itself has had trouble learning from clini-
cal data. Notably, MD Anderson Cancer Center in Hous-
ton put a halt to its Watson project last year after spending
more than $62 million on it. Still, Watson IBM executives
say the machine is in use at 150 organizations.
AI’s limitations can tell us where the industry should be
putting its resources and where researchers should focus.
“There’s a lot of hype about the potential of AI for improv-
ing inefficiencies, finding new sources of value and unlock-
ing trapped value,” said Brian Kalis, managing director of
digital health and innovation for Accenture’s health busi-
ness. “A big part of this is stepping back and understanding
what the business outcomes you’re trying to achieve are.”
Even if a health system can identify the problems it
wants to solve, actually putting AI in place is a big deal.
“For those who do not establish their own internal devel-
opment capability the way that Memorial Sloan Kettering
has,” said Ari Caroline, chief analytics officer at the New
York cancer center, “vendor costs in the AI space can be
substantial and would typically be weighed against other
major IT expenditures.”
What’s more, that spending can be risky, since it might
be going to startups whose technology has not yet been
proven. “Health systems are worried about their current
business model and how long it will last,” said Dr. Bob
Kocher, a partner at Venrock. “They have very low mar-
One point of entry into AI could be EHRs themselves,
where the clinical data that algorithms depend on reside.
But, as Beth Israel’s Tandon points out, AI isn’t what most
EHR vendors specialize in. “Most hospitals depend on their
EHR vendors to make innovations,” he said, and “most
healthcare organizations don’t have any control over the
vendor platform they use.” When the data needed for AI are
trapped in EHRs, and the EHR vendors aren’t yet focusing
on AI, healthcare organizations are stuck. “The data are in
a place where the know-how doesn’t exist, and the know-
how is in a place where the data doesn’t exist,” Tandon said.
Whether AI succeeds depends in large part on how avail-
able the necessary data are, wrote authors from Jason, a
scientific advisory group, in a December 2017 report for
HHS about AI in healthcare. “AI application development
requires training data and will perform poorly when signif-
icant data streams are absent,” they wrote.
While healthcare is awash in data, those data are often
not consistent, clean or in sets large enough to “teach” AI
algorithms enough to be trustworthy. Just as the lack of in-
teroperability hinders continuity of care and burdens pro-
viders, so too does it hinder and burden AI.
“If you’re going to let a machine make a decision for you,
you better be darn sure that the data you’re feeding it are
good,” Meadows said. “I think healthcare is kind of in a
transition, because we’ve worked for years and years to
get EHRs in place, and really, those are just transactional
systems,” she said. “How do we begin to bring all the data

March 5, 2018 | Modern Healthcare 19


1920 Karel Capek, a Czech novelist
and playwright, coins the term
“robot” (from the Czech “robota,” for
“serf labor”) in his play “R.U.R.”
1950 Alan Turing proposes what will
become known as the Turing test,
used to determine a machine’s ability
to exhibit intelligent behavior
1955 John McCarthy creates the
term “artificial intelligence”
1957 Frank Rosenblatt creates
the perceptron, an algorithm for
classifying images
1962 Arthur Samuel’s checkers-
playing program beats checkers whiz
Robert Nealey
1964 Joseph Weizenbaum creates a
natural language processing program,
ELIZA
1968 “2001: A Space Odyssey” is
released and a star named HAL is born
1997 IBM’s Deep Blue computer
beats chess champion Garry Kasparov
2011 IBM’s Watson computer wins
Jeopardy, playing against two top
champions
2013 MD Anderson Cancer Center
and IBM announce plans to develop
the IBM Watson-powered Oncology
Expert Advisor
2014 Amazon introduces its
virtual assistant Alexa, which
WebMD and health systems
now use to retrieve general
health information, among
other uses
2015 Alphabet’s AI division
DeepMind partners with the
U.K.’s National Health Service
to access health records,
which the company will later be
accused of mishandling
2016 Alphabet’s DeepMind
defeats a Go champion
2017 MD Anderson Cancer
Center puts its IBM Watson
project on hold

together to make educated decisions and have the clean- dicators are in some cases,” he said, which could make it
liness of data?” difficult to train the algorithm.
Some healthcare systems are taking the first steps to make The data also have to be unbiased. Otherwise, they might
sure data are clean—that is, reliable, accurate and free of in- favor certain companies or lead to diagnoses that are true
consistencies—from the get-go. “We’ve decided to make our for the population whose data trained the algorithm but
clinical data much more amenable to machine learning and not true for another population, one that might not have as
making sure we’re consistently extracting structured clini- much access to healthcare in the first place and therefore
cal features from unstructured text,” Sloan Kettering’s Caro- doesn’t have its data in any algorithmic systems. That leads
line said, something that’s done either manually or through to problems of both ethics and liability.
natural language processing. EHRs can make that difficult, “I worry that there’s going to be bias in training data that
he said, since often clinical information exists only in free leads AI to do things that might be commercially beneficial
text in notes because EHRs were designed to be financial, for some, but you’d never know, because it’s a black box,”
not clinical, systems. Venrock’s Kocher said. “I worry about consumer protection
Getting information out of the EHRs—and keeping it se- and the ethics of what data you use to teach it and what you
cure in the process—is one thing. There’s also the problem tell the AI to optimize for.”
of getting AI insights back into workflows. “How do we in- The black box problem also poses issues for physicians,
sert that back into a workflow to do something, who lack insight into what the AI is actually doing. It’s not
to drive value?” Cleveland Clin- that they’re afraid of being replaced; it’s more that they’re
ic’s Morris said. “If you don’t, afraid of basing decisions on information they can’t see.
you’re just adding cost; you’re Because of how mathematical modeling works, it’s
just adding tools.” sometimes possible for users to have no idea what the de-
To get around that problem, cision tree looks like. “If the physician doesn’t know that
Cleveland Clinic leaders are ex- cause X leads to result Y, they’re going to be appropriately
amining their data architecture, skeptical,” Ross said. “The clinician needs to be able to open
figuring out how to structure their the black box and see how it came to its answer.” In an ideal
EHRs and other systems so data can case, that access might also give the physician information
flow both in and out, ultimately get- from which he or she can learn.
ting to the right person. Indeed, clinician involvement is important, many
Not only do the data have to be pointed out, no matter how smart the machines get.
“I worry about clean and interoperable, but they “There’s a strong need for the engagement of medical
consumer protection have to be based on well-estab- experts to validate and oversee AI algorithms in health-
and the ethics of lished clinical indicators. “It’s not care,” said Dr. Wyatt Decker, Mayo’s chief medical infor-
what data you use always a technology problem—it’s mation officer, who prefers the term “augmented human
to teach it and what
you tell the AI to also a clinical maturity problem,” intelligence” over “artificial intelligence.”
optimize for.” said Peter Durlach, senior vice “We don’t intend to replace experts or providers with
Dr. Bob Kocher
president of strategy for vendor machines,” he said. “We intend to use machines to help
Partner Nuance. “The clinical folks haven’t providers have less clerical burden, to have more accurate
Venrock even agreed on what the clinical in- treatments and diagnoses more quickly.” l

