HCPro.com - Executive Leadership - DO NOT USE Top Stories

Hospital Legionella risk management tool flawed

Wed, 04 Jul 2012 13:12:00 GMT

A tool that many hospitals use to assess the risk of Legionella in facilities may give a false sense of security.

The Legionella risk management tool that relies heavily on percent positivity—“if 30% or more of the tested sites were positive, then an elevated risk of disease is assumed”— has a significant error rate, according to an article appearing in Environmental Health & Engineering, June 20.

Click her to read more.

Treat Your Doctors Like Pilots

Fri, 25 Jun 2010 15:01:00 GMT

As many of you loyal readers know, I spent the early part of this week at HFMA's Annual National Institute in Las Vegas. One of the things I like to do at these shows is talk to vendors and their customers about what's bothering them and what's been successful in their efforts to improve their organizations—mostly hospitals and health systems.

One of the most interesting of those conversations came with Paul Weygandt, MD, who happens to be not only an orthopedic surgeon, but is also a lawyer with an MBA—and is a private pilot. Never mind wondering whether such a person is truly a human being and not a super-cyborg that never needs sleep, Dr. Weygandt has some most interesting theories about what activities and policies will increase patient safety while also putting more cash in the hospital's figurative pocket.

Weygandt is now vice president of physician services with Atlanta-based consulting firm J.A. Thomas & Associates, but he came to that job five years ago following a successful stint as the system executive for medical management at Conemaugh Health System in Johnstown, PA, as well as vice president of medical affairs at the system's Memorial Medical Center.

Weygandt has spent much of his career trying to navigate a healthcare system that as a whole has paid less than optimal attention to patient safety, as numerous statistics show. Perhaps those sobering statistics are why Weygandt has become such a big fan of the healthcare reform legislation, at least from the clinical side, as it makes healthcare providers accountable for quality and cost as the center of the accountable care organization concept that so many are rushing to try to figure out.

You see, Weygandt is on a crusade to try to reconfigure the way doctors and the rest of the care team works together. And his model doesn't require the physician to be the dictatorial head of the patient care team, through whom all decisions, even minor ones, must flow. Instead, he advocates a cultural change similar to what has gone on in the airline industry over the past few decades, which has dramatically reduced the workload of commercial pilots-in-command. In fact, Weygandt contends that this metamorphosis is the number one contributor to increased flight safety over the past 30 years.

Similarly, he advocates reducing the workload of physicians whenever possible, even if the doctor thinks he or she doesn't want that. I'll let him explain:

"The key way to decrease the workload of the physician is not the electronic health record," he says. "The physician can't monitor everything. We need to do away with the notion of the physician being the dictatorial captain of the team members on the ship. The physician is the leader, but the most important thing is not the leader, it's the team."

An example is physician documentation, Weygandt says. Proper documentation not only ensures the hospital is being paid correctly for what is being done to the patient, but also is critical to patient safety and every other variable that determines effective, safe and efficient patient care.

"I want air traffic control for the physician," he explains, using another concept borrowed from aviation. "The pilot has to follow the instructions of the air traffic controller or risk endangering not only his passengers but himself."

Similarly, Weygandt, a surgeon himself, welcomes questions and expertise from team members, from case managers who know how to navigate the continuum of care and ensure patient safety, to clinical documentation specialists who can translate physician language into codable language that ensures both the doc and the hospital get paid what they deserve for services they perform for patients. Even the housekeeping staff should feel comfortable pointing out issues that may interfere with safe patient care.

"These people need to be assertive though," he says. "Even the housekeeping staff can be some of your biggest patient safety advocates."

Not even close to all doctors would share that attitude, clearly, but Weygandt's theories make common sense, and he estimates that if every hospital had such a collaborative team-based approach to patient care, we could shave 20% from the cost of healthcare. Regardless of whether that estimate is ultimately valid, in an industry beset by patient safety issues now and potential revenue problems in the future, it's the only way to fly.

Note: You can sign up to receive HealthLeaders Media Corner Office, a free weekly e-newsletter that reports on key management trends and strategies that affect healthcare CEOs and senior leaders.

AHA: Congress Must Expand Medicaid Share Now to Avoid State Health and Hospital Cuts

Thu, 24 Jun 2010 12:04:00 GMT

The American Hospital Association is giving its campaign to extend federal Medicaid funding another strong push, saying that if Congress waits too long to provide relief, states and hospitals may be forced to further cut critical staff and curtail healthcare programs for the poor.

"We don't have updated figures for 2009 yet, but one third of hospitals were losing money in 2008," says Caroline Steinberg, AHA trends analysis vice president. She says hospitals experienced the worst financial performance in a very long time in 2008 because of the recession. Total margin revenues "were only 2.6 in 2008, and that was down from 6.9 in 2007, a significant drop in financial performance."

"The federal government has more of an ability to help the states than the states have to help themselves," she says.

Hospitals have become more efficient, delayed programs, and cut back staff, according to a new AHA survey in March and April, 2010. But they are still struggling. They also can't absorb the costs of care if state Medicaid programs cut back further.

The AHA specifically wants Congress to extend the increase in Medicaid matching funds put in place last year by the economic stimulus bill. The program, called the Federal Medical Assistance Percentage (FMAP) is set to run out at the end of the year.

Congress may think it can wait until then to approve a last minute extension, but they have to realize that states, and hospitals, are setting their budgets for the coming fiscal year now, Steinberg says. "States are in the middle of budget cycles," she says. "They need to know for planning and to prepare for what they will do if they lose federal assistance."

If they aren't assured now that the money will come, state Medicaid programs are poised to make coverage decisions and hospitals may make staffing decisions that impact the delivery of care, not just for Medicaid patients who need care, but all patients, Steinberg says.

On Tuesday, the National Governor's Association sent Congressional leaders a letter on behalf of 47 state governors essentially making the same case.

"Although the nation's economy shows signs of improvement, states' fiscal condition continues to deteriorate," notes the letter. "Consequently, governors continue to support a two-quarter extension of the enhanced FMAP provided under the American Recovery and Reinvestment Act (ARRA) as the most efficient way to help states avoid further layoffs and service cuts that could otherwise slow recovery."

The letter added that while the current FMAP does not expire until Dec. 31, "[d]elaying action until the end of the calendar year will force states to act now to reduce pending budget gaps by enacting further cuts in their workforce and core services, both of which will serve as a drag on the economic recovery."

