"The Ronan Report" provides insight about the activities at the Western Maryland Health System in Cumberland, Maryland, and about the changes taking place in healthcare today from a CEO's perspective.

Friday, December 21, 2012

Merry Christmas & Happy New Year

I will be taking a blogging hiatus after today until January 2nd.  For my last blog of the year, I wanted to extend a blessed holiday season to everyone.  To all the employees, medical staff members and board directors--thank you for what you do for our health system throughout the year.  Safe travels during the holiday season to all. I am looking forward to a healthy and happy 2013.

Thursday, December 20, 2012

WMHS Holiday Meal

Yesterday was our Holiday Meal at the Health System.  What a great day!  Management serves the meal to employees and visitors.  For the first time in a while, all the servers were asked to decorate aprons with a holiday design.  Included in today's blog is a photo of my apron and a photo of the executive staff donning their aprons.  The aprons looked great; lots of creative designs.  When I arrived at Joann Fabrics on Saturday to buy the materials for the apron, I announced that I was clearly out of my element.  My apron took me all day on Sunday to make and when I was done I then napped for three hours.  I also learned from previous apron design attempts when I glued my apron to carpet in the family room.  Every aspect of the day was great and I now have great ideas for future apron designs.

Wednesday, December 19, 2012

Bye, Tom

Today is the last day that I will work with Tom Dowdell, Senior Vice President and Chief Operating Officer for WMHS as he begins his new life of retirement on December 29th.  Tom and I began our careers in Cumberland six weeks apart, Tom around Halloween in 1989 and I started in mid-December 1989.  We never imagined that we would work together for 23 years; most marriages don't last that long.  We became friends instantly with the same Black Irish sense of humor.  We laughed together, cried together, but most importantly respected the hell out of each other.  We served as each other's confidents;  we mentored each other and on some occasions even tormented each other. 

The legacy that Tom has left for us is amazing from the consolidation of the two hospitals to form the Western Maryland Health System to building a new hospital and over two decades of unbelievable accomplishments before, after and in between.  I am not sure what December 31st, the next day that we would have worked together after today will be like, but I have wonderful stories and fabulous memories that will last a lifetime.  God speed, Tom.

Tuesday, December 18, 2012

An Unauthorized Biography of Congress

I saw a headline on another blog this a.m. stating that the infamous biographer, Kitty Kelly, is thinking about writing an unauthorized biography on Congress.  The idea really struck me as being a good one.  I find it amazing that the approval rating for Congress is at record lows, and yet, individual Congressional representatives are idolized.  Their individualized ratings are extremely high; but as an elected body, they are abysmal.  Kitty Kelly calls it a secret society.  Really?  I think it is pretty obvious as to what they are all about: getting re-elected.  Of recent, I am involved with a state initiative that requires federal involvement.  Every elected official who is involved doesn't care about the particulars of the outcome just the outcome and how can they use it to their benefit for re-election and self-promotion.  Maybe, if Kitty doesn't write the unauthorized biography, I will.

Monday, December 17, 2012

Making Sense of the Newtown Tragedy

There isn't any way to make sense of what happened Friday morning in Newtown, CT.  It was an absolutely horrific tragedy for which there is no logical explanation.  To be perfectly honest, I have minimized watching, listening or reading about what happened.  The national electronic media has become an absolute disgrace when such horrific incidents occur.  They are all looking for that edge in being the first to report an exclusive aspect of any story.  In doing so, they ignore fact checking; they just run with what they have been told and don't care if they are inaccurate.  The bottom line is that they were successful in grabbing our attention. 

As for the gun control issue, quite frankly, the only scary thing about banning assault weapons is where will the ban stop?  No average Joe needs to have an arsenal of assault weapons, even one for that matter.  But, once a ban starts, where will it stop?  Pamela and I own guns for our safety in this day and age and every time an incident like Friday occurs, the appropriateness of our reasoning becomes stronger.  Going forward, I will make every effort to maintain that right. 

In my opinion, the biggest issue from Friday is how our country is dealing with the mental health issue.  Funding continues to be cut and in many cases eliminated at every level of government.  We have some extremely ill individuals in this country who are freely walking among us every day.  It is no longer politically correct to institutionalize those who are in need the services of mental health professionals.  Some of these folks need a great deal of help, but we leave it up to them in their compromised state to decide for themselves if help is necessary. 

I was encouraged by the Lt. Governor from Alaska, who attended Sandy Hook Elementary School as a child growing up in Newtown, CT.  Lt. Governor Mead Treadwell spoke of what has been done in Alaska due to the crisis of mental health issues and suicide in that state. He said that what we need first and foremost is a more robust mental health system in the US.  Because of Alaska's double the national average suicide rate, they have set aside funding to address their issues in Alaska.  They are doing a great deal with research and new methods for treating mental illness in his state. 

I hope that when President Obama said that we will stem gun violence in our schools through meaningful action that it will be an across-the-board solution and not one focused exclusively on banning guns.  By the way, I applaud President Obama for going to Connecticut last evening to begin the much-needed healing in that community.

Friday, December 14, 2012

Smarter Health Care Regulations

In yesterday's Wall Street Journal, there was an op-ed piece from Rich Umbdenstock, President of the American Hospital Association.  Rich's message on behalf of hospitals from across the country is to the Federal Government.   That message is that we don't need any more regulations, we need smarter regulations. 

Currently, there are over 122,000 federal regulations which hospitals are responsible for each day. Many of these regulations are unnecessary, outdated, duplicative and counterproductive.  What first and foremost comes to mind are the four separate federal programs that conduct redundant reviews of hospital payments to uncover improper billing.  One is Recovery Audit Contracting (RAC), and it has become the most frustrating since the RAC auditor determines that care should have been handled differently and payment is now withheld even though everyone who delivered the care agrees that the care was appropriate.  Hospitals are forced to appeal the decision and we have been right 75% of the time and winning our appeals.  Now, there are so many appeals that the process has slowed to a crawl and our money is being withheld prospectively for a much greater period of time.  These appeals cost hospitals a great deal of time, money and other resources and yet our concerns are ignored.  