20 Modern Healthcare | March 5, 2018

IT INSIGHT
Waystar™, the Combination of Navicure® and ZirMed®,
Simplifies and Unifies Healthcare Revenue Cycle
Unified cloud-based revenue cycle technology empowers organizations to
collect more with less stress and less cost
Matthew Hawkins
CEO of Waystar
Waystar is the combined organization of
Navicure and ZirMed, the two top-rated
providers of revenue cycle technologies
according to KLAS® and Black Book Research®.
The companies united in November 2017. Waystar simplifies and
unifies the healthcare revenue cycle with innovative technology
that empowers clients to collect more with less stress and less
cost, so they can focus on their goals, patients and communities.
Why did Navicure and ZirMed come together to form
Waystar? How are the two companies better together?
MH: By uniting the industry’s two top-performing revenue
cycle technology leaders as Waystar, we are ensuring
providers across all care settings are more empowered to
optimize their financial and operational results leveraging
our end-to-end solution offering. Healthcare organizations
no longer need to choose between the two best providers of
revenue cycle technology. With Waystar they get both. Our
innovative technologies and top-ranked service enable us to
simplify and unify the revenue cycle for our clients across
the care continuum. In fact, Navicure and ZirMed have
competed against one another for KLAS’ top honors in each
of the last ten years. One of the two companies has been
honored as Best in KLAS® every year since 2010 including
2018. This speaks to how hard we work to continue to earn
our clients’ business each year. As one company we’ll work
even harder to provide enterprise-class solutions and an
exceptional client experience.
What’s keeping healthcare leaders up at night in 2018
and how is Waystar addressing those market demands?
MH: Most healthcare organizations struggle to implement best
practices across several stages of the revenue cycle. A typical
organization must try to adhere to dozens of payers’ changing
requirements. Getting paid is a never-ending battle. What’s
worse, most technology vendors can address only a portion
of the revenue cycle challenge. Waystar’s solutions help unify
and simplify the revenue cycle in virtually every care setting
with advanced data analytics capabilities. As the industry
continues to consolidate, integrated health systems are
increasingly looking to technology partners that can provide
solutions across all care settings. Navicure and ZirMed coming
together as Waystar ideally positions us to drive further
advancements and help organizations collect more efficiently.
How can RCT solutions like Waystar’s help
organizations address healthcare consumerism,
while simplifying and unifying reimbursement?
MH: With the continued proliferation of high-deductible
health plans, patients are seeing their premiums and
deductibles rise. Patient choice and shopping also continue
to increase the threat of patient retention. With this,
organizations are looking to improve all interactions with
patients and deploy better patient-centric billing and
payment practices. Where billing was once a business-
to-business transaction between providers and insurers,
consumer-centric pricing transparency and convenience
challenges providers. Innovative solutions are making it
easier for patients to understand what they owe and provide
payment choices and convenience to enable them to pay
more quickly and reliably. They include a cost estimate before
or at the time of service, improving transparency and giving
patients confidence and flexibility to pay with a credit card
securely stored on file. Through these various processes,
organizations can meet their patients’ needs while driving
better financial performance. Automating your entire revenue
cycle can further streamline reimbursement while improving
both your bottom line and patient satisfaction.
How can embracing a unified cloud technology help
organizations take charge of their revenue cycle?
MH: The appeal and demand for cloud-based technologies
is exploding across all industries around the world, and the
U.S. healthcare industry is no exception. Not only can cloud-
based software help better predict and identify trends in
an organization’s financial data across multiple locations,
it’s also easier to scale when your organization opens new
offices or acquires other practices. Unified cloud-based
solutions upgrade features, functionality, and security patches
automatically, making them easier to manage than traditional
applications. The cloud also offers a secure and convenient
way to quickly bring revenue cycle capabilities online to ensure
organizations can respond to growing consumer demand in a
timely manner. With cloud technology, practice and hospital
staff are no longer bombarded by menial tasks including
pulling data reports, hunting down patients for payment or
sifting through hours of paperwork. Instead they can focus on
better patient care.
This IT Insight was
produced and brought to you by:
To learn more about Waystar, please visit
www.waystar.com
March 5, 2018 | Modern Healthcare 21
By Steven Ross Johnson

A
t UPMC, clinicians use predictive analytic tools to sionmaking and increasing
help reduce the risk of disease. They’re pursuing efficiencies.
narrow but still vital goals like reducing hospital- The unit’s first project was
izations and applying new diagnostic tools that developing an AI model that
help patients self-manage their own conditions. can identify patients with
UPMC and some other providers see potential in AI congestive heart failure by
helping determine whether a patient’s condition is termi- evaluating their medical re- “We’re discharging
nal. That would allow providers to prescribe palliative care cords upon admittance. patients not
rather than treatment. “We did it to remind clinical just with a bag
In other words, smaller goals are better. staff that if you have someone with of pills but with
“We’ve done ourselves a disservice in propagating the pneumonia, for example, but they technology.
hype around AI,” said Dr. Rasu Shrestha, chief innovation also have CHF, you don’t give them Dr. Rasu Shrestha
officer at the UPMC system. Shrestha says more palatable fluids because that might exacer- Chief innovation officer
uses for AI might come from a use-case perspective rath- bate their CHF,” said Dr. Michael UPMC
er than placing too grand expectations on AI. “I think we Cantor, an internist and associate
would start to get to the future that we are desiring,” he said. professor at NYU Langone Health.
Shrestha sees AI as being used to augment—rather than The heart-failure project led to
completely redefine—healthcare. an analytics model that predicts which patients are prone
The use of any technology in population health would to sepsis—a condition that affects more than 1.5 million
be an advance given that previous solutions have involved Americans annually and accounts for 1 in every 3 deaths
simply connecting patients to community resources in or- that occur in hospitals.
der to address non-clinical health determinants. “Basically, we’ve been rolling out models every few
months,” Cantor said. Clinical demand dictates which mod-
Risk stratification els will be built. Once they are developed and evaluated,
When New York University Langone Health launched its they’re included in NYU Langone’s electronic health record
predictive analytics unit in 2016, it was looking to reduce system for integration into the clinical workflow.
unnecessary hospitalizations by enhancing clinical deci- “A big part of the project planning and development is

22 Modern Healthcare | March 5, 2018

making sure that once the model is live that it gives that in-
formation that people will act on,” Cantor said. The goal is
not simply to “throw information out there.”
During the clinical evaluation phase of some projects,
the unit develops best practices on how to handle condi-
tions flagged by the AI model.
Cantor said AI has been helpful in treating acutely ill
patients, but he hopes to see models that identify ways to
prevent people from ever needing to come to the hospital.
But it would take time to factor in social determinants of
health. It also would require training the healthcare staff or
hiring professionals with new skills.
“A lot of places don’t have the personnel who know
enough about predictive modeling to adopt them effec-
tively,” Cantor said. “When you’re trying to find people like
that, you’re competing with Google and Amazon.”
Patient self-management
Improving 30-day readmission rates, flagging patients at
risk, shortening hospital stays and mitigating disease risk
are just some of issues AI is helping hospitals currently ad-
dress, said Brian Kalis, managing director of digital health
and innovation for consulting firm Accenture.
But the technology could also help providers improve pa-
tient engagement.
“We’re seeing the use of virtual agents to help people
guide and manage their care using less human labor in-
tensity,” Kalis said.
AI can help patients self-manage their conditions at
home and skip in-office doctor visits.
“We’re discharging patients not just with a bag of pills
but with technology,” Shrestha said, referring to UPMC’s
patient-monitoring program that uses machine learning
to manage chronic conditions. UPMC invested in the tech-
nology in 2016. It was created by Texas-based Vivify Health.
Upon discharge, patients with conditions such as heart
failure or diabetes are given a tablet computer or instruct-
ed to use their own mobile device to transmit their health
information to UPMC. The device monitors a patient’s
symptoms of the disease, blood pressure, weight and ox-
ygen levels while at home. It also contacts their physician
if needed.
The data are analyzed to predict when a patient is at risk
of ending up back in the emergency department so clini-
cians can intervene by phone or a nurse visit.
“They’re able to stay in an environment where they can
eat, work, stay and play and not have to come back to the
ED,” Shrestha said.
More than 1,100 patients were enrolled in the program
the first year it was launched, Shrestha said. It has a 92%
compliance rate among patients and a satisfaction score of
91%. During that first year, Pittsburgh-based UPMC report-
ed Medicare beneficiaries enrolled in the program were
76% less likely to be readmitted within 90 days of discharge
than patients without the remote monitoring.
“In the past we’ve been able to achieve some level of suc-
cess by taking more of a low-tech approach,” Shrestha said.
“But what we’re seeing right now increasingly is when it
comes to identifying or risk-stratifying the patient popu-
lation, this entire loop of population health management
becomes more efficient and effective if you’re able to bring
capabilities that would allow for you to really get at these data
elements in ways that we’ve not been able to previously.”
Piali De, CEO of Senscio Systems, maker of another
home-based AI patient-monitoring application for patients
with multiple chronic health conditions, said AI facilitates
remote patient monitoring.
“There’s just a lot of data and a lot of correlations,” De said.
“Discovering those correlations is the essence of popula-
tion health management because it’s impossible to know
what’s working for the most complex populations without
the use of AI.” l
March 5, 2018 | Modern Healthcare 23
Infection
control
It’s a key priority—and
“While the most
important thing
is not to harm
challenge—for high- the patient,
there is also an economic
performing hospitals cost to the system.”
Dr. Mary Jo Cagle
Chief clinical officer, Cone Health