To bolster the point, the AHA released data from a survey of 572 non-federal, short-term acute care hospitals from March and April, 2010. The responses were summarized as follows:

Patients continue to delay or forego care because of lack of insurance, and 70% of responding hospitals reported lower overall patient volumes, while 72% reported depressed volumes of elective procedures.
Of those responding, 74% reported reduced operating margin; 50% reported reduced non-operating income and 44% reported reduced access to capital.
87% reported increased bad debt and charity care, and 65% reported an increase in the percentage of patients covered by Medicaid, the Children's Health Insurance Program or other programs.
Of those responding, 76% said they had cut administrative costs, 73% delayed capital investments, 53% reduced staff, 25% cut services, 8% divested assets, 3% merged with another facility, and 24% made other changes to weather the storm.
Although the economy is starting to look better, hospitals are not ready to respond. Of those hospitals surveyed, 98% have not restored services or programs that had been cut, 89% have not added back staff or increased hours and 67% have not started or continued capital projects.

"Hospitals are struggling to update their facilities and equipment to meet the needs of their communities and keep pace with advances in medicine as access to capital has remained stagnant and worsened for some hospitals," according to the AHA survey summary. "The new data reveal that difficulties accessing capital persist for hospitals, with 44% reporting reduced access to capital continues and nearly a quarter reporting that their ability to access capital is getting worse.

"These difficulties in borrowing are particularly worrisome as hospitals scramble to invest in information technology to qualify as ‘meaningful users' to obtain Medicare and Medicaid incentive payments for information technology authorized under the ARRA and avoid future penalties."

Live from HFMA-ANI: Lessons on Efficiency from Vegas

Wed, 23 Jun 2010 12:37:00 GMT

It didn't take me long to come up with a recurring theme of the Healthcare Financial Management Association's Annual National Institute here in Las Vegas: efficiency.

Hospitals are going to have to get a lot more efficient under healthcare reform, there's no question about that. The main reason is that there is no reason to believe that reimbursement is going to get any better than it is right now. We may have finally reached the breaking point for three key stakeholders: the government, the patient, and the employer.

As I walked around and talked to people, in the exhibition hall and at the breakout sessions here, efficiency of one kind or another is all anyone wanted to talk about. Getting your length of stay down by using hospitalists was one person's crusade. From another, overcoming the challenge of collecting the patients' portion of the bill when they present for service.

Another, the use of self-serve patient kiosks to improve satisfaction and cut back on staffing needs. Still another, the use of huge amounts of data on physician practice patterns that allow management to have difficult conversations with physicians and arm them with the information that proves some docs are much less efficient than others. Still another person wanted to talk about expanding the use of physician extenders to do more of the routine patient care work, freeing up docs to do more high-value work.

There are dozens more ways vendors and educators are trying to move the needle on hospital efficiency. As I moved through the Venetian/Palazzo complex to get back to my room to write this blog, I marveled at perhaps the epitome of efficiency, the Vegas casino, in this case, the Venetian/Palazzo. Huge numbers of people come through this place every day. And everything you see, do, and hear around here is aimed at most efficiently separating you from your money.

It's a different kind of efficiency, sure, but don't think that every piece of your experience here is aimed at getting you from one place to another quickly and with as little effort on your part as possible.

From a bank of eight elevators serving every 15 or so floors here, to the ease of purchasing tickets to shows, to the slot machines that are everywhere, they want you to spend, and spend fast, and their mission in life here seems to revolve around removing any possible impediment to your spending that money. They know they only have you here for a short time, so any time spent waiting in line or getting from one place to another is time you won't be spending money. So they make everything easy.

Hospitals could take a lesson.

Live from HFMA-ANI: Searching for Savings in the Reform Era

Tue, 22 Jun 2010 12:31:00 GMT

Hospitals aren't sitting on their collective hands waiting for healthcare reform to take a bite out of their bottom lines. In less than 24 hours at the Healthcare Financial Management Association's Annual National Institute in Las Vegas, I've heard nothing but a constant refrain about efficiency, value, and cost cutting. Hospitals aren't yet sure how to get there, but they know they must as they prepare for the gradual implementation of the healthcare reform law over the next several years.

They know that they will slowly be getting less reimbursement per patient over time even as more patients are covered. That means they must demonstrate that their services provide long-term value for patients.

Glenn Steele, MD, CEO of Geisinger Health System in Danville, PA, set the tone with a presentation about Geisinger's journey toward better value for patient care. That's famously been described, including in the pages of HealthLeaders magazine, as Geisinger's warranty, which means the hospital committed to paying for any readmissions within a guaranteed amount of time for cardiac procedures, initially.

They're rapidly working on more.

Steele, concerned that medical price inflation might mean eventual price controls unless a market-based solution is found, conceded that Geisinger had certain advantages over other hospitals in that it is an integrated delivery system, complete with a health plan. That allowed Geisinger to take these risky bets with procedures without jeopardizing its financial well being.

A telling quote: "If we had a magical technique for extracting that suboptimal care, and redistributing that, there would be plenty of resources out there to cover people who haven't been covered. So how do you extract that? There's no relationship between quality and costs. If we can attack that lack of relationship between quality and cost, we've got a lot of potential.”

But the best part is that the initiatives worked. Patients were healthier, they got better care, Geisinger made more money, and the health plan's costs went down.

So is Geisinger's example that "magic” formula that can be replicated across the country? Sadly, probably not. But that doesn't mean there aren't other solutions out there, if healthcare will just innovate in improving its processes. So, other than amorphous healthcare legislation whose rules are still being written, what incentives do you have to innovate? In other words, what happens when you're still getting fee for service payment and still trying to get ready for a shift to being paid for value, and getting paid for keeping patients out of your hospital?

I don't know, and neither does anyone else. But you're charged with finding your own way.

Some of Steele's suggestions for process re-engineering and innovation:

Unjustified variation
Fragmentation of caregiving
Perverse payment incentives (outcome irrelevant)
Patient as passive recipient of care

A huge amount of Geisinger's re-engineering is having non-docs do things that docs used to do. It frees up the docs to do other more valuable things that frankly docs enjoy doing, says Steele, a doctor himself. Quite often you get improvement in quality as well as increased value if you really redesignate who does what,” he adds.

EMRs aren't the only answer. Neither is greater patient participation in their own health maintenance. Neither are dedicated physicians or even interesting demonstration projects. But they're all part of a whole. The answer is there is no holy grail.