Hospitals strive to put patients first and make careful use of decreasing resources, but regulators make that more difficult each day.  In order to successfully implement the triple aim of health care reform (better quality, healthier patients and lowering the cost of care), regulators must review all federal regulations to ensure that they allow hospitals to be successful going forward.  Those 122,000 federal regulations equate to a process out of control when you add state regulations, Health Services Cost Review Commission regulations for Maryland hospitals, the IRS requirements, OSHA, MIOSH and the list goes on.

Thursday, December 13, 2012

Missing the Mark on Accountability

Recently, I read a great article that I ended up sharing with the entire management team today.  The article was from the Harvard Business Review and was entitled, "One Out of Every Two Managers Is Terrible at Accountability."

Some of the more salient points of the article included: the single most shirked responsibility of executives is holding people accountable; leaders routinely step back from the heat; managers are obsessed with managing their popularity; they try to avoid tough conversations; controversy and conflict in the workplace have been replaced with efforts not to offend; the younger workforce expect praise and recognition, but are not open to critical feedback or talking about employee weaknesses, only celebrating their strengths.  Clearly, there is a delicate balance to making sure that there is an appropriate amount of recognition and celebration, but we have to do a better job as leaders in ensuring that expectations are met.  We no longer have the luxury of allowing employees to get it right most or part of the time.  We have to expect it all of the time; and if it doesn't happen, then we work to figure out how to achieve those pre-established expectations going forward.  Accountability as a leadership behavior we be our Leadership Development focus for 2013.  I'll let you know how we do in the coming months.

Wednesday, December 12, 2012

Setting the Record Straight on Tearing Down Hospitals

In yesterday's local newspaper, there was a letter to the editor taking the County Government and the Board of Education to task for tearing down the former Sacred Heart Hospital.  The feeling is that the building is a perfectly good building and should be used for economic development purposes or a Veteran's Hospital.  It is important for the letter writer to know that there had been numerous conversations with the Federal Government on the reuse of both Memorial Hospital and then Sacred Heart as potential sites for VA hospitals.  The answer had been an emphatic "NO" from the VA Administration; even Senator Mikulski was told, "NO."  The VA is building new hospitals for veterans, fewer than before the economic downturn, but not re-deploying ones that have been previously used as hospitals.  These former hospitals require tens--if not hundreds--of million dollars to renovate and bring up to code; and it is important to note that WMHS built a new hospital for a very good reason. 

Which brings me to the use of the hospital for economic development purposes.  Prior to trading Sacred Heart Hospital for land adjacent to our Willowbrook campus, we engaged a developer to assess the campus for uses beyond a hospital.  After a lengthy tour and subsequent assessment of the entire campus, we were informed that the only use would be for another hospital and that would require tens--if not hundreds--of million of dollars in renovation costs.  It would be far less expensive to tear down the buildings and build whatever one may desire on that land than to attempt to retrofit the existing buildings for other purposes.   So, the bottom line is that it may seem like a good idea to those who don't have all of the facts, but what the Board of Education and the County are embarking on is the right way to go.

Tuesday, December 11, 2012

Right to Work Legislation

Today, the Michigan legislature will vote on making that state the 24th to adopt right to work legislation.  Labor unions from across the country will converge on Michigan to challenge the law's passage.  What is interesting is that Michigan has an unemployment rate that is 9.1%, the sixth highest in the nation.  Over the last ten years, eight of the ten states that have the greatest personal income growth have right-to-work laws in place.  Such laws allow states to attract new employers and jobs.  The unions and even the President say that this is all about politics; actually, it's about freedom to choose.  If I want to join a union, I'll join a union, but I shouldn't be required to be a union member as is the case in 26 other states, including Maryland.  What I find interesting is that the President and Congressional representatives from Michigan who are opposed to the new legislation can find the time to weigh in on this issue, with even the President visiting Michigan yesterday.  Why not stay in DC and solve the Fiscal Cliff crisis facing our entire nation?

Monday, December 10, 2012

Where Have Our Leaders Gone?

Where have our leaders gone is a question many Americans have been asking since the 2010 interim elections.  We are at twenty-one days and counting until the Fiscal Cliff occurs.   If our leaders fail to act, the US will almost immediately go into a recession just as the 49 out of 50 states are seeing themselves surviving the last recession (except for Connecticut).  The top 8 states that are leading the US in economic growth are all energy producing states in the areas of oil and natural gas.  Texas, Alaska and North Dakota lead the pack.  Where does Maryland stand?  We are what's called an Administrative and Government Sector State. With hundreds of thousands of jobs for Marylanders compliments of the Federal Government, we are very dependent on the success of the Federal Government.  That is not good news with the impending Fiscal Cliff.  With the expiration of the Bush-era tax cuts and $1.2 trillion in automatic spending cuts, that will translate to job loss in the federal government and in sectors like defense and health care.  All three of these areas will significantly impact Maryland.  It is hoped that President Obama will bring his leadership to Capitol Hill and reach across the aisle to get to matter resolved before 12/31.  Then again, we have been hoping for constructive collaboration from our leadership for the last two years, but to no avail.

Friday, December 7, 2012

Meaningful Use

Just what is Meaningful Use?  It gives health care providers financial incentives to improve patient care, reduce costs and to create an infrastructure to integrate health records.  Under the American Recovery and Reinvestment Act, aka TARP or stimulus funds, hospitals and other providers could request reimbursement under Meaningful Use, provided we could substantiate how our money was spent and that we achieved the expected results.  Once the request was developed and the results verified through an audit process, it was submitted to the Federal Government.  This week, we received $3.3 million from the government based on what we have spent  at WMHS on information technology advances that fell under Meaningful Use criteria.  Quite honestly, I never thought that we would see the money.  After all, the US is in an economic crisis, the Fiscal Cliff is ahead and sequestration is looming.  I thought that any remaining TARP funds or Stimulus monies would be the first to go, but that wasn't the case, thankfully.  We have a request pending for another $1.4 million from the State also for Meaningful Use and, hopefully, that will come in the very near future.  Our investment in information technology has been considerable over the last few years and it will continue well into the future.  Such technology will be required going forward in order to get paid by the payors, as well as to extract data to improve the delivery of  patient care.  Both are extremely beneficial to our business and getting some of those monies that we invested back is great.