By Maria Castellucci

one Health has made prevention of hospital-ac- industry overall spends an average of $9.8 billion annually

C quired infections a strategic priority for its orga-

nization.
The infections can not only harm or kill pa-
tients, they are also costly; HAIs lengthen hospital stays,
cause readmissions and eat up valuable resources.
to treat HAIs.
“While the most important thing is not to harm the pa-
tient, there is also an economic cost to the system,” said
Dr. Mary Jo Cagle, Cone Health’s chief clinical officer.
Although HAIs have decreased nationally in recent
A major part of Cone Health’s strategy to attack infections years, they still happen frequently. On any given day, about
is prevention. For instance, the system now tests patients 1 in 25 hospital patients have at least one healthcare-asso-
before scheduled procedures for the bacteria Staphylococ- ciated infection, according to the Centers for Disease Con-
cus aureus, which can cause MRSA infections and lead to trol and Prevention.
sepsis, pneumonia or bloodstream infections. If a patient The success Cone Health has seen in infection con-
does have such a bacterial infection, clinicians use a med- trol hasn’t been easy. Successful infection control has
ication before surgery to treat it. Patients are also told to required the system to make investments in specialists,
bathe before surgery with a specific soap. hand hygiene programs and special cleaning machines.
The efforts by Greensboro, N.C.-based Cone Health have “We are continuously looking for ways to improve our
paid off. The system has lowered MRSA infection rates processes and looking at what needs to be put in place
from 47 patients a year in 2012 to fewer than 17 in 2017. Ad- that best protects our patients,” Cagle said.
ditionally, the rate of patients with surgical-site infections Also, CMS’ value-based purchasing programs increase
dropped by 32% from a rate of 1.07 in 2012 to 0.72 the financial pressure to get HAIs under control.
in 2016. The agency’s Hospital-Acquired Condition Re-
THE TAKEAWAY
Its work in infection control played a role in duction Program penalizes 25% of hospitals with
Cone Health being recognized this year by IBM Despite efforts by a 1% payment reduction for higher infection rates
Watson Health on its 100 Top Hospitals list. For hospitals and the compared with their peers.
the first time in its 25 years releasing the annu- CMS to improve Despite the efforts by hospitals and the CMS to
al roster of the 100 Top Hospitals, IBM Watson rates of hospital- improve HAI rates, the IBM Watson study shows
factored in HAIs because the CMS now tracks acquired infections, there is more work to be done. The analysis,
data on the still-major problem; the infections more work needs to which uses 2016 CMS Hospital Compare data and
contribute to 99,000 deaths each year, and the be done. included 2,785 U.S. hospitals, found the winners’

24 Modern Healthcare | March 5, 2018

 The 100 Top Hospitals: infection rates were on average near-
ly 19% lower than their peers. “There
National Benchmarks for Success-2018 (1 of 3 ) is variation here, showing there is still
Listed by category and in alphabetical order room (for hospitals) to improve,” said
YEARS Julie Shook, 100 Top Program director
MAJOR TEACHING HOSPITALS LOCATION ON LIST at IBM Watson Health.
Advocate Illinois Masonic Medical Center Chicago Seven
There are many reasons why pre-
venting infections is still so hard, and
Banner-University Medical Center Phoenix Phoenix One chief among them is that the inpatient
Banner-University Medical Center South* Tucson, Ariz. One population is sicker, said Janet Haas,
Cedars-Sinai Medical Center Los Angeles Two president of the Association for Profes-
sionals in Infection Control and Epi-
Mount Sinai Medical Center Miami Beach, Fla. One demiology. As more care moves to the
NorthShore University HealthSystem Evanston, Ill. Nineteen outpatient setting, patients admitted to
Northwestern Memorial Hospital Chicago Nine hospitals are now more medically com-
plex with a higher likelihood of multi-
Ochsner Medical Center Jefferson, La. Six
ple chronic conditions, she said.
OhioHealth Doctors Hospital Columbus Eight Cagle at Cone Health agreed, saying
Penn State Milton S. Hershey Medical Center Hershey, Pa. One “the patients that we are treating now
are much more acutely ill than those five
Providence-Providence Park Hospital Southfield, Mich. Ten years ago, so the challenge now is how to
SSM Health St. Mary’s Hospital-St. Louis St. Louis Three continue this journey to zero harm.”
St. Luke’s University Hospital-Bethlehem Bethlehem, Pa. Six
Continuous monitoring
UCHealth University of Colorado Hospital Aurora Five HAIs also can be unpredictable.
University of Wisconsin Hospital and Clinics Madison Five Leaders at Sentara Leigh Hospital, a
teaching hospital in Norfolk, Va., on
the 100 Top list for the fourth time, ex-
TEACHING HOSPITALS YEARS perienced that firsthand. After years of
(200 OR MORE ACUTE-CARE BEDS) LOCATION ON LIST decline in catheter-associated urinary
Aspirus Wausau Hospital Wausau, Wis. Six tract infections, hospital officials were
confused when they saw the infections
Beaumont Hospital-Grosse Pointe* Grosse Pointe, Mich. Two were suddenly rising from a record-low
Bethesda North Hospital Cincinnati Eight rate of 0.35 in 2016 to 0.81 in mid-2017.
Bryn Mawr Hospital Bryn Mawr, Pa. Four The clinical leadership team scoured
the data and reviewed protocols on
BSA Health System* Amarillo, Texas Five
proper Foley catheter management to
Christ Hospital Health Network Cincinnati Eight find out why. They concluded nurses
Cone Health* Greensboro, N.C. One sometimes weren’t properly inserting
the catheters, a critical contributor
Good Samaritan Hospital Cincinnati Five
to infections. The team recently re-
Jewish Hospital-Mercy Health Cincinnati Two trained staff on the best techniques for
Kettering Medical Center Kettering, Ohio Thirteen catheter insertion and recommended
two nurses be present for catheter in-
Mayo Clinic Hospital Jacksonville, Fla. One
sertion to check the other’s work.
Mercy Hospital St. Louis St. Louis Six If hospital executives weren’t con-
Miami Valley Hospital Dayton, Ohio Two stantly tracking infection rates, the
Mount Carmel St. Ann’s* Westerville, Ohio One uptick could have been overlooked.
“We have high-performance teams of
PIH Health Hospital-Whittier Whittier, Calif. Four physicians, nurses and leaders (at the
Riverside Medical Center Kankakee, Ill. Nine system-level) that provide oversight on
Rose Medical Center Denver Eleven infection prevention … (so there is) on-
going monitoring,” said David Master-
Sentara Leigh Hospital* Norfolk, Va. Four son, president of Sentara Williamsburg
Sky Ridge Medical Center Lone Tree, Colo. One (Va.) Regional Medical Center, which
was recognized by IBM Watson Health
The Watson Health 100 Top Hospitals study (formerly Truven Health Analytics) has been published for this year for the second time.
25 consecutive years. Sentara Healthcare, which operates
*One of 13 Everest Award winners, hospitals that have achieved the highest current performance and the fastest
improvement in the past five years. Everest winners have been published for 10 consecutive years. 12 hospitals, also benefits from a team
Source: IBM Watson Health of infectious-disease specialists, which