But such experiments and process re-engineering are necessary, even vital, if we don't want to face price controls in the future, says Steele.

We'll have more comprehensive reporting from HFMA-ANI tomorrow. Stay tuned.

Millions Lost To Contractual Underpayments, and How My Cable Bill Can Help

Mon, 21 Jun 2010 14:44:00 GMT

About four years ago I had a problem with my cable bill. You see, for the longest time I just assumed that my cable bill cost what it cost and I was auto-paying it. That was until I was taking my annual inventory of expenses, and I noticed that every few months my bill seemed to go up just a little bit. I wasn't buying a lot of on-demand movies, so it gave me pause.

I called the cable folks and they started rattling off a litany of reasons for my bill "adjustments"—there were tax increases, rate increases, promotional channels (that I'd never declined and thus were added automatically)—all because I wasn't paying attention. I should've. I estimated that I lost about $150 that year with all their shenanigans, but it was all completely legal and it was my fault for missing it. Needless to say, now I check my cable bill every month and I will likely never autopay that one again.

Keep my cable bill tale of woe in mind because I'm about to offer you a hard pill to swallow; as many as 40% of your payers are likely underpaying you AND they aren't doing it intentionally AND they aren't violating your contracts. In fact, what's happening is actually your mistake and it's costing hospitals and practices approximately $1.5 billion, or roughly $300,000 annually per hospital.

IMA Consulting, a Chadds Ford, PA firm, offers some insights on what mistakes hospitals are making that cause losses through contractual underpayments in Manage Your Payer Contracts to Optimize Collections. The fact is that payer contracts are complex and with healthcare reform taking effect, your contracts are likely to become much more complex in the next several years. Some hospitals and health systems are already using contract tracking software and that's very useful in preventing underpayments—the thing is the software is about to be outpaced by these new and improved payer contracts. So your contract software "failsafe", if you've been fortunate enough to have one in place, is about to give way.

Now, missing one or two contract payments isn't much money, but missing a lot can add up to hundreds of thousands to millions over time. What makes this area so confounding is that contractual underpayments are difficult to identify—they simply aren't obvious, not only to the hospital but also to the payer—which is why I say this isn't intentional on their part. After all, most payers are also using older systems and software, but even if they did discover that they were underpaying you, do you think they would alert you to it?

Robert Sutton, partner at IMA Consulting and co-author of the article looking at this problem offered his strategies for remedying this situation.

Negotiate simple contracts. Sutton suggests that these contracts be clear and concise and simple enough that your biller can understand them. This will also make the contract more likely to work with your existing contractual management software.
Assemble a team. This group will work on the negotiations together—including representatives from each department that will be impacted by the contract (e.g., the CFO, patient accounting, patient access, HIM and legal). This group, which should also include key physicians on the staff, should be responsible for reviewing not only proposed contracts but also modifying the existing ones or those about to expire. They should also be in charge of monitoring any rate changes in the contracts and alerting the rest of the staff. Sutton recommends that this group create a matrix to track the different dates and key distinguishing details of the contracts. Be sure to make note of any provision that deviate from the hospitals standard contracts.
Make technology top-priority. It's not about having some contract tracking software in place, Sutton says, it's about using that technology to the fullest. "The contract updates have to make it into the system in a timely manner and they need to be checked regularly," he says. "The person who does this needs to be a part of the contract negotiation team and they need to fully understand all the different pieces of each contract." Eventually the contract software will catch up with the new payer contracts that are likely to unfold in the coming few years, but until it does, this person is a linchpin for ensuring facilities are fully reimbursed. Moreover your patient accounting contract management system or module should be configured to determine reimbursement for each level of service; this will help you collect your A/R at the time of billing.
Take time to educate. It seems like taking the time to educate your staff is the last thing you have, well, time for. Fact is, you must make the time to educate everyone who is involved with these contracts or you will continue to see your net revenue reduced. Depending on how many contracts you have and how frequently they change, you should set up regular meetings with your teams to review any and all adjustments to these contracts. Use the matrix you developed as a starting point, but don't allow that matrix to be the only training tool you use. By getting these folks in the same room, they will educate one another and you can be sure that all the correct information is disseminated simultaneously.

These strategies can mean the difference between unaccounted for net losses in revenue and your hospital bringing in thousands more this year. What my cable bill taught me a few years back is this: when you rest on your laurels, you lose money. It's unfortunately but no one is going to point out where your hospital is losing money, it's up to you to find the problems and fix them.

Note: You can sign up to receive HealthLeaders Media Finance, a free weekly e-newsletter that reports on the top finance issues facing healthcare leaders.

Could Nonprofit Hospitals Become an Endangered Species?

Fri, 18 Jun 2010 16:14:00 GMT

Several of us were meeting recently about story ideas in HealthLeaders magazine. A story idea I mentioned about nonprofit status was discussed in our conference call, and I speculated that given the increasing levels of insured patients, that some people might get the idea that tax breaks are no longer necessary for nonprofit hospitals and health systems.

Undoubtedly, some will get that idea, especially in an era where the federal government beholds huge deficits as far as the eye can see, and no easy way of raising additional revenue, otherwise known as raising taxes. My point was that if hospitals are no longer having to spend huge amounts covering charity care and bad debt write-offs, will they be seen as a potentially big source of revenue not only for the feds but for state governments as well?

My contention was that they would. Another idea postulated as we discussed that story idea was that many hospitals, especially of the local, government-owned variety, might consider ditching their nonprofit missions entirely and move toward a for-profit business model. Most of us shot that down as extremely far-fetched, though some wags might argue that many nonprofits operate like for-profits as it is, with the high executive salaries and focus on the bottom line that characterize such institutions.

Certainly there's a lot of revenue at stake if all such entities were taxed. But much of the hubbub about this subject has died down recently with the passage of healthcare reform legislation. That doesn't mean powerful people, like Sen. Charles Grassley, aren't still thinking about it. And little sandstorms of controversy periodically erupt over hospitals and their nonprofit status. Just this week, New Hampshire's attorney general launched an inquiry into salaries of CEOs at nonprofit hospitals.

So following the meeting, I started thinking a little more about that far-fetched alternative theory. As I said, we shot it down. I mean, what would be the motivation? But then as I thought about it more, I can see a few good reasons for doing so. Still, I can't think of any hospitals that would take such a drastic step willingly. Regulations for justifying that tax break would have to get a lot more teeth. And think about the negative public relations hit hospitals would take, for foregoing their tax-exempt status. And think about the hit they would take to the pocketbook, even though they would be relieved of the charitable contribution requirement. Still, I'd be interested in hearing from anyone who has a good argument for that course of action.