Thursday, December 6, 2012

Maintaining Strong Economic Ties to Our Community

As I have blogged previously, WMHS is the region's largest employer with 2300 employees.  Our employees receive over $143 million in salaries and benefits and have an economic impact on the community of over $234 million.  For every job at WMHS, another 2 jobs are supported in the local economy equating to another 4,500 jobs in our region.  The overall economic impact of WMHS on the region exceeds over $300M with local purchases for goods and services exceeding $20 million.  During FY 2012, over $16 million was spent on financial assistance for patients who could not afford their care, which was a 28% increase over the previous fiscal year.  Another $26 million supported programs and services that benefit the community.  These programs fell into the following categories:  community health services, health professions education, mission driven services, financial contributions to non- profit organizations and community building activities.  Wow, that's a lot to be extremely proud of!

Wednesday, December 5, 2012

FY 2012 Accomplishments

Each year, we publish a list of accomplishments at WMHS that occurred the preceding fiscal year.  Although FY '12 was a challenging year financially, we did redesign how we deliver care consistent with the goals of health care reform as well as to better position ourselves going forward.  During the year, we worked to improve the delivery of care component of health care reform's triple aim through programs to reduce readmissions, improve outcomes and enhance quality.  We also collaborated with our medical staff, improved our patient safety results and established new processes in the ED to better facilitate care.  The second component of the triple aim is to reduce the cost of providing care.  We added resources for delivering the right care in the right place and numerous cost saving initiatives were started generating a savings of $6.5 million for FY '13.  The third component of the triple aim is to create healthier patients and we did so through new programs focused on improving community health, promoting nutrition, increasing our outreach efforts into the region and serving as a role model for wellness with our own employees.  Fiscal year 2012 was certainly a year to remember in that we had our financial challenges but we also dramatically changed how we do business.  We created a model that will serve us well into the future.

Tuesday, December 4, 2012

The CDC has Spoken

The Centers for Disease Control announced yesterday that the flu season has already started with confirmed cases being reported in the South.  This is the earliest start to the flu season in almost a decade.  The last time the flu season started early it claimed the lives of over 48,000 Americans, and it just so happens that this same deadly strain of flu is what is being reported as this year's strain.  On average, though, half as many Americans die from the flu each year. The good news is that the current flu shot seems to be an excellent match with this unique virus strain. 

At WMHS, this the first time that we are requiring flu shots of all of our employees and medical staff.  Declinations can be given for health and religious reasons.  As of today, over 86% of our employees and 85% of our physicians and advanced practice professionals have received their flu shots.  The most vulnerable population for contracting the flu is the elderly; with our new approach to treating patients in the most appropriate location while reducing admissions and readmissions to the hospital, the majority of patients who are now hospitalized are both elderly and severely compromised with a host of chronic conditions.  I can't think of a better reason for our staff to get the flu shot.  Requiring flu shots of our staff is consistent with 41 of 46 hospitals in Maryland; it's consistent with our mission (Superior Care for All We Serve) and core values of Innovation, Compassion, Respect, and Excellence.  Most importantly, we owe it to our community, our patients, our families and each other.

Monday, December 3, 2012

Let's Talk Meetings at WMHS

Last week, we held our Let's Talk meetings for employees throughout the health system.  Our focus was twofold--sharing a video that highlights our Trauma Program at WMHS to show the importance that we have in our community and making sure that our staff is aware of our industry's financial challenges as health care reform continues to evolve.  It is important to note that the Triple Aim of Health Reform (Better Care, Healthier Patients and Communities and Lower Total Cost of Care) are all positive aspects of where health care is headed.  Unlike the 60 Minutes segment last evening on one for- profit health care provider, Health Management Associates, that is accused of driving increased revenue through "do or die" admission targets.   

WMHS is successfully reducing admissions and readmissions.  We have also implemented measures to reduce hospital-acquired conditions such as infections, pressure ulcers and ventilator-assisted pneumonia while increasing patient satisfaction.  It is true that better care equates to better outcomes resulting in increased revenue through Maryland's pay-for-performance initiative.  We went from losing $1.2 million in revenue last year because our quality scores trailed other hospitals in Maryland to a turnaround of $1.5 million gain this year.  We continue to shift our services by providing the right care in the right place as evidenced by our new Wound Center, our Anticoagulation Clinic, our Diabetic Medical Home, our CareLink Program, our Congestive Heart Failure Clinic and case managing our most chronic patients.  At WMHS, we continue to strive to fulfill our mission of Superior Care for All We Serve through evidence based care, patient centered care, a continued focus on keeping our patients healthy and out of the hospital, collaborating with our physicians and advanced practice professionals, being innovative in all that we do and having a continued awareness of our cost of doing business.  Believe or not, running a health system with annual revenues of over $325 million isn't as easy as some make it out to be, especially in this era of reform.

Let's Talk Meetings at WMHS

Last week, we held our Let's Talk meetings for employees throughout the health system.  Our focus was twofold--sharing a video that highlights our Trauma Program at WMHS and showing the importance that we have in our community, along with making sure that our staff is aware of our industry's financial challenges as health care reform continues to evolve.  It is important to note that the Triple Aim of Health Reform: Better Care, Healthier Patients and Communities and Lower Total Cost of Care are all positive aspects of where health care is headed.  Unlike the 60 Minutes segment last evening on one for- profit health care provider, Health Management Associates, that is accused of driving increased revenue through "do or die" admission targets.   