March 5, 2018 | Modern Healthcare 25

 The 100 Top Hospitals:
National Benchmarks for Success-2018 (2 of 3 )
Listed by category and in alphabetical order
TEACHING HOSPITALS (CONTINUED) LOCATION YEARS
(200 OR MORE ACUTE-CARE BEDS) ON LIST
SSM Health St. Mary’s Hospital-Madison Madison, Wis. Five
St. Luke’s Boise Medical Center Boise, Idaho Ten
St. Luke’s Hospital Cedar Rapids, Iowa Seven
Sycamore Medical Center Miamisburg, Ohio Nine
UCHealth Poudre Valley Hospital Fort Collins, Colo. Twelve
United Regional Health Care System Wichita Falls, Texas Three
Sentara Healthcare, which operates
12 hospitals, also benefits from having
a team of infectious-disease specialists, LARGE COMMUNITY HOSPITALS YEARS
which many hospitals struggle to attain. (250 OR MORE ACUTE-CARE BEDS) LOCATION ON LIST
Advocate Condell Medical Center Libertyville, Ill. Four
many hospitals struggle to attain.
Advocate Sherman Hospital* Elgin, Ill. One
“There simply aren’t enough infec-
tious-disease specialists to manage Asante Rogue Regional Medical Center Medford, Ore. Six
these programs, and that is a major Butler Memorial Hospital* Butler, Pa. Three
challenge,” said Dr. Keith Kaye, presi-
CaroMont Regional Medical Center Gastonia, N.C. Five
dent of the Society for Healthcare Epi-
demiology of America. Edward Hospital Naperville, Ill. Three
Hoag Hospital Newport Beach Newport Beach, Calif. Three
Limited resources Mease Countryside Hospital Safety Harbor, Fla. Ten
Infection preventionists have been
in hot-demand in recent years with Memorial Hermann Memorial City Medical Center Houston Seven
the growth of antibiotic stewardship Mercy Health-St. Rita’s Medical Center* Lima, Ohio Three
programs. The Joint Commission in Mercy Hospital Oklahoma City* Oklahoma City Three
January 2017 began to include anti-
microbial stewardship programs as a Northwestern Medicine Winfield, Ill. Nine
Central DuPage Hospital
stipulation for hospitals to maintain
accreditation and this year the CMS Rio Grande Regional Hospital McAllen, Texas One
began to require nursing homes to Scripps Memorial Hospital La Jolla San Diego Three
have an antibiotic stewardship pro-
Shawnee Mission Medical Center Shawnee Mission, Kan. Four
gram. One aspect of the CMS’ rule
is that as of November 2019, nursing St. Clair Hospital Pittsburgh Four
homes must have a trained infection St. David’s Medical Center Austin, Texas Nine
preventionist on staff. St. Francis Downtown Greenville, S.C. Four
As a result, health systems have had to
get creative to secure a pipeline of infec- St. Joseph’s Hospital* Tampa, Fla. Two
tious-disease specialists. HonorHealth, St. Vincent Evansville Evansville, Ind. Four
which includes 100 Top Hospital winner
Scottsdale (Ariz.) Thompson Peak Med- MEDIUM COMMUNITY HOSPITALS YEARS
ical Center, has started an infection pre- (100-249 ACUTE-CARE BEDS) LOCATION ON LIST
ventionist internship program. It’s the
Baylor Scott & White Medical Center-Round Rock Round Rock, Texas Three
hospital’s first time on the list.
“We realized it was a tough recruiting Blanchard Valley Hospital Findlay, Ohio Six
environment for trained infection pre- Bon Secours St. Francis Hospital Charleston, S.C. Five
ventionists as the federal government Chester County Hospital West Chester, Pa. Two
layered on” infection-control require-
ments, said Dr. Stephanie Jackson, chief Cleveland Clinic Florida Weston, Fla. Six
quality officer of the five-hospital sys- Indiana University Health North Hospital Carmel, Ind. One
tem. She added that such programs give
HonorHealth’s hospitals a resource that The Watson Health 100 Top Hospitals study (formerly Truven Health Analytics) has been published for
25 consecutive years.
“smaller systems probably wouldn’t be *One of 13 Everest Award winners, hospitals that have achieved the highest current performance and the fastest
able to tap into.” improvement in the past five years. Everest winners have been published for 10 consecutive years.
Indeed, IBM Watson’s study found Source: IBM Watson Health

26 Modern Healthcare | March 5, 2018

 Achievement,
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 The 100 Top Hospitals:
National Benchmarks for Success-2018 (3 of 3 )
Listed by category and in alphabetical order

MEDIUM COMMUNITY HOSPITALS (CONTINUED) YEARS

(100-249 ACUTE-CARE BEDS) LOCATION ON LIST
Kalispell Regional Medical Center Kalispell, Mont. One
Logan Regional Hospital Logan, Utah Eight
Mercy Health-Clermont Hospital Batavia, Ohio Nine
“We realized it was Mercy Medical Center Cedar Rapids, Iowa Six
a tough recruiting
Montclair Hospital Medical Center Montclair, Calif. Three
environment for trained
Ochsner Medical Center-Baton Rouge Baton Rouge, La. Three
infection preventionists
as the federal government OhioHealth Dublin Methodist Hospital Dublin, Ohio Six
layered on” infection-control Sherman Oaks Hospital Sherman Oaks, Calif. Three
requirements. Sentara Williamsburg Regional Medical Center Williamsburg, Va. Two
Dr. Stephanie Jackson St. Alphonsus Medical Center-Nampa Nampa, Idaho Two
Chief quality officer, HonorHealth Texas Health Harris Methodist Hospital Fort Worth Three
Southwest Fort Worth
UCHealth Medical Center of the Rockies Loveland, Colo. Two
that infection rates among commu-
nity hospitals were worse than among West Valley Medical Center Caldwell, Idaho Five
teaching hospitals. The benchmark Wooster Community Hospital Wooster, Ohio Four
medium community hospitals re-
ported HAI rates 44% lower than their SMALL COMMUNITY HOSPITALS YEARS
peers while benchmark major teach- (25-99 ACUTE-CARE BEDS) LOCATION ON LIST
ing hospitals had just 8.2% lower HAI
Cedar City Hospital Cedar City, Utah Seven
rates compared with their peers.
Of the results, Haas at APIC said, “I East Liverpool City Hospital* East Liverpool, Ohio One
think that speaks in part to having a Florida Hospital Wesley Chapel Wesley Chapel, Fla. One
team of infection preventionists, which
Hawkins County Memorial Hospital Rogersville, Tenn. Three
larger hospitals tend to have more of, and
smaller hospitals tend to have fewer of.” Hill Country Memorial Hospital Fredericksburg, Texas Seven
Detailed data on infection rates are HonorHealth Scottsdale Thompson Peak Scottsdale, Ariz. One
especially critical to prevention efforts, Medical Center
which can be hard for small hospitals Lakeview Hospital Bountiful, Utah Eight
with limited resources, Kaye said.
Lakeview Hospital Stillwater, Minn. Seven
Advocate Illinois Masonic Medical
Center, a major teaching hospital in Lakeview Medical Center Rice Lake, Wis. Three
Chicago on the 100 Top list for the sev- Pampa Regional Medical Center Pampa, Texas One
enth time, gets nearly all of its infection
Parkview Huntington Hospital Huntington, Ind. Six
data from its parent system 13-hospi-
tal Advocate Health Care, said Susan Parkview Noble Hospital Kendallville, Ind. One
Nordstrom Lopez, president of the hos- Spectrum Health United Hospital Greenville, Mich. Eight
pital, noting that the data are provided
Spectrum Health Zeeland Community Hospital* Zeeland, Mich. Four
in a “usable format.”
“Our health information system pro- Springhill Medical Center Springhill, La. One
vides an incredible amount of informa- St. Anthony Summit Medical Center Frisco, Colo. One
tion to make determinations around St. John Owasso Hospital Owasso, Okla. Two
how we prioritize infection control
moving forward,” said Ken Laube, St. Luke’s South Hospital Overland Park, Kan. One
vice president of clinical excellence at St. Vincent Fishers Hospital Fishers, Ind. One
the hospital. “It’s so important to drive Stillwater Medical Center Stillwater, Okla. One
quality improvement.”
Lopez added, “I think it would be The Watson Health 100 Top Hospitals study (formerly Truven Health Analytics) has been published for
very difficult for (an independent) hos- 25 consecutive years.
*One of 13 Everest Award winners, hospitals that have achieved the highest current performance and the fastest
pital to have the resources to access improvement in the past five years. Everest winners have been published for 10 consecutive years.
this big data.” l Source: IBM Watson Health

28 Modern Healthcare | March 5, 2018

 CO N N EC T. LE A R N . A DVA N C E YO U R C A R E E R .