HHS Details $250M Investment in Primary Care Workforce

Thu, 17 Jun 2010 12:12:00 GMT

Health and Human Services Secretary Kathleen Sebelius announced that the federal government has targeted $250 million to bolster the nation's primary care workforce.

The funding represents the first allocation from the $500 million Prevention and Public Health fund for fiscal 2010, created by the Affordable Care Act. Half of the fund—$250 million—will attempt to boost the number of primary care providers in this country by:

Creating additional primary care residency slots: $168 million for training more than 500 new primary care physicians by 2015;
Supporting physician assistant training in primary care: $32 million to develop more than 600 new physician assistants;
Encouraging students to pursue full-time nursing careers: $30 million for more than 600 nursing students to attend school full-time so they can complete their education faster;
Establishing new nurse practitioner-led clinics: $15 million for 10 nurse-managed health clinics to train nurse practitioners;
Encouraging states to address health professional workforce needs: $5 million for states to plan strategies to expand their primary care workforce by 10% to 25%.

"These new investments will strengthen our primary care workforce to ensure that more Americans can get the quality care they need to stay healthy," Sebelius said in a media release. "Primary care providers are on the front line in helping Americans stay healthy by preventing disease, treating illness, and helping to manage chronic conditions."

Roland Goertz, MD, a family physician in Waco, TX, and president-elect of the American Academy of Family Physicians, says the funding is "a great first step."

"It addresses the key issues. It helps us move toward the patient-centered medical home as a model of care delivery, working with registered nurses, PA nurses, and others in the system," Goertz says. "But we need to have a movement toward rebalancing. And the imbalance has been created over a long period of time. We haven't had an adequate balance of primary care physicians in this country since the 1960s. It can't just be one time for two or three years. It has to be for a sustained period of time to correct the imbalance."

Time to Break the Taboo of Wooing Well-insured Patients

Wed, 16 Jun 2010 14:48:00 GMT

You won't often overhear a hospital marketer loudly proclaim at a dinner party that their organization is trying to attract more insured patients. It's understandable—most people in healthcare got into that field to help people, and admitting aloud that you're trying to bring in wealthier clientele just doesn't seem right. This taboo needs to end now. High-value patients keep hospitals in business and enable them to care for the poor and uninsured.

I write about the strategic importance of high-value patients in the June issue of HealthLeaders magazine. The definition of a high-value patient varies depending on an organization's current business goals. It may mean a patient with insurance, a patient who uses a service line that is a strategic priority, or a patient who has been treated before and may need follow-up care—or all three.

MedStar Health, a nine-hospital system based in Columbia, MD, recently began focusing its efforts on ED patients who were not admitted and inpatients who presented with a visit to key service lines. It did this by launching a targeted direct mail campaign, a common method for reaching out to high-value patients.

"The critical thing is to identify who the high-value patients are and what strategic direction you wanted to take with them," says Jeff Miller, assistant vice president of marketing for the health system. "The key first step in the process for us was to meet with each individual hospital and determine what their business goals were and then determine what the high-value patient meant to those business goals."

DeKalb Medical, a three-hospital system based in Atlanta, also used direct mail for its ability to target specific populations and because it was a less-expensive alternative to the local media market.

Traditional media, such as TV, radio, and print advertising “is very wasteful because I can't zone in the way I really need to," said Terri Whitesel, director of corporate communications for the health system. "I could easily spend $50,000 to $60,000 a week and not get there—and with today's budgets that's not practical."

Online advertising can also be an effective way to target high-value patients, because Web sites can provide you with detailed information about their visitors, including geographic location, age, gender, and, if it is an e-commerce site, how much money they spend and what kinds of products they buy.

For their direct mail efforts, both MedStar and DeKalb use CRM software from CPM Marketing Group in Madison, WI, to segment the patient population and craft the correct messages for each audience.

This segmentation can allow you to send out a variety of messages based on age, ethnicity, gender, and incident rate.

For example, at DeKalb, a young woman who has yet to have a mammogram will receive a different postcard than an older woman who had a mammogram years ago but hasn't returned, Whitesel said. The imagery on the direct mail piece changes for each target audience, as well.

Once you've succeeded in attracting high-value patients, you must consistently continue to reach out to them to keep well-insured patients coming back. Doing so can help your organization remain profitable, which means you can continue to help those who need it most.

Credit Rating Agencies Have Been Botching Some Important Ratings

Mon, 14 Jun 2010 14:02:00 GMT

When it comes to your hospital or health system credit rating, most CFOs do everything they can to try to get, or keep, a AAA rating. But really, what does that rating truly mean? Maybe it shouldn't mean that much.

Banks, and a host of investors, use these ratings to help guide them in their lending and investing practices but when the ratings are wrong their mistakes can misdirect a lot of people. Thanks to a host of bad predictions by ratings agencies and some rather nefarious activities by many large corporations in the finance industry, the economy took a bit of a turn and with it so did many businesses, hospitals, and investors.

To be fair, the rating agencies—of which there are 10, but three are the most well-known and used (Standard and Poor's, Moody's and Fitch)—aren't always wrong in their analysis and rating. Nevertheless, it seems in the last ten years the ones they have been wrong about have cost all of us dearly—financially. See my other column if you want to read more about that.

I have worked in finance and I have worked in publishing and I can tell you that both industries have their pluses and minuses. But one thing I didn't enjoy about finance was all the SEC compliance rules. They are truly a pain point for many working in the industry, but they are a necessary evil. That is until you realize that it's mostly toothless paperwork that's mostly filed by the honest minions while the less-than-honest folks are still doing whatever they can to earn a buck.

I suppose it shouldn't surprise me, or any of you, to learn that after the banking industry was investigated and many of them were found to be conducting business in a less-than above board manner, that now the investor's rating agencies are about to undergo scrutiny. It's important for healthcare financial leaders to be aware of how some pending legislation and legal actions might influence investor ratings in the years to come. But first, allow me to make a wild prediction—not an accusation—investigators are going to find out that ratings agencies may have been more flexible with some ratings scores than with others. Are you shocked? I doubt it.

I hate to be a pessimist, but it seems to me that money has a tendency to encourage folks to do the wrong thing. I'm not sure what happened to the moral backbones that people used to have, but it seems a lot of people would rather walk "easy street" than take in the view from the "high road"—and a lot of those people seem to gravitate toward the finance industry.