WMHS is successfully reducing admissions and readmissions.  We have also implemented measures to reduce hospital-acquired conditions such as infections, pressure ulcers and ventilator-assisted pneumonia while increasing patient satisfaction.  It is true that better care equates to better outcomes resulting in increased revenue through Maryland's pay-for-performance initiative.  We went from losing $1.2 million in revenue last year because our quality scores trailed other hospitals in Maryland to a turnaround of $1.5 million gain this year.  We continue to shift our services by providing the right care in the right place as evidenced by our new Wound Center, our Anticoagulation Clinic, our Diabetic Medical Home, our CareLink Program, our Congestive Heart Failure Clinic and case managing our most chronic patients.  At WMHS, we continue to strive to fulfill our mission of Superior Care for All We Serve through evidence based care, patient centered care, a continued focus on keeping our patients healthy and out of the hospital, collaborating with our physicians and advanced practice professionals, being innovative in all that we do and having a continued awareness of our cost of doing business.  Believe or not, running a health system with annual revenues of over $325 million isn't as easy as some make it out to be, especially in this era of reform.

Friday, November 30, 2012

You're Killing Us

"You're killing us" should have been the message yesterday when hospital CEOs from around the country met in Washington, DC, for the American Hospital Association's Advocacy Day.  Approximately 200 CEOs met on Capitol Hill yesterday with their Congressional representatives to warn of the impact on the access to the care for our patients through arbitrary across-the-board cuts to Medicare and Medicaid.

Between ongoing state and federal budget cuts, state initiated assessments (taxes) to fund Medicaid, the Fiscal Cliff of a 2% reduction in payments to hospitals, the jeopardy that the Maryland Waiver is currently in jeopardy due to the above-mentioned provider assessments, denied days for care that has been provided due to the picayune documentation requirements of payors, withheld monies as a result of the government's somewhat flawed Recovery Audit Contractor (RAC) process (in this case, money is withheld for care that is provided and then the care has to been substantiated in a long, drawn-out process), the financial impact of these cuts on hospitals will threaten our ability to effectively care for our patients .  Simply put, WMHS waits months for monies that should have been paid but are held usually for what seems to be whatever reason the payor can think of.  Eventually we get paid, but the administrative costs associated with the appeals continue to be a burden on hospitals.  With health care costs running about $1.7 trillion per year in the US, hospitals recognize that change has to occur. 

At WMHS, we have made great progress in keeping patients healthy and out of the hospital, ultimately reducing health care costs.  But, that has happened over the last two and one-half years and we are now finally seeing results.  The payors, including CMS, want us to put cost saving initiatives in place overnight and have them generating results by morning.  Real long-term solutions are what is necessary in order to still provide quality patient care while reducing the cost of that care.

Thursday, November 29, 2012

Gender Bias, Really?

I read an article in yesterday's USA Today regarding birth control pills.  I am not a clinician, but I am a husband, a father of two adult daughters, a brother and a son.  The article was actually a debate among physicians as to whether or not birth control pills should be sold over the counter.  Some actually stated that it is a gender bias issue since condoms are available over the counter so why not birth control pills.  Huh?  Unless I am missing something, condoms are applied not ingested.  Seeing what it took for the women in my life to either get adjusted to birth control pills or be informed that they were not a candidate due to risk of blood clots and stroke, in particular, is enough for me to weigh in on the side of "what are you people crazy?".  It is obvious to me that a lot has to go into taking birth control pills and that not everyone is a candidate.  For those arguing the gender bias issue since there is no age restriction on the purchase of condoms, the same would apply for birth control pills.  So, what happens when the teenager who wants to become sexually active buys birth control pills and unknowingly is in a high-risk category for stroke?  The outcome, although more the exception than the rule, is still a bad outcome.  This is really not a good idea and I am surprised that some clinicians are advocating for the change.

Wednesday, November 28, 2012

Healthcare Keeps Changing

Yesterday through Rumor Control, I heard, according to at least one orthopedic surgeon, that WMHS is now putting restrictions on patients in need of orthopedic surgery.  I can assure you that any restrictions are not from WMHS –they are from those who eventually pay the bill for the surgery.  The payors, particularly Medicare, want to make sure that less invasive treatment and therapy are occurring before the surgeon and the hospital jump right to surgery.  Our orthopedic surgeons have always approached surgery very conservatively.  However, in order to show a robust demonstration of compliance, we now have to document medical necessity prior to surgery through a preoperative checklist.  We have to make sure that conservative treatments were tried and failed for at least 3 months before surgery is scheduled.  Again, this is a requirement of Medicare, not the WMHS administration. 

With all of the changes occurring in healthcare, we at WMHS have to do a better job of educating our physicians and staff as well as our patients.  There are now so many restrictions that are being leveled at hospitals and physicians by the various payors that we need full-time staff just to track the ever changing requirements, such as the medical necessity checklist for hip and knee surgery.
I continue to be amazed at the ways in which the payors, especially Medicare, try to avoid paying providers for care that is delivered.  There are many changes initiated by Medicare that have improved the delivery of care, but there are some that haven't.  Stay tuned.

Tuesday, November 27, 2012

National Recognition

In yesterday's national publication, AHA News, WMHS was recognized for our RN Transitionist Program.  This initiative was the brainchild of Dr. George Garrow, Chief Medical Officer, and Carol Everhart, Director of Care Coordination, at WMHS.  We now have two nurses dedicated to the program and they visit patients who will be going to a nursing home after discharge.  They coordinate their discharge between the hospital and the nursing home then visit the patient upon their arrival at the nursing home.  The RN then returns on subsequent days to ensure that the patient--now nursing home resident--remains well enough to stay in the nursing home and not be readmitted to the hospital.  Certainly if the resident needs to be readmitted, they are; however, through this program and improved coordination of the patient's discharge, nursing home readmissions have been reduced dramatically.  It is great when our efforts to keep people healthy and out of the hospital are recognized and especially when it is national recognition.  Thank you, Dr. Garrow and Carol. 

Monday, November 26, 2012

Do the Benefits Outweigh the Risks?

Over the weekend, I read an article in the United Kingdom's Sunday Express newspaper.  The article was about the National Health Service in Britain facing a £20 billion (pound) shortfall in its budget and the opportunity to save £3 billion by eliminating physician office visits.  The in-person visits would be replaced with Skype or Facetime between the physician and the patient.  The immediate criticism of these virtual clinics is the inability for those who are technically challenged, such as the elderly or the poor having the ability to access mobile technology due to the cost.  The idea is one that is being borrowed from India, where it is reported to have been successfully implemented. 