A CHIE V ING NE X T GENE R AT ION HE A LT HC A R E T R A NSF OR M AT ION

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 Physician acquisition
indigestion
MERRILL GOOZNER Editor Emeritus
T
he hospital systems buying physician practices say vertical integration
will facilitate care coordination and lower costs.
Where’s the evidence?
If consolidation immediately lowered
costs, hospital groups wouldn’t be fight-
ing so hard to fend off the CMS’ propos-
al to install site-neutral payments for
tests and procedures done in outpatient
settings. While the rates at hospital-ac-
quired physician practices have been
cut, they still get higher fees than prac-
tices that remain under physician com-
pensation rules.
Moreover, the upward arc of physi-
cian compensation, the largest expense
in any practice, hasn’t moderated with
the growth of hospital-employed physi-
cians. Contrary to the fears of many phy-
sicians caught up in the consolidation
wave, hospital administrators continue
to grant most specialties pay hikes that
outpace inflation by a healthy margin.
Modern Healthcare’s Physician Com-
pensation Database, which tracks aver-
age salaries based on a survey of a dozen
compensation consulting firms and
organizations, shows the average pay
for 22 specialties, including the relative-
ly low-paying fields of family practice,
pediatrics and internal medicine, rose
10.8% between 2012 and 2017. Average
physician pay now stands at $386,000 a
year, up 10.9% from $348,000 in 2012.
In percentage terms, that pay hike is
4 percentage points more than the
national inflation rate over the same
period. In other words, despite consol-
idation, doctors in recent years have
30 Modern Healthcare | March 5, 2018
consistently pulled down steady, infla-
tion-adjusted pay increases—something
that has eluded most American workers.
The money isn’t being spread around
evenly. Radiologists, anesthesiologists
and non-invasive cardiologists have seen
slight pay declines (after adjusting for in-
flation). Internal medicine docs and psy-
chiatrists, on the other hand, have seen
better-than-average pay hikes, a good
thing since that better pay promotes pri-
mary care and behavioral health.
But some of the biggest pay increases
have gone to in-hospital specialties—
ER docs and hospitalists. High-paying
proceduralists like invasive cardiolo-
gists, orthopedic surgeons, oncologists
and dermatologists have also seen bet-
ter-than-average increases.
The acquiring systems say it will
take time before we begin to see the
cost-reduction benefits of vertical inte-
gration. Organizations must implement
structural changes to accommodate
new functions like care coordination.
They also must adopt new attitudes to
enable payer-provider collaboration. It
takes time, they say, to create a culture
that encourages once-independent phy-
sicians to become the team players and
team leaders needed to deliver higher
quality, standardized care.
These changes do require substantial
investment, especially in doc-friendly
health information technology. Elec-
tronic health record systems must be
unified; data must be aggregated from
multiple providers in ambulatory and
post-acute settings; and hospital systems
must be able to perform the data analyt-
ics that enable care coordination.
It adds up to a daunting agenda for
streamlining and innovation, especial-
ly in health IT. In fact, the broad scope
of that agenda is one of the primary
drivers of hospital-physician consol-
idation. Few independent physician
practices can access the capital needed
to make these investments.
There is a vision for hospital systems on
this journey, though it’s rarely expressed.
The goal is to become an integrated de-
livery system, like Kaiser Permanente
or Geisinger, that can be centrally man-
aged with a fixed budget. It’s a compel-
ling vision and one worth pursuing.
But the centrifugal forces that could
disrupt those plans are gathering speed.
Outside capital is being poured into
stand-alone imaging and procedure
centers, storefront and workplace clin-
ics, and concierge-style primary-care
practices. Their business models de-
pend on the eventual disaggregation of
healthcare delivery.
Systems can’t afford to ignore those
threats. The time to generate value from
the past decade’s physician practice ac-
quisition binge is growing shorter. l
Healthcare leaders must do more to address
the hidden epidemic of clinician burnout
By Drs. Jonathan Lewin and Jeffrey Balser
M
ore than 1,800 years ago, the Greek physician Galen observed:
“That physician will hardly be thought very careful of the health of his patients
if he neglects his own.”
Galen’s insight should be taken to
heart by healthcare leaders today.
There is growing evidence that the
nation’s physicians, nurses and other
healthcare professionals face a hidden
threat to their health in the very work-
places that employ them.
A new report from the Blue Ridge
Academic Health Group, a study
group of academic health center
CEOs that has met annually for the
past 22 years and which we current-
ly co-chair, finds that addressing this
silent epidemic should be one of the
highest priorities in our institutions
and across the industry.
What’s at stake is the “joy of work”
that the most productive and empa-
thetic clinicians bring to their patients;
the sense of professionalism that every
doctor, nurse and other health profes-
sional has a right to expect; and the
satisfaction, quality and safety that is
rightfully demanded by patients.
The Blue Ridge report makes one of
the first systematic attempts to quan-
tify the economic impact of physi-
cian burnout, finding it amounts to
as much as $150 billion a year, or 4.7%
of our nation’s annual healthcare ex-
penditures.
That figure reflects burnout-driven
physician turnover; the productivity
loss of early retirements; and the pro-
jected cost of burnout-related medical
errors. It does not include, however,
the total impact of an estimated 300
to 400 physicians who commit suicide
annually (according to the American
Foundation for Suicide Prevention),
Dr. Jonathan Lewin, left, is president
and CEO of Emory Healthcare and Dr.
Jeffrey Balser is president and CEO of
Vanderbilt University Medical Center.
representing the equivalent of two
to three graduating medical school
classes lost each year.
In all of these areas, much more re-
search is needed, and we are grateful
to acknowledge the important leader-
ship role being played by the National
Academy of Medicine’s Action Collab-
orative on Clinician Well-Being and
Resilience.
The first large-scale study of U.S.
physicians, conducted in 2011, found
that burnout was more rampant
among physicians than in the work-
force at large, with 45.5% reporting
at least one symptom. A 2014 survey
found an even higher rate, of 54.4%,
with authors Dr. Tait Shanafelt of the
Mayo Clinic (now chief wellness offi-
cer for Stanford Medicine) and his col-
leagues concluding, “More than half of
U.S. physicians are now experiencing
professional burnout.”
Ironically, the same forces of ac-
countability and data transparency
that we all applaud—including the
wholesale move to electronic health
records—are some of the forces con-
tributing to physician distress. In
particular, the clerical tasks associ-
ated with escalating healthcare doc-
umentation burdens are a savage
application of the law of unintended
consequences.
Growing demands for productivity
and downward pressures on reim-
bursement are among other factors
brought to bear on physicians.
We need to de-stigmatize clini-
cians who ask for help; encourage
transparency; empower all members
of the care team to be watchful for
symptoms, in themselves and others;
and focus on system improvement.
We support such moves as elevating
the role of chief wellness officer in
health-system management; rethink-
ing the physical and organizational
design of clinic space to co-locate phy-
sicians and care teams; and teaching
every student, resident and physician
to take their own health and wellness
needs as seriously as they do those of
their patients.
After all, neither we nor our patients
can afford to lose so many of those
who have invested so much to serve
as our healers, and on whom we so
strongly depend. 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.
March 5, 2018 | Modern Healthcare 31
 Modern
Healthcare
Article on racism in healthcare
THE ONLY HEALTHCARE BUSINESS NEWS WEEKLY | FEBRUARY 26, 2018 | $5.50
not only timely but necessary
Your Feb. 26 cover story (“Racism:
Challenging the unspoken rules” p. 12)
on the effects of racial discrimination
RACISM
Challenging the
and bias on black professionals and
those of other minority backgrounds
unspoken rules
getting administrative positions in hos-
pital systems is not only relevant and
timely, but necessary.
I am an African-American attorney,
yet I still have to overcome biased per-
ceptions about whether I can do my job.
A majority of my friends and I have three
or more degrees related to healthcare,
and your article is spot on when it states that having multi-
ple advanced degrees merely gets your foot in the door. The
problem is also prevalent in the legal practice of healthcare
where there is very little diversity and/or senior minority
representation in law firms, government positions or in the
legal affairs departments of hospital systems.
And if you are “good” enough to get the position, you end
up spending as much time trying to do your job as you do
overcoming and managing perceptions about you—all
while watching your nonminority attorney colleagues,
whose professional experience doesn’t even begin to com-
pare to yours, receive responsibilities and professional de-
velopment that is never, or disproportionately, offered to
you. And because the perception of them is so great, they
can do mediocre work and still be given the benefit of the
doubt whereas, if I submitted the same quality of work
product, I am perceived as not taking my work seriously or
worse. The fact that I don’t even feel safe saying this in a
comment section, sending it from my work email address,
or sharing your article on my LinkedIn page further sup-
ports the article’s premise.
In sum, thank you for this article. I have shared it with
all my healthcare friends and in a minority public health
Facebook group I subscribe to. And I am already receiving
many “I thought it was just me” responses.
Author requested anonymity
Level of actual racism in healthcare
likely quite negligible today
Regarding the Feb. 26 cover story “Racism: Challenging
the unspoken rules” (p. 12), diversity is a politically correct
word for affirmative action. Affirmative action does not work
and actually harms those it is intended to help. The only rea-
son to hire an employee for any position in any organization
is because they have the knowledge, skills, experience and
32 Modern Healthcare | March 5, 2018
ability to do the job, period.
Ironically, most of the people
quoted in this article who said they
had to stay quiet were actually in
fairly high-level positions within
their organizations. With 50-plus
years in the healthcare industry,
my experience is that the level of
PAGE 12
actual racism is negligible. During
four years as an executive at Ce-
dars-Sinai Medical Center in the
The Top 25 Minority Executives
in Healthcare Page 16
1970s, the facility was like the Unit-
ed Nations, with doctors of all eth-
nic backgrounds, tons of FilipinoShinto Thomas
nurses, and support staff of every
creed, color and religion, all work-
ing together to provide the best care for their patients. And
that was more than 30 years ago.
James B. Davis
President
Practice Management Information Corp.
Los Angeles
We need active programs to address
disparities in healthcare C-suites
Diversity is not a euphemism. While I respect the opinion
of James Davis (above), the comment is the very reason why
we need active programs designed to address the dispari-
ties in healthcare leadership.
He is making the assumption that candidates selected
based on affirmative-action policies were not qualified in
other areas. Perhaps they were the best overall candidates
in a pool of otherwise qualified candidates. Blowing a dog
whistle that implies affirmative action was a failure be-
cause the people it actually helped were inferior to other
(non-black) candidates seems like a euphemism for racism.
I would argue that ethnic diversity, at some schools, is
only one aspect by which some students may qualify for
college admission. However, it is not the sum total of a
college admission package. In terms of leadership, are we
to assume that only 10% to 15% of the best leaders in this
country are minorities, when almost 40% of the U.S. popu-
lation are in a minority group?
Marlow Levy
St. Augustine, Fla.
Letters welcome
Write us with your comments.To send us a letter electronically,
go to modernhealthcare.com/letters; by fax, 312-280-3183.
Announce your Promotions, New Responsibilities, Retirements or New Hires
To place your ad contact Ilana Klein l 312.649.5311 l iklein@modernhealthcare.com
BIG
PROMOTION?
LET US SHARE THE NEWS.
TO SUBMIT YOUR LISTING GO TO:
MODERNHEALTHCARE.COM/PEOPLEMOVES
OR CONTACT ILANA KLEIN
iklein@modernhealthcare.com
HEALTHCARE BUSINESS
SOLUTIONS
Fresenius Medical Care North
America, Waltham, MA
Ahmad Sharif, MD,
MPH, SCPM,
was recently
appointed Chief
Medical Information
Officer at Fresenius
Medical Care North America.
He previously served as
VP of Clinical Health IT for
Fresenius Kidney Care and
is the former Chief Medical
Information Officer for a
Tenet Health market. He
holds his master’s degree
in Public Health Policy and
Management from the
University of North Texas
and received his Advanced
Project Management
Certification from Stanford
University.
MARKETING & PR
imre health, New York, NY
Jeff Smokler,
Marketing
communications
agency imre has
promoted Jeff
Smokler to partner
after six years leading the
firm’s healthcare business.
Smokler, who was previously
President of imre’s
healthcare business unit,
joins owners Dave Imre,
and Mark Eber and Partner
Crystalyn Stuart to lead the
agency into its
25th year. imre health
provides full-service
marketing communications
with a unique focus on
creating and managing
empathetic, patient-
centric social and digital
marketing programs for
pharmaceutical companies.
March 5, 2018 | Modern Healthcare 33
Interoperability
provides EMTs
with feedback
By Rachel Z. Arndt GETTY IMAGES