There is a fantastic article in CFO magazine this month about the credit rating disaster. Take the time to read it and educate yourself on what's going on behind the scenes—it's history that is worth reading, but not worth repeating.

The CFO magazine article recounts numerous examples of how Standard and Poor's and Moody's Investors Service have flubbed their ratings reviews for various large companies (e.g., giving Enron an investment grade credit days before it went into bankruptcy, and let us not forget about these agencies stellar predictions for mortgage-backed securities). What's always surprising to me is how they can get it so wrong, but there aren't any ramifications.

With so many people dependent on these reports, shouldn't they be more consistently correct? If a heart surgeon continually told all his patients that they were going to live long full lives, but after the surgery only half of them lived a week, I'm sure he would be fired and sued. Let's just say that as far as their educated predictions go, neither rating agency has been accurate enough lately to get a job as a fortune-teller at the circus. Is that harsh? Not when you consider how many millions of people count on these ratings and how many billions of dollars have been lost in the past few years because of their misplaced optimism (translation AAA ratings) with various large companies and banks.

As a hospital leader, you know how important outcomes are. Patients arrive at your hospital looking for help, you explain things and then give them a general prediction of the results for their treatment. Now, those "odds," for lack of a better term, aren't always right, but more often than not things go according to plan and the desired outcomes are achieved. If that wasn't the case, your hospital would be out of business, or at the very least it would be waist deep in malpractice suits.

Then again, your end goal is to make a specific person well vs. the rating agencies' goal of making money for themselves. That profit motive is their primary motivator. Now, if you are motivated to make a profit, then you are motivated to find the biggest source of money to get that profit. NEWSFLASH—the biggest source of money isn't Ma and Pa Store Owner on Main Street who is looking to invest a little money for their retirement. Nope, it's Mr. Fat Cat Big Business, the companies that need the ratings to entice Ma and Pa to invest in the first place. The ratings agencies shouldn't be allowed to profit by working with these companies.

The CFO magazine article notes that while Moody's has a compliance group to enforce laws and internal policies, a former employee testified to a House committee that the "credit policy group was routinely overridden by line managers in the name of winning business, while the compliance group was understaffed and had little professional compliance experience."

Shouldn't these agencies be required to be impartial and nonprofit? Moreover shouldn't they be run like Consumer Reports, where they operate based on paid subscriptions from the consumer, which makes them accountable to them for their results?

Reimbursement: These Are the Good Old Days

Fri, 11 Jun 2010 16:18:00 GMT

"Anticipation, anticipation,
Is making me late
It's keeping me waiting . . ."

In case you can't put the tune to the words, or in case you're younger than me, those are the lyrics to the chorus of the old Carly Simon song, Anticipation. As I was reviewing my notes from a recent conversation with MedAssets Chairman, President, and CEO John Bardis, I found myself humming the tune after he told me about the general mood of hospital and health system CEOs at his company's recent Healthcare Business Summit.

Yeah, I'm weird. My wife tells me so all the time. But those lyrics make sense in the context of what's to come from the healthcare reform law.

The reason I was humming the song was not the well-known chorus, but the second verse of the song, almost as well known:

And tomorrow we might not be together
I'm no prophet, and I don't know nature's ways
So I'll try to see into your eyes right now
And stay right here, 'cause these are the good old days
These are the good old days
And stay right here, 'cause these are the good old days
These are the good old days
These are the good old days
These are the good old days
These are the good old days

Though Bardis certainly didn't use those words when we spoke, he said that the most consistently profound point that was raised in his conversations with hospital and health system leaders was the recognition of all the CEOs that current levels of payment might be the highest that they will ever be.

They believe reimbursement is on the way down, as do I. No other answer makes any sense for a sector that is one-sixth of the United States' economy, but for which costs are growing at up to four times the rate of inflation.

That leaves administrators to manage their clinical operating structure to respond to that while continuously focusing on quality clinical care and patient satisfaction. That's a pretty tough challenge, considering hospitals and health systems, if they're lucky, make a 4% margin these days.

MedAssets strives to help hospitals and health systems improve financial strength by implementing spend management and revenue cycle management solutions that help control cost, improve margins and cash flow, increase regulatory compliance, and optimize operational efficiency. Bardis contends that this law will break the "insurance and pharma cartels."

That might sound great if you're a hospital leader, but really, such fractures will bring more challenges to you, not less.

"In the past if you looked at the branded drug cartels and the insurance cartel, indirectly they benefited each other," he says. "As costs went up, those cost increases bounced off the provider and into the private pay pools. That private structure was able to pass those cost increases onto individuals, companies, municipalities and unions."

But that paradigm is passing away, he says. Recent unemployment levels have shown fractures in risk pools in states where elements of economic deterioration have been above the norm, like in California, with a 13.1% unemployment rate, as well as a drastic reduction in municipal and state jobs.

This fracturing of the risk pools explains commercial insurers' attempts to raise rates drastically—up to 30% in a year in some cases—attempted increases for which attorneys general and insurance commissions are not standing.

"This exposes [insurers' and drugmakers'] inflexible commitment to a business model that doesn't answer the questions the market needs today," he says. "The model has been my way or the highway, so it hasn't had the flexibility of the forethought to change meaningfully."

Preventing Missed Revenue Opportunities

Wed, 09 Jun 2010 14:59:00 GMT

Robert Sutton, partner at Chadds Ford, PA-based IMA Consulting, discusses tips for preventing missed revenue opportunities due to third-party payer contractual underpayment.

A Code of Conduct for Physicians

Wed, 09 Jun 2010 13:50:00 GMT

When the American Medical Association recently released a 10-point "Code of Conduct" for health insurers, the public reaction from payers was pretty passive and politically correct.

"We do adhere to the code of conduct principles as outlined by the AMA. In fact, we have been doing so for quite some time," said Ross Blackstone, spokesman for the Health Care Service Corp. Other industry representatives issued similarly tame defenses.

But privately, some people in the health insurance industry have been much less welcoming of the AMA's 10 commandments. "I won't practice medicine if you don't practice actuarial science," one insurance consultant said.

Payers and physicians have a long history of bad blood, and the AMA's somewhat aggressive code didn't do much to improve relations.