From my perspective, the idea is a good one as we are trying such a mobile link between our nursing home and the hospital, but it certainly has its limitations.  Offering the virtual clinic as an option for those who are technically savvy is a good idea, but the complete replacement of office visits is not a good idea.  The risk of missing something via telehealth or mobile technology could be far greater and would be a more significant issue in the US without more comprehensive tort reform.  So, there are lots of benefits with this technology and it should be expanded upon, but not depended upon exclusively.

Wednesday, November 21, 2012

Just One More Thought...

I know that I said that yesterday would be my last blog until next week, but I had to let everyone know just how popular my daily blog has become.  As I drove past those same bus stops this AM with an outside temperature of 29 degrees, the same kids who were woefully under dressed yesterday were wearing jackets today.  I can only conclude that their parents were shamed into doing something after reading yesterday's blog.  Anyway, it was nice to see that someone had some sense, whether it was the kids who had to be frozen by the time the bus came yesterday or their parents seeing them when they came home from school dressed that way.  All in all, a very good outcome.

As we all prepare for Thanksgiving tomorrow, we have a great deal to be thankful for.  A number of my Facebook friends have been giving thanks each day leading up to Thanksgiving for someone or something in their lives; a very nice touch.  I am especially thankful for my wonderful family, a great health system that I am a part of and a very special community in which I live.  Happy Thanksgiving.

Tuesday, November 20, 2012

It's 32 Degrees Outside. Where's Your Coat?

I am on  my way to work this AM and pass a school bus stop with high school aged students waiting for their bus.  What I found amazing was that none of them had a coat or jacket on; only one female was wearing a sweater and a thin one at that.  The boys were dressed in basketball shorts and t-shirts and the girls were dressed in jeans and shirts.  How can their parents let them out of the house like that when it's 32 degrees out?  Maybe I am just getting old. But it's freezing!  This was not a lower income neighborhood where affordability could be an issue, but a traditional middle- class neighborhood.  What I find amazing is that the elementary school kids waiting for the bus on days like this are bundled up with hats, coats and gloves; thank you mom and / or dad.  Middle school kids at least have on a jacket, but then there are the high school kids being COOL by having the least amount of clothes on as possible while waiting for the bus.  A minor issue for some, but how are we as health care providers supposed to keep families healthy and out of the hospital when parents allow or ignore what their high school aged kids are doing. I guess better this than a whole lot of other bad behaviors that high schoolers could be doing.

As I take a respite from blogging, have a blessed Thanksgiving and safe travels.

Monday, November 19, 2012

Care Like You Have Never Seen It Before

As I mentioned in Friday's blog, I attended a two-day meeting last week outside of DC on the future of health care.  The one word to describe the meeting would be "WOW!"  As an industry, hospitals, health systems, physicians, other providers and, most importantly, patients are in for quite a change.  As I have blogged in the past, the cost of health care going forward is unsustainable.  Government can't continue to afford the $1.7 billion annual expense of health care.  To put that unsustainability in perspective, if eggs, milk and a bag of oranges had increased in price at the rate health care has since 1945, those eggs would be $55 a carton, the milk would be $48 a gallon and the oranges would be $134 for a bag of 12.

Health care consumers are going to see that they have choices; however, those choices will be similar to when you go to the veterinarian to have your dog or cat treated.  In this case, rarely is there a third party payor involved.  You have a choice for the type and extent of testing, whether or not you would like to have a surgical procedure and what type of supply or equipment that you would like used.  However, as is the case when  you take Fido to the vet, there will be a great deal of out-of-pocket expense for those choices.  For us, a third party payor, whether it's an employer who is self-insured, as is the case at WMHS, an insurance company, or a health care exchange or the state / federal government, will cover care to a certain level, but will not be able to cover all of the health care expenses incurred, especially the "Cadillac" of everything that we have come to expect without some level of sharing on the part of the recipient of the care. 

As hospitals in Maryland, more and more of our payments are now at risk based on the quality of that care; it's called Quality Based Reimbursement.  Hospitals in the other 49 states won't be impacted for at least another year.  We are now directly accountable, as we should be, for reducing infections, the mortality of our patients, reducing admissions and readmissions, the level of satisfaction of our patients, any preventable conditions, over utilization of services, tests and procedures, better and more comprehensive care of our high utilizers of our services to keep them out of the hospital and the list goes on.  Such approaches will reduce the cost of care eventually, but implementing those changes can be very costly initially, as was the case at WMHS last fiscal year.  Health care really is changing and WMHS is trying like hell to keep pace with those changes.  As an industry, health care leaders have to educate their various constituencies as to the changes that they are living with today and those planned for the near future.

Friday, November 16, 2012

When is Enough, Enough?

Yesterday and today, I am attending a meeting outside of DC on the future of health care as a result of the 2012 election.  Actually, I was invited to serve on a panel with the intent of informing health care executives in Maryland, DC and Virginia how WMHS has fared under our new payment methodology.   I informed the group that the Triple Aim of Health Care Reform can be accomplished but it has its challenges. 

During the meeting, I learned from an exchange between the moderator for the panel discussion and former Senator Blanche Lincoln (D -AR), that hospitals and health systems in the US are responsible for complying with 120,000 federal regulations.  I knew it was bad, but had no idea as to how bad.  Now please understand, that doesn't include any state regulations, HSCRC regs for Maryland hospitals or the Joint Commission requirements. Hospitals are routinely criticized for their complexity and bureaucracy; here's the reason why.  No wonder, management guru Peter Drucker says that health care is the US's most complex and challenging industry to manage. 

By the way, former Senator Lincoln was great.  She was charming and engaging and I wouldn't hesitate to vote for her.  She lost her Senate seat after 12 years because she was a moderate Democrat who did not embrace the labor union platform.  The entire theme of her presentation was that this time our President needs to lead our country through these current fiscal challenges and that Congress needs to reach across the aisle to reach a compromise to avoid that fiscal cliff.  Her prediction is that both will happen.