Usually after emergency medical technicians bring a “It’s a really good Information Network and
patient to a hospital, they have no idea what the final diag- source of validation community groups are cur-
nosis and outcome are. That’s not the case with Gold Cross rently looking into how they
for the EMTs. This
Ambulance EMTs in Salt Lake City. Thanks to a health in- could use the data to connect
formation exchange, those EMTs have access to informa- lets us see where people with programs that tar-
tion they would otherwise never know: what happened to we don’t match up get, for instance, people at risk
their patients after the ambulance ride. with the hospital of falling.
“It’s a really good source of validation for the EMTs,” said diagnosis codes, But for now, the data are
Brooke Burton, a paramedic and quality director for Gold and we can turn used primarily for education.
Cross. “This lets us see where we don’t match up with the that into learning For instance, McDonald and
hospital diagnosis codes, and we can turn that into learn- experiences.” fellow EMTs recently picked
ing experiences.” up a patient who presented
Utah’s HIE makes that feedback loop possible. Every Brooke Burton, a paramedic with typical stroke symptoms
and quality director for
time Gold Cross transports a patient to the hospital, EMTs Gold Cross and it turned out that hospital
send a record of that care to the state HIE, the Utah Health providers diagnosed him not
Information Network, a private, not-for-profit organiza- with a stroke but with a psy-
tion. After that, the hospital (as long as it’s one of the 90% chological disorder. When the EMTs learned about the dis-
of Utah hospitals participating in the HIE) does the same, crepancy in diagnoses, they discussed the final diagnosis
submitting diagnosis, disposition and demographic in- and learned more about the disorder.
formation to the same HIE. The HIE then pushes the data Though there are other organizations doing similar
to Gold Cross’ patient-care reporting system (equivalent work in the U.S., this approach is still unique, said Liz Co-
to an electronic health record), ESO. So as soon as EMTs thren, engagement manager with the Advisory Board Co.
log into the software, they see outcomes for the patients “Pre-hospital providers have kind of had to fly blind,” she
they transported. said. “This takes the guess factor out and allows pre-hospi-
Diagnosis data encourage EMTs to dig deeper when tal providers to do a better job of delivering the right care at
assessing patients, said Jack Meersman, a paramedic the right time to the right patient,” she said.
and compliance officer for Gold Cross. “Just because it’s One reason more health systems aren’t providing this
shaped like an apple and is red like an apple and tastes kind of feedback, she said, could be cost. It’s one thing
like an apple doesn’t mean it’s necessarily an apple,” he when the ambulance service is owned by a health sys-
said. By getting EMTs to better assess what kind of fruit tem. But when it’s owned by a county or private entity,
that look-alike really is, as it were, Gold Cross can help cut who would bear the cost is less clear. In Gold Cross’ case,
down on medical errors by backing up their decisions with a 2015 interoperability grant from the Office of the Na-
data-driven evidence. tional Coordinator for Health Information Technology
“When we get information that matches our field impres- helped finance the link with the HIE, which itself also
sions, it lets us know that we’re on our game and that we’re provided funding.
actually working appropriately and in the public’s best in- What’s more, interoperability could pose a challenge,
terest,” said Jeff McDonald, who’s been a paramedic with especially when there are disparate EHRs. In Gold Cross’
Gold Cross for 10 years. “When we’re not correct, we’re able case, the HIE goes a long way in solving that problem. “The
to go back and find out why.” care continuum is very large,” Burton said, “and this is an
In the future, providers might also use the HIE informa- example of where patient care can be improved through
tion in prevention programs. Gold Cross, the Utah Health interoperability.” l