A few of the points in the code—relating to rescissions and spending on medical services—were already covered in healthcare reform legislation. Others, such as a request for "respectful relations," seemed like vague potshots. There were, of course, valid criticisms in the code, particularly when it comes to administrative simplification and physician relations. But on the whole, it seemed like one segment of the industry simply airing its grievances with another.

What if, as a person in the insurance industry suggested to me, payers wrote their own code of conduct for physicians? Based on feedback from a few industry representatives, it might look something like this:

1. Engage in fair billing. While the majority of physicians already adhere to this point, the same could be said for insurers and some points in the AMA's code of conduct. There are, however, a few bad apples that over-bill or sometimes commit fraud.

2. Disclose conflicts of interest. "Physicians should be subject to the same transparencies as the insurers. Patients should have a right to know whether or not their physician owns the imaging center where they are sent for their CT scan, should know how much their physician is charging for their cardiac cath, etc.," says Peter Gurk, MD, medical director for Bluegrass Family Health.

3. Learn the business side of medicine. Insurers often have the best relationships with physicians who understand the business aspects of managed care and are willing to partner with their payers.

4. Embrace the evidence. The AMA requested that medical necessity be defined as care a prudent physician would provide in accordance with "generally accepted standards of medical practice." But that doesn't necessarily mean evidence-based care and could include practices that are commonly practiced but not necessarily the best option.

If a group of health plans released a code of conduct for physicians, would that accomplish anything? Probably not. And it's unlikely that the AMA's code of conduct will, either. Again, the physician organization had some valid criticisms, but the delivery of the message only makes public the wedge between the two groups.

Blame doesn't lie solely with the AMA. Both groups have to overcome a rocky history and learn to work better as partners. Gurk, who has worked both as a physician and for a health insurer, offers the best advice: "Drop the adversarial relationship on both sides."

Note: You can sign up to receive Health Plan Insider, a free weekly e-newsletter designed to bring breaking news and analysis of important developments at health plans and other managed care organizations to your inbox.

Bravado Does Bring About Success: The Tale of Saint Barnabas

Mon, 07 Jun 2010 14:36:00 GMT

At the end of this week, June 11, is the Feast of Saint Barnabas, so it seems fitting that this is the week I should tell you two tales of Saint Barnabas—the man and the New Jersey Health System. Saint Barnabas, the man, was actually Greek (born Joseph) and back in the first century he was a Christian convert and one of the earliest Christian disciples in Jerusalem. Together with Saint Paul he undertook countless missionary journeys to bring converts into the church. Given the nature of the times, encouraging people to forego their other religious affiliations was risky—even life-threatening—yet driven by fervent belief, Saint Barnabas decided not to let fear for his own safety stop him from acting on God's behalf.

Centuries later and in a totally different field, Saint Barnabas Health Care System in West Orange, NJ, which operates nine hospitals as well as several outpatient, nursing and rehabilitation and assisted living facilities, also decided to push fear aside to convert the financial side of their business. The Saint Barnabas System provides treatment and services to more than two million patients annually and employs 18,200 people (4,600 physicians and 445 residents and interns.)

Though a large facility, the recession certainly hadn't passed the system by, and they were in default on their debt, affecting their investor's service bond rating. Moreover, at one point they were operating with 28.5 days cash on hand. However, they also had some positives working in their favor; the system held 25% market share and it was generating $2.8 billion in revenue annually, with daily cash collections of $7 million. Net accounts receivable was 43 days and just 29% of AR was over 90 days, plus it had a 93% clean claims rate. Many CFOs would've maintained the status quo and rode out the recession, but that's what makes this tale so unique.

You see, to achieve the $7 million in cash collection, the system had outsourced most of its collections processes to vendors and they were spending large amounts to bring in that money. Moreover, all their claims were reviewed manually by billers, making it a very labor intensive and costly endeavor. In May 2009 Jay Picerno, a self-described "typical, conservative CFO", joined the system as its executive vice president and chief financial officer. Upon reviewing the situation, he knew something bold—even fearless—needed to be done to bring the system to higher financial ground.

"We had a lot of outside collection agencies so our overall net back on our cash collections wasn't that good," said Picerno, during a MedAssets conference presentation this past April. "We knew long-term we couldn't continue in that direction. So we took a bold step and said we want to fix our balance sheet."

He tinkered with the idea of bringing more technology or adding a strategic in-house team member, but the ideas didn't seem as though they would move the system in a different direction. It was then that Picerno connected with a consulting firm the facility had used before for software, MedAssets, in Alpharetta, GA. Out of these discussions, a new idea was born: embedded teaming to address the back office.

Embedded teaming is similar to a partnership, however the third-party resides within the organization and works side-by-side with the facility. Additionally, MedAssets' incentives and goals were aligned with how well the overall system performed. Goals and objectives for both the front and back end were laid out as part of the projects management and then tracked to ensure that both sides were on target.

"We looked at this and asked, 'how do you flip the revenue cycle without disrupting the cash flow?' because we couldn't afford to do that," says Picerno. "We told MedAssets they could come in to figure it out, but they couldn't talk to our business office or anyone on the back office, and they had to fix the problem and do it for less money than we were doing it today." It was a challenge, yet the embedded partnership prevailed.

Do You Have What It Takes to Fire Your Consultants?

Fri, 04 Jun 2010 17:36:00 GMT

Why don't you fire your consultants? It's a provocative question and its tough to answer, but CEOs, you're part of the problem. In fact, when it comes to getting value from your multitude of consulting engagements, you're the main problem. The simple truth is that you don't often fire your consultants because you depend on them. They nurture that dependent relationship, in fact. It's just good business for them.

So says Gordon Perchthold, co-author of Extract Value from Consultants: How to Hire, Control, and Fire Them. Perchthold, a consultant himself, says overreliance on consulting talent can mean a lot of wasted money for the widget manufacturer as well as the hospital or health system. Overconsulting can as well mean lackluster results and lower morale from lieutenants and the rank-and-file. Right, you're saying. So tell me something I don't know.

OK, try this contention on for size: CEOs get addicted to consultants, and no matter how savvy they are, top executives often get roped in by tricks of the trade that sometimes stretch a consulting engagement for a relatively small matter into a years-long relationship that's more beneficial for the consultant's employer than for, you, the client.

Like substance abuse, says Perchtold, the first step to getting help is to admit you have a problem.

"Consultants do have a role," he says. "Organizations have execs who build up silos that work against change and consultants can help with that. But as soon as they are on board, consultants start working the relationship. They spend quite a lot of time to persuade the execs take actions that the consultants want and that usually results in follow-on work."