Thursday, November 15, 2012

Hurricane Sandy

I mentioned Hurricane Sandy in an earlier blog this week and noted that I would comment.  Last night, I had the opportunity to speak with a physician who has a home in New Jersey about his experience.  He said that it was truly like a war zone along with all of the hardship that such an experience would bring; fortunately the death toll was low, but it could have been far worse.  He said that he was amazed at the level of preparation that existed at Home Depot, for example.  Our government, not so much.  Home Depot took their resources and products from across the nation and completely overloaded the East Coast in advance of the storm.  He said that he was amazed as to their level of preparation. 

As for government, they mobilized around 48 hours after the hurricane hit.  There was chaos, confusion, shortages of everything, no power, no food, no water, no gasoline, houses flooded or destroyed......it was sheer bedlam.   I read of FEMA and the Red Cross being ill prepared initially; didn't they learn anything from Katrina?  At WMHS, we work very hard to learn from others, as well as ourselves, after crises and disasters.  We strive to make sure that we take the Home Depot approach rather than the approach of government.

I am thankful that life is beginning to be restored to somewhat normalcy in the NJ / NY area and hope that after this disaster, our government will "go to school" on the experience.

Wednesday, November 14, 2012

What Obamacare Means for Business

As I have blogged before, there a many positives with the Affordable Care Act (Obamacare); however, there are also negatives.  One glaring weakness is the minimum cost of a health benefit package as projected by the Congressional Budget Office.  The cost of the benefit package will be $5000 for an individual and $12,500 for a family. That translates into an additional $2.28 an hour for full-time employees with individual coverage and an additional $5.89 an hour for family coverage.  Adding the cash minimum wage to the family coverage benefit, the new minimum wage for employers becomes $13.14 per hour.  Many employers can't afford the added cost of health insurance in this economy and that is why you hear that employers will reduce staff, reduce employee hours, raise prices or force employees into a health exchange.  Low and moderate wage earners would receive a generous subsidy from the government by going into an exchange, but higher income employees get no subsidy.  This would force low income workers to work in companies that don't provide health insurance with an expectation for higher wages.  The higher income worker will work for companies that provide health insurance.  This will be an unbelievable burden on the tax payer with millions of employees taking advantage of the government subsidized coverage.  It will be interesting to watch.  If companies ignore what these employees prefer, then they could go out of business.  Stay tuned.

Tuesday, November 13, 2012

Meeting with the President

I read in the Wall Street Journal this a.m. that President Obama has invited twelve CEOs to meet with him at the White House to discuss a variety of critical issues facing our nation.  Even though my invitation must be delayed somewhere in the delivery process, I gave some thought to what I would discuss with the President given the opportunity.  First, pull out all stops to get the economy back on track.  Be a leader by working with Congress to an end that addresses our out-of-control debt.  Make the hard decisions that will return us to prosperity.  If you want to create jobs, then get to work on the Keystone pipeline and off-shore drilling.  Not only will both create jobs but they will diminish our dependence on foreign oil.  Be proud of our country and talk about our greatness to world leaders so they want to invest in America.  Recognize that you are held to a higher standard and bring the much promised transparency that you committed to during the first campaign for the Presidency.

Now, specific to health care: work to align incentives among providers (hospitals and physicians); you can't have one set of providers paid on volume and the other on value.  Address tort reform on a federal level.  You are putting providers in a precarious position by reducing admissions and re-admissions as well as reducing the amount of tests being ordered, yet leaving providers vulnerable to needless lawsuits and tort reform to the individual states to enact.  Lastly, recognize that cuts to providers will not reform health care; there needs to be a focus on prevention and wellness like never before along with an industry-wide focus on quality and cost.

Even if I am not in attendance tomorrow, I hope that such a meeting will get us back on track as a nation.

Monday, November 12, 2012

A Lot Can Happen in Less Than a Week

We re-elected a President last week, Hurricane Sandy clean up continues, a respected General resigns in scandal, the deep division of our country and our government raised its ugly head immediately following the election and the call for tax increases and no compromise started early on Wednesday AM.  First the re-election, not my candidate, but still my President.  I don't think that the Senate Democrats got the mandate from the American people that they claim they have.  The election map of America reflects urban vs. pretty much the rest of the country.   The continued division isn't good for anyone; I just hope that as President Obama assesses his next term, he realizes that he must reach a compromise with Congress on the economy or we are destined to be left in a financial spiral with little chance for recovery.  Also, you may try to tax your way out this mess, but it will take more than that.  A comprehensive plan is needed with true leadership from the President, Senate President Reid and Speaker Boehner. 

Now onto General Petraeus. Wow, knock me over with a feather; I didn't see that one coming.  This guy has walked on water through his service to our country as a military leader and then as CIA Director.  You would think that he would have known better, but obviously he didn't.  The affair had been going on for some time and he ended it a few months ago.  Apparently, the only reason the affair came out was that the spawned lover was under the impression that another woman had taken her man away.  It was the other woman who reported the threatening emails to the FBI.  Quite honestly, it's pretty scary that someone could that easily influence the director of the CIA and no one knows about it within our government.  Reports are that the general and his mistress weren't even that discreet.  Really disconcerting.  I will blog about my thoughts on Hurricane Sandy tomorrow.  It's good to be back blogging after a brief hiatus.

Tuesday, November 6, 2012


Today is Election Day and I encourage everyone to get out and vote.  I had the opportunity to vote last week as a part of early voting in Maryland.  I was surprised at how crowded it was when I arrived.  The poll workers said that it was like Election Day on that particular day since it was so crowded.  I love the convenience of early voting since voting on Election Day had its challenges for me.  I try to be at the office by 7 AM each morning, but since the polls open on Election Day at 7 AM, I am delayed in getting to the office.  I certainly don't begrudge anyone's right to vote; but on Election Day when I would arrive at the polling place to vote, there was always a very long line by 7 AM.  Many of the retired folks were there bright and early to exercise their right to vote.  I wished that they would stay home and have another cup of coffee until about 8 AM. 