34 Modern Healthcare | March 5, 2018

 AI spending boom
on the horizon
Whether artificial intelligence and machine learning revolutionize healthcare over the
next few years remains to be seen, but based on spending projections, the market is
about to take off.

Worldwide—and industrywide— Healthcare market value

revenue for cognitive and of AI ...
AI systems ...
… projected for 2021

$6.6 BILLION
… projected for 2020

$46 BILLION
… for 2017

$12.5 BILLION … for 2014

$600 MILLION
—International Data Corp.
—International Data Corp.

35%
Top five AI applications, ranked by estimated

$150 MILLION
annual benefit by 2026
Robot-assisted surgery $40 billion
Virtual nursing assistants $20 billion
of healthcare
Amount that AI is projected to Administrative workflow assistance $18 billion
organizations plan
save healthcare annually by 2026
to utilize AI by 2019; Fraud detection $17 billion
—Accenture
50% intend to use it
within five years Dosage error reduction $16 billion
—Accenture
—HIMSS Analytics

Top 5 barriers for adopting AI Areas for greatest initial impact from AI

Feel tech is still developing 23.1% Population health 23.5%

Unproven business case 14.6% Clinical decision support 20%

Infrastructure constraints 12.3% Patient diagnosis 20%

Opportunities hard to understand 11.5% Precision medicine 14.1%

Current data integration 11.5% Hospital/physician workflow 8.2%

—HIMSS Analytics —HIMSS Analytics

March 5, 2018 | Modern Healthcare 35

‘We started to think
about really embracing
substance-use disorder
as a chronic illness’

At Family First Health, integrating substance abuse treatment with primary care has Englerth: Internally,
become a key factor in battling the opioid epidemic. Jenny Englerth, CEO of the York, maintaining an adequate
Pa.-based federally qualified health center with six locations, said that doing so requires workforce has become
a cultural shift among clinicians, but that patients have openly embraced the approach. more and more of a
Even as Family First Health worked over the past year to create this integrated approach, stressor. Where people are
Englerth and her peers watched anxiously as Congress played a dangerous game finding training programs
of hot potato with federal funding. Lawmakers allowed funding for community health and how we are able to
centers to expire at the end of September, and the funding then became intertwined have a pool of candidates
in a larger debate over federal spending. Eventually, Congress authorized two years of that best represents the
funding—$3.8 billion in fiscal 2018 and $4 billion in fiscal 2019. Englerth recently spoke communities we serve—
with Modern Healthcare Managing Editor Matthew Weinstock. The following is an everything from language
edited transcript. to cultural understanding—
just becomes more and
more difficult. And we
Modern Healthcare: What stress and tension. multiple part-time jobs. see expectations around
kind of stress did the last few Feeling all those Most of our patients salary and benefits
months of not having federal things cumulatively, the who are able to work are continue to create more
funding—and not knowing if reauthorization debate was working more than one and more pressures on our
it was coming—have on your like an exclamation point on part-time job, but aren’t environment.
organization? the stress of the past year. receiving benefits through As I look at our patient
their employer, and those population, there’s a higher
Jenny Englerth: I like to MH: Can you expand on part-time jobs are all burden of mental illness,
frame it as a cumulative issues like food subsidies vulnerable, so their income depression, anxiety and
impact. Certainly, over and employment and how the becomes more vulnerable mood disorders that are
the last few months, we political climate affects your over time. All of those most likely underdiagnosed
were focused heavily on patient population? factors come together to and undertreated. And
the reauthorization related really impact health at then, like so many parts of
to community health Englerth: In south-central a community level and the country, we overlay an
center funding, but we Pennsylvania, we are blessed then impact our role and opioid crisis.
also are aware of changes with a pretty robust job the clinical burden that In addition, there’s a long-
to Medicaid and other market. We’re sitting at about providers have to address, standing and inadequately
benefits that support our 4% unemployment right whether in a community served population with
patients—food subsidies, now, which means that most health center setting or substance-use disorder.
employment opportunities. everybody who’s likely able in a hospital or health
All of those things either to be employed is employed system setting. MH: Mental health and
create strengths in the in some way. But like most substance abuse issues tend
most vulnerable parts of of the country, we’ve seen MH: How have those to go hand-in-hand. What
our community or create a shift from full-time, fairly stressors directly affected kind of things are you doing to
increased vulnerability and waged jobs with benefits to Family First Health? address those problems?