So why are Perchtold, and his coauthor Jenny Sutton, spilling the secrets of the trade? First, they do have a book to promote, and they've seen the way some consulting firms build long-term relationships with clients that may not serve the client as much as the consulting company. A lot of CEOs are former consultants themselves, so they might be familiar with "problem creep." That's the practice of consultants working to find engagements for their colleagues back in the office who are looking for billable gigs. But that makes consulting engagements inefficient at least and borderline unethical at worst.

"A lot of CEOs are former consultants and what happens is they bring in their former employer," Perchtold says. "We've challenged that because there's a conflict of interest in the selection process."

But who's watching to make sure the client is the one who's benefitting from the relationship? In many cases, no one, Perchtold says. He's careful to note that he's not trying to denigrate the profession or to contend that something illegal or unethical is going every time a certain group of consultants gets ingrained into an organization's culture. Consultants are often brought in to cure inefficiencies or find ways to cut costs. The irony is that the consulting budget may be among the most bloated and inefficient of all categories of spending within an organization.

Perchtold contends that a few large organizations have such a poor grasp on how much they're spending on consultants across the board that they sometimes have to hire a consultant to figure that out.

"A lot of times the consultants will be one of the highest-spend categories, but they do all they can to minimize the truth that they are one of the major categories," he says.

The issue with a lot of consulting spending is that the employees who are doing the work with them in the organization come from the operational side.

"They never learn about managing the consultants, and what you have is inexperienced operations people matched up with consultants who come from the best business schools and who manage their own consultant colleagues every day. The result is that they are good at managing clients for their own objectives."

The idea isn't that you're being swindled, rather that most consulting firms will deliver something, but not as much as they could, because they have "leveraged" themselves into activities over which they have less and less knowledge over time.

Is A Double Whammy Ahead for Hospitals and Healthcare Reform?

Tue, 01 Jun 2010 15:51:00 GMT

Healthcare coverage is both a blessing and a curse–it really all depends on whether you are the patient or the hospital. The newly signed Patient Protection Act is designed to help millions of uninsured patients get proper healthcare coverage, yet the fallout from that coverage is likely to have some less than desired effects for hospitals and their bottom lines.

At first blush the new law should help take care of the cost of the uninsured patients who are often arriving at the hospitals emergency department, however, it may also have an unintended side effect, which is that now patients may utilize both the ED and primary care doctors for their general care. In May, Chadds Ford, PA-based IMA Consulting released Will Healthcare Reform Alter the Landscape of the Emergency Department?, looking at the impact new legislation may have on the ED environment. Some of what they found wasn't surprising, such as:

Uninsured ED patients are the primary cause for ED overcrowding and excessive lengths of stay.
Uninsured patients do not see primary care physicians or delay care to the point at which the ED provides the only alternative.
When seen in the ED, their diagnostic course is more complex and time consuming, hence the longer length of visits.

However, what may go against the general thought process is the idea that when people have health insurance they are less inclined to visit the ED.

"One of the pieces of research we looked at was that people who tend to have insurance—particularly Medicare and Medicaid, tend to access the ED more than people who are uninsured," says IMA Consulting Director Bob Gift. "This is possibly because they're not necessarily stuck paying the entire bill."

Gift says people who don't have insurance—though they may opt for the ED when they do become sick—also tend to avoid care altogether, waiting until the last possible moment to access the system.

"Now patients may think, I have insurance so 'what the heck; I may as well go to the ED'," he says. Unfortunately, as most hospital financial leaders will tell you, EDs are already operating at or near capacity and there's already a dearth of primary care physicians. Consider these national statistics:

More than 325,000 patients per hour or more than 119 million annually, seek care in the ED.
From 1993 through 2006, the compound annual growth rate of ED visits was 3.6% and that number continues to climb.
Since 2000, the number of EDs and hospital beds has decreased either due to facility closures or eliminated services (i.e., Deaconess Hospital in Cincinnati, OH and St. Vincent's Hospital in New York, NY).
Just 13% of ED patient visits result in inpatient admissions, with hospitals reporting that currently an increased number of their inpatient admissions are coming through their EDs.

Interestingly, though they are currently seeing more inpatient admissions through the ED, that's likely to change for hospitals in the future, and therein lays the rub. Revenue generated from inpatient admissions that offsets the cost of the ED. In the California HealthCare Foundation report, California's Emergency Departments: Do They Contribute to Hospital Profitability?, far from being a cost burden, the ED actually has a positive influence on hospitals' financial performance. Though EDs lost an average of $84 on each patient treated and discharged, patients admitted to the hospital from the ED generated an average profit of $1,220 per admission—thereby covering any losses generated by patients who were discharged.

Don't Cut Here! Lower Inpatient Satisfaction Scores an Ominous Sign

Fri, 28 May 2010 15:04:00 GMT

You remember 2009 right? It was a tough year, economically, and hospitals weren't spared.

Cost savings were the order of the day. Many, many hospitals responded with innovative cost cutting strategies, including asking their employees to identify waste and help save jobs. For some, that tactic wasn't fast enough. Many other hospitals and health systems responded to the economic crisis by laying off workers. Many times, they were able to avoid laying off people in the clinical space in favor of administrative layoffs.

But even those layoffs appear to have taken their toll, as a recent consumer satisfaction survey reveal. According to the American Consumer Satisfaction Index, which measures consumer satisfaction for 10 economic sectors, while many other economic sectors improved their customer satisfaction rates, hospitals were not among them. In fact, between the first quarter of 2009 and the same period in 2010, hospital satisfaction dropped 5%. Only the energy sector provided company in falling customer satisfaction.

Given that sector's recent woes, that's not good company. And it's interesting that inpatient satisfaction recorded the biggest drop. In fact, ambulatory care actually recorded a 1% increase in satisfaction compared to last year.

It's not unusual for customer satisfaction to drop in a recession, but this data point should be a warning sign to senior leaders in healthcare. Why? Because patients are getting wiser toward customer service, and so should you. Customers (otherwise known as patients) will be voting with their feet sooner or later. My bet is on sooner. Yes, you'll be judged by payers on outcomes, but you'll be judged even more harshly by patients on their experience while in your hospital.

What does customer service have to do with a hospital stay? Well, to start with, it signifies a shift in the way hospitals should view their patients. As I mentioned, they are customers, just like in any other business. They deserve to get what they pay for, even if they pay for it indirectly.

The results are puzzling, if only because our own 2010 HealthLeaders Media Industry Survey shows that many CEOs have made patient satisfaction one of the top strategic goals for their organizations in recent years. For example, improving patient satisfaction was the second-highest ranked priority for the next three years in this year's survey, while more than 38% selected it as a top priority this year, compared to 26% in 2009.

Perhaps that means improvements are in the pipeline, and the American Consumer Satisfaction Index will show better results this time in 2011. In the meantime, these are the most recent results, and they're not so good.

If Massachusetts is a Bellwether, Insurers May Soon Cut Payments

Wed, 26 May 2010 14:09:00 GMT

Once again, Massachusetts is providing a testing ground for national healthcare policy. While the U.S. Congress is only beginning a debate about regulating and capping insurance premium increases, the Massachusetts government has already denied proposed rate hikes, and insurers' reactions in the state may foreshadow what's to come at the national level.

First, a caveat: It can be risky to read too much into what happens in Massachusetts. Sometimes the state is a leading indicator of the successes and failures of national healthcare reform (the final legislation took a similar approach, after all). But often what happens in Massachusetts is simply what happens in Massachusetts. It is a unique market with its own strengths and challenges, and every change doesn't necessarily portend how other states will react to similar policy.

But in this case it's easy to connect the dots. In April, the state Division of Insurance refused to allow insurers to raise premiums to their proposed levels in the small-group market. Last week, four major Massachusetts insurers claimed that the decision to cap rate increases led to more than $150 million in first-quarter losses. This week, some of those same insurers are telling hospitals and physicians that they will freeze or slash payments in the upcoming round of contract negotiations.

In essence, the insurers are shifting their losses to hospitals and physicians.

When given the chance, most private companies will do what they can to avoid a tax or cost increase. If they can shift the price to the consumer without losing customers, they will. In this case, the government has locked down the amount that insurers can shift to those who buy their product, so now they're looking in the other direction, at providers.

There has already been a similar federal law proposed to regulate health plan premium hikes nationwide by requiring insurers to submit increases over a certain amount to the Secretary of HHS or a state agency for approval. If we stick to the Massachusetts-as-bellwether theory, then it is likely that capping rates nationwide could lead to more insurer losses, and in turn more payment reductions to hospitals and physicians.

But markets and profit margins are different everywhere, and price controls won't necessarily affect a payer in rural Oklahoma the same way it will one with most of its customers in greater Boston.

The warnings coming from Massachusetts payers do very little to address the problem that the rate caps were intended to address: Spiraling costs. Hospitals and physicians are already struggling with cuts to Medicaid and Medicare, and many don't have the margins to absorb a reduction in private rates at the same time.

Maybe providers will take it upon themselves to weed out waste in order to stay afloat with lower reimbursement levels. But the best examples of systems that increase quality while reducing costs seem to come from those that involve partnerships between providers, patients, and payers. Massachusetts insurers are moving in the other direction, with more emphasis on contract negotiations and incentives for adversarial relationships.

Insurers are being pressured by politicians and employers to do something about healthcare costs, and have an opportunity to realign their relationships with providers to dig out some of the waste in the system.

Everyone is partly responsible. There's waste in providers' practices, waste in payer policies, and waste cause by government regulations. If the reform goal is to cut out healthcare waste, each party involved needs to do more than play a game of hot potato and pass costs to someone else.<

Note: You can sign up to receive Health Plan Insider, a free weekly e-newsletter designed to bring breaking news and analysis of important developments at health plans and other managed care organizations to your inbox.

AMA Says Health Plans Should Enforce Rules in New 10-Point 'Code of Conduct'

Tue, 25 May 2010 12:14:00 GMT

The American Medical Association yesterday released its new Code of Conduct, a list of dos and don'ts that it says all health insurers should enforce.

The physician group says it hopes to publish a scorecard showing which plans play by these rules in a few years, in time for the launch of health exchanges enabled by health reform legislation.

As it released the new code, the AMA also sent letters to eight specific health insurance companies that it says have not had good track records in the past. They are Aetna, Cigna, Coventry Health Care, Health Net, Humana, Health Care Service Corp., UnitedHealth Group Inc and WellPoint.

"The decision to deal with these particular companies was not a random draw out of a hat," says AMA President J. James Rohack. "These companies were picked based on who has market dominance, and in particular, these companies were the ones that physicians had the most concerns over their past behaviors."

Rohack says that the code has been in the making for about 18 months, and "calls for transparency, so patients have the ability to choose insurers not only on the basis of price, but on the basis of the conduct toward their enrollees." A CD with resources will be distributed as well, to help physicians monitor each insurer's compliance with the code.

The AMA developed the code with support from 43 state medical associations and physician groups representing 19 types of specialized care, from the American Academy of Dermatology to the Renal Physicians Association.

In response, spokesman for America's Health Insurance Plans, Robert Zirkelbach, said, "Our top priority is ensuring patients have access to the safest and most effective healthcare treatments. All stakeholders need to work together to reduce gaps in care and the continued variation in practice patterns."

He added, "Health plans have pioneered innovative programs to reward quality, promote prevention and wellness, coordinate care for patients with chronic conditions, streamline administrative processes, and provide policyholders with greater peace of mind. We will continue to work with policymakers and other healthcare stakeholders to improve the quality, safety, and efficiency of our healthcare system."

The 10-point code includes 41 provisions, including:

1. Rescission and Cancellation. Health plans should not cancel plans "for innocent mistakes on applications, nor after significant delay," or for patients who become injured or severely ill after the policy is issued. Nor should plans pay bonuses or rewards for rescinding policies of sick consumers. Any cancellation must be subject to independent, outside review.

2. Premiums and Spending on Medical Services. Health plans must make profit and non-medical or administrative expenditures transparent to the public, and spend a "substantial bulk" of the premium dollar on direct medical care. They must price products fairly and give clear information on what's covered, copayments, coinsurance, and other information regarding the patient's financial responsibility.

3. Access. Provider directories must be accessible in paper and electronic format, including lists of which physicians, hospitals and other providers are accepting new patients, and which ones are restricted or out of network, or require other financial terms such as increased copayment.

4. Respectful Relations. Health plans must protect confidentiality of each enrollee's medical information, and "must cease such unfair practices with physicians as demanding unreasonable contract terms, improperly applying contractual discounts, unilaterally amending contracts or refusing to acknowledge contract terminations."