For early voting this year, I was one of 500,000 early voters in Maryland last week.  When I arrived for early voting, I knew the gentleman checking in voters.  He said even though he knew me, he still had to ask my name, address and birthdate.  I gave it to him, but said that he should be asking for my driver's license or some other form of identification.  He laughed and said that I wasn't the first to suggest it.  So why don't we have such a requirement, as is the case with the new voter ID law in Virginia.  You have to show ID for virtually everything these days and having a voter ID requirement is Maryland simply makes sense.  If it's because there is limited or no ability for the poor to afford or obtain identification, give it to them for free and have it available in locations beyond MVA, such as the post office, health dept., police dept., etc.  In this day and age, fraud is rampant throughout life so why not put as many safeguards in place as possible?

I will not be blogging again until Monday; have a great weekend, but first get out and vote.

Monday, November 5, 2012

Tour of a Lifetime

This morning, the WMHS Foundation culminated a year's worth of mission tours into a breakfast recognizing our Trauma Program.  Throughout the year, each mission tour consisted of a tour of our Trauma Center and a 15-minute video that captured the horrific accident and life and death struggle of Ashton Zegles.  At our culminating breakfast, a group of around 100 heard of four other grateful trauma patients whose lives were saved by the staff at WMHS.  The breakfast ended with a visit and brief remarks from Ashton and her mother, Michelle.  Ashton lost a leg as a result of the accident, but she has fully recovered from the accident and continues to lead a wonderful life.  Ashton and her mother continue to be extremely grateful to WMHS for saving Ashton's life, as was the case of the other four grateful patients.  I continue to be in awe of our staff that creates such stories each day at WMHS through their actions in life and death situations.  We are so fortunate to have a committed and dedicated staff that goes beyond the routine care of the patient.  This staff clearly has a calling since what they do each day is so much more than just a job. 

Friday, November 2, 2012

End-of-Life Spending on Health Care

Yesterday, I blogged about the rationing of health care. It is a very difficult topic to discuss as no one wants to withhold anything from anyone especially related to one's health and well being.  However, what I find interesting is that the fear of rationing could be more of an "American thing," if you will.  My reason for thinking that way is depicted in the graph below.  It shows US spending for health care by age group compared to other countries.  On the graph, you will see that beginning at age 58 spending in the US begins a rapid ascent and reflects much higher spending per capita for older adults in the US compared to other industrialized nations.  In the US, the federal government spends $1.7 trillion per year on health care and 44 cents of every dollar spent is borrowed due to our debt situation; obviously unsustainable.  Countries like Spain, Great Britain, Germany and Sweden have figured out how to keep spending to a reasonable level for their citizens; possibly, we could learn how they have accomplished the ability to care for their citizens no matter what their age.  Have a good weekend after a very challenging week for many of us.

Wednesday, October 31, 2012

Managing in a Crisis

In my thoughts this week were health system and hospital management teams impacted by Hurricane Sandy.  I am very fortunate to have an exceptional team pictured below who lead this organization during extremely challenging times.  The group pictured below is participating in a statewide emergency preparedness conference call on Monday as the hurricane was beginning to impact Maryland. (This was one of a number of calls that began on Friday and continued into the weekend.)  We are also supported by a wonderful staff of employees and physicians who become instant heroes when disasters hit. WMHS fared very well by comparison to McCready on the eastern shore of Maryland that had to deal with flooding in their hospital and Garrett Memorial to our west that had to deal with over 2 feet of snow. 

Then there is the NYU Medical Center in Manhattan that had to evacuate close to 300 patients during the hurricane because their backup generator failed.  Included in the evacuation was their chairman of the board, who was hospitalized with pneumonia.  On Tuesday, one of their other board members then went public that the board and management knew that the generator wouldn't work because of its age and condition.  Apparently, they are involved with a massive renovation to modernize the medical center, including their generator; but one then wonders why they didn't take steps in advance not to put patients in harm’s way.  There will be a lot of questions asked of NYU's leadership, including those from Mayor Bloomberg who has already started to ask why the city couldn't depend on NYU Medical Center when they were needed the most.

Tuesday, October 30, 2012

After the Hurricane

Throughout yesterday, last night and into this morning, everyone at WMHS was exceptional related to planning for and working through the hurricane.  The Governor declared a state of emergency for the entire state; and when that happens, you have a responsibility to keep people (patients and staff) out of harm’s way.  There are always some who want it to be business as usual in order to accommodate their personal needs, schedule and / or income.  However, everyone has to understand the uncertainty of a storm; in this case, a deadly hurricane.  We have no idea as to how much rain, how much wind or if it will be rain vs. snow.  We were on the fringe of this hurricane being devastating for the area; but fortunately, we dodged a very big bullet.  Actually, the land hurricane in July was more severe for our area. 

When you are involved in disaster planning, you have to plan for the worst.  Our staff travel from well into southwestern PA and a number of counties in WV, along with Garrett County, which ended up with over a foot of snow.  Their safety is our concern, especially in a state of emergency.  Power bumps or the loss of power can be deadly for patients undergoing a procedure, treatment or surgery; why put our patients in such situations.  We have a responsibility to our patients, our staff and our community; and yesterday into today we lived up to that responsibility.  Thanks everyone for a job very well done!

Monday, October 29, 2012

Hurricane Sandy

I have been in health care for over 37 years and I continue to marvel at the level of dedication of hospital and health system employees.  As with every other potential critical event, advance planning for the impact of Hurricane Sandy of our health system and our community began on Friday of last week and continued throughout the weekend.  Our leadership participated in meetings and conference calls over the weekend with Allegany County Emergency Management.  Culminating the weekend's planning was a statewide emergency management conference call last evening at 8 PM.  The process resumes this AM with an internal WMHS planning meeting at 9 AM then the opening of our command center that will remain open until noon on Wednesday.  We have to plan for a host potential issues with first and foremost protecting our patients and staff while they are in our facilities.  All of our staff were informed on Friday that we will provide for sleeping and showering arrangements at the health system in the event that they can't or don't want to travel in the severe weather that is expected.  Because of the extensive planning in advance along with the wealth of knowledge and experience of our middle and senior leadership, we should be fine.  These are the same people that flawlessly opened a new medical center and has prepared for, as well as, survived numerous crises over the years.  I am honored to be associated with such a great staff.   We are all hoping at WMHS that our planning for Sandy is simply a well planned exercise in emergency planning and that we are not impacted by Sandy at all.

Friday, October 26, 2012

One of Fifteen

Recently, I read an article in the Baltimore Business Journal, "Maryland's Independent Hospitals Say Cost Pressures Taking Their Toll."  Due to continued financial pressures on hospitals along insufficient  resources to support continued operations, independent hospitals, of which WMHS is one, are gradually eroding away.  WMHS is one of only now fifteen independent hospitals in Maryland.  The majority of general hospitals, of which there are 46, have joined with one of the big three systems in Maryland: University of Maryland Medical System, MedStar or Johns Hopkins.  However, our goal is to continue to remain independent for as long as we possibly can...........and forever would be nice.   Our preference is to continue to have decisions related to health care be made in our own community, rather than 150 miles away. 

Shortly after we opened the new medical center, a friend and colleague from Johns Hopkins responsible for system development and outreach came for a visit.  He was very impressed with what he saw at WMHS.  However, when the subject of mergers and acquisitions was brought up by him, he informed me that the Hopkins acquisition strategy is "don't call us, we'll call you." If only he had told me that strategy when all of the rumors were circulating as the new hospital was being built that Johns Hopkins would be taking over upon completion.  At that time, I even had past and present members of the Western Maryland delegation calling me to ask if that rumor was true.  In the past, UMMS was interested in having preliminary discussions.  As for MedStar, they are a great organization just like the other two, but no expressed interest in WMHS and that is a good thing. 

It is especially challenging for those hospitals in the urban areas that are trying to remain independent.  The "big three" have unbelievable resources available to them and it is very difficult to compete with that.  At WMHS, we have strong working relationships with a number of hospitals, including UMMS linked to Trauma, Hopkins with our new Diabetic Medical Home, WVU with our neonatal program, and the list goes on.  Our board certainly keeps their fingers on the pulse of the industry and should the time come for WMHS to look at a partner, they will know.  Until then, it is my goal to remain independent and continue to provide the best possible care to our patients in our community.

Thursday, October 25, 2012

Effective Use of Labor in Hospitals Going Forward

In the most recent issue of Health Leaders magazine, there is an article, "Labor Efficiency a Growing Tactic."  The article is very timely for WMHS in that it reports on a recent survey of hospital and health system leadership across the country related to cost reduction initiatives, including reductions in personnel.  Thirty four percent of responding hospitals said that the annual savings generated from recently implemented initiatives range from 1% to 3%, twenty four percent said from 4% to 5% and twenty five percent of those surveyed said from 6% to 10%.  At WMHS, those initiatives that we implemented to date this fiscal year will reduce spending by about 3%, so we are consistent with the majority of hospitals reporting on implementing cost and labor reduction initiatives. 

These same hospitals / health systems said that the greatest savings came from cost reduction strategies in the areas of "stuff and staff" just like at WMHS.  Thirty two percent of the savings came from supply chain efficiencies, twenty one percent of the savings came from labor reductions, twenty one percent came from more efficient use of labor and nineteen percent came from revenue cycle improvements; all areas of focus at WMHS this year.  Lastly, the survey reported that those personnel categories targeted for reduction were as follows: 51% non-clinical; 23% clinical; 18% leadership (VP and up), all targeted areas at WMHS, as well.  Hopefully, articles and comparisons like this will help as we try to continue to explain changes in health care now and going forward.

Wednesday, October 24, 2012

Today's Baltimore Sun Article

In today's Baltimore Sun, there is an article listing the 89 Maryland facilities out of over 3000 nationwide that has purchased drugs from the New England Compounding Center since this past May.  This is the facility that is linked to the tainted steroid that has sickened over 300 with meningitis, resulting in the death of 23 people.   We have dealt with a number of inquires since the story first broke as to whether or not WMHS received drugs from this facility.  The article lists 89 facilities in Maryland; however,WMHS is not one of them.  WMHS did not purchase nor receive any drugs from this facility.  The Baltimore Sun article lists only one facility in Cumberland and it is not affiliated with WMHS.  A link to the article is attached.


Tuesday, October 23, 2012

What Does WMHS Mean to the Region?

In addition to being the largest employer with over 2200 employees and having an economic impact of over $300 million per year on the region, from time to time it is important to remind folks of the host of services that we provide. 

These include:
·         A designated area wide trauma center with a trauma team consisting of trauma surgeons, anesthesiologists, critical care specialists and other support personnel 24 hours a day, 7 days per week.
·         Special designation as a Cardiac Intervention Center and a Stroke Center, ensuring that patients have access to life-saving services within prescribed time-frames.
·         Emergency medical care 24 hours a day, 7 days per week.
·         Medical direction to pre-hospital providers, such as paramedics and EMTs throughout Allegany and Garrett counties as well as the surrounding counties in WV and PA.
·         Specialty coverage for medical, surgical, orthopedic, OB/GYN, pediatric and a host of other services.
·         Subspecialty coverage for cardiology, neurosurgery,  and neonatal services on a 24 hour basis.
·         Twenty-four hour coverage for all aspects of lab, radiology, respiratory therapy, OR, Behavioral Health, Open Heart Surgery and Interventional Cardiology.
·         Relationships with other academic medical centers and specialty hospitals for spinal cord injuries, burns, specialty pediatrics, hand injuries, eye and neonates.

We provide excellent medical care and treatment as a full service community hospital.  We have developed relationships with other providers to best care for the patients that we serve.   If WMHS is not as well versed in a certain area of medical expertise or if we don't see as many cases of a particular type that would ensure the proficiency of the staff, we will not hesitate to transfer our patients to the best setting for their care.

As you can see, we offer a great deal to this community in terms of economic impact, community support, wellness and, most importantly, in the care and treatment of our patients.

Monday, October 22, 2012

Keeping our Kids Fit

In my Blog for August 16, I mentioned that we had a meeting with administrators and teachers from three local schools to plan the kick-off events for their involvement with Project Fit America.  The Project Fit America program includes outdoor and indoor fitness equipment