36 Modern Healthcare | March 5, 2018

“In hindsight, changing our behavior without thinking about
or understanding the broader picture likely contributed to
some of the move from controlled substances to heroin.”
Englerth: We have probably
traveled the path of many
primary-care providers over
the past five years, which
was originally focusing on
our own internal behaviors
and prescribing patterns.
In hindsight, changing our
behavior without thinking
about or understanding
the broader picture likely
contributed to some of
the move from controlled
substances to heroin.
Then we started to better
understand the issue and
started experiencing on
a daily basis the stories—
everyone from caregivers,
parents, sisters, brothers,
employers—talking about
deaths due to overdoses in
our community.
We knew that, just
like we had undertaken
an effort to integrate
behavioral health to
better diagnose and treat
depression and anxiety
in a primary-care setting,
we had to play a similar
role that wasn’t just about
limiting or eliminating our
prescribing of narcotics,
but it had to be about
doing something more.
We’re right in the thick of
that cultural shift to really
embrace as a primary-care
provider that these are
needs within our patient
population, and we have
to adapt and evolve our
system in order to meet
them. So we’ve taken on
prescribing medication-
assisted therapy, seeking
additional resources so
that we can build out a
support team, which is the
most important thing. It’s
not just about writing that
prescription for Suboxone
or Vivitrol, but having a
whole team that can …
reframe treatment and
recovery from a primary-
care plan, which is pretty
exciting work.
We’re experts for
treating chronic illness. We
understand how to do that.
When we stepped back
and started to think about
really embracing substance-
use disorder as a chronic
illness, it opened lots of
opportunities for us to
engage in treatment.
As I said, we’re in the
thick of cultural change
and it is not something
that all people coming
out of medical school and
residency have bought
in to. There are a lot of
adaptations that we have
to make, but we’re really
working hard among all
of our staff to equip them
with the knowledge so
they can better understand
substance-use disorders
and chronic illness.
MH: Do you think patients
understand this shift of trying
to treat substance abuse as
a chronic disease? Is that a
barrier you have to overcome
as well?
Englerth: We find tons of
receptivity from patients.
Right now we have about
250 individuals who are
currently in our center
of excellence for opioid
use. We’ve only been up
and running for about a
year, but our experience
is that it makes perfect
sense to patients. They are
accustomed to seeking
out their primary-care
providers when they’re
dealing with any kind
of health-related issue.
Patients have been really
receptive and have
consistently provided us
with feedback.
One of the things that
we started hearing from
some of our funding
partners was, ‘What’s your
discharge plan for people?
How many days?’
It was our first abrupt
example of, ‘Primary care
is just completely different.’
We don’t discharge
people; we recognize
the treatment of chronic
illness as a lifetime event.
And we want to be part
of that journey all along.
That really makes sense to
patients and it’s helped us
engage with patients.
MH: Another issue confronting
FQHCs is the relationship
with other providers. We are
seeing increased competition
for patients between health
centers and hospitals, as
well as collaboration. What’s
the dynamic like for you in
Pennsylvania?
Englerth: We see all of the
above. And the UPMC
health system has just
entered our corner of the
world. So the dynamic
will shift and change a bit,
and we’re preparing for
that. But in serving rural
communities, we need to
leverage the idea that we
are all on the same team as
healthcare providers.
I’ve been fortunate to
work within a community
where—and I’m not saying
March 5, 2018 | Modern Healthcare
there hasn’t been tension
and pressure and missteps
on all sides—but in general,
we’ve been able to have a
conversation that really
comes from that common
framework and trying to
leverage the FQHC assets
along with the strengths
that a health system and
hospital can bring.
I know that sounds a
little Pollyanna on my
part, but my framework
continues to be that if
we don’t create it locally,
someone in Washington is
going create it for us, and
we won’t be able to blame
them at that point.
MH: You mentioned UPMC
moving in. How have you been
preparing for that?
Englerth: This again is
probably sounding a little
Pollyanna and simple, but
there have to be personal
relationships involved.
People have to know my
faith, and I have to know
theirs. There has to be a
localized connection. If
we stay at arm’s length
through emails and
shooting messages through
the media, then the
conversation is unlikely to
be collaborative.
At this point, just like I’ve
worked with other health
system partners, it’s really
about building personal
relationships and in that
process, being open to
learning their perspectives
and their pain points and
challenges and bringing
forward ours as well.
We are experts in serving
a community that they
may want to serve for
different reasons. I have
always believed that some
of our power can come
from the knowledge and
connection that we have to a
community. l
37
Largest security breaches of electronic health records
Reported 2017 EHR security breach incidents, ranked by number of individuals affected
INIDVIDUALS
RANK PROVIDER LOCATION AFFECTED TYPE OF BREACH

1 Salina Family Healthcare Center Salina, Kan. 77,337 Hacking/IT incident

2 Pulmonary Specialists of Louisville Louisville, Ky. 32,000 Hacking/IT incident

3 Sport and Spine Rehab Fort Washington, Md. 31,120 Hacking/IT incident

4 SSM Health St. Louis 29,579 Unauthorized access/disclosure

5 Advanced ENT Head & Neck Surgery* Palmdale, Calif. 15,000 Theft

6 Neurology Foundation Providence, R.I. 12,861 Unauthorized access/disclosure

7 Advanced Spine & Pain Center San Antonio 8,352 Hacking/IT incident

8 University of Mississippi Medical Center Jackson 7,492 Hacking/IT incident

9 University Healthcare, West Virginia University Medicine Martinsburg 7,445 Theft

10 Covenant Medical Center* Saginaw, Mich. 6,197 Unauthorized access/disclosure

11 Valley Women's Health Aurora, Ill. 5,155 Hacking/IT incident

12 Daniel Drake Center for Post-Acute Care Cincinnati 4,721 Unauthorized access/disclosure

13 Princeton Pain Management Plainsboro Township, N.J. 4,668 Hacking/IT incident

14 Capital Nephrology Greenbelt, Md. 4,000 Hacking/IT incident

15 Vanderbilt University Medical Center Nashville 3,247 Unauthorized access/disclosure

16 Virginia Commonwealth University Health System* Richmond 2,716 Unauthorized access/disclosure

17 Professional Counseling & Medical Associates Paris, Tenn. 2,500 Hacking/IT incident

18 St. Charles Health System Bend, Ore. 2,459 Unauthorized access/disclosure

19 Dermatology and Laser Center Orange Park, Fla. 2,000 Unauthorized access/disclosure

Atchafalaya Internal Medicine Associates Morgan City, La. 2,000 Hacking/IT incident

Note: All breach incidents are currently under investigation by HHS unless noted otherwise.
*Indicates resolved breach report
Source: HHS’ Office for Civil Rights Breach Portal

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.

38 Modern Healthcare | March 5, 2018

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MARCH 26 MARCH 15 Don’t miss this opportunity to be featured in what’s

consider an invaluable guide by our readers, and
ensure your prospective candidates acquire a better
J U LY 2 3 J U LY 1 2 understanding of what your university’s programs
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March 5, 2018 | Modern Healthcare 39

Cats vs. dogs?
In research,
it’s canines by
more than a
whisker
n the age-old battle of cats vs. dogs, are our feline friends
Igetting the short end of the leash from researchers?
A recent piece in the New York Times stuck a paw in
the debate, talking to various researchers (both cat and
dog lovers).
Times science writer James Gorman searched a
biomedical journal database, and found more than
twice as many results for dog studies, with cats scoring
139,858 results. This despite evidence that studying
cats could yield insights into lymphomas and polycystic
kidney disease in humans, for starters.
“The research has lagged behind in cats. I think
they’re taken less seriously than dogs, probably to do
with societal biases. I have a vet in my group who thinks
that many of the cancers in cats may actually be better
models for human cancer, but there has been almost no
research into them,” Elinor Karlsson (who has three feline
Detecting heart disease with a look—and some AI
oogle researchers say their new
G algorithm can see your chances of
heart disease.
Researchers from Google and its
sibling company, Verily Life Sciences,
announced that by scanning the back
of a patient’s eye their new artificial
intelligence algorithm can assess risks
for cardiac problems.
The study, published in the journal
Nature Biomedical Engineering, suggests
that through analyzing the scans, the AI
algorithm can detect cardiovascular risk
factors, such as the person’s age, gender
The eye scan has the potential to be quicker
and more efficient than traditional blood tests.
40 Modern Healthcare | March 5, 2018
GETTY IMAGES
pets) of the University of Massachusetts told the New
York Times.
Research funding is also harder to come by for cats,
said cat geneticist Leslie Lyons of the University of
Missouri (team cat), who worked on a new reference cat
genome.
The wide range of dog sizes and shapes help attract
scientists to study them, according to Elaine Ostrander,
(team dog) at the National Institutes of Health. Dogs have
more genetic diversity, with about 400 breeds and just
40 for cats.
Humans’ extensive breeding of dogs for certain
characteristics and behaviors caused that array, of
course, while the same can’t be said of cats. But Lyons
calls it possible. “We could have a Chihuahua cat and a
Great Dane cat,” Lyons told the Times, adding, “I think
that would be a little dangerous.” l
and blood pressure. The examination can
predict risk of heart attack and stroke.
This new approach could offer a quicker
and more efficient analysis than traditional
blood tests. So far, the study shows that the
AI algorithm results are roughly as accurate
as the current method.
The research opens more possibilities for
AI to be incorporated in improving hospital
practices. “They’re taking data that’s been
captured for one clinical reason and getting
more out of it than we currently do. … Rather
than replacing doctors, it’s trying to extend
what we can actually do,” Luke Oakden-
Rayner, a medical researcher at the University
of Adelaide who specializes in machine
learning analysis, told The Verge. l
 TRANSFORMATIONAL
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PRESIDENT & CHIEF EXECUTIVE OFFICER MANAGING DIRECTOR MANAGING DIRECTOR
WESTERN CONNECTICUT HEALTH NETWORK BERKELEY RESEARCH GROUP BERKELEY RESEARCH GROUP

“$75 million in financial

improvements implemented
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IMPROVE
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President & Chief Executive Officer
Western Connecticut Health Network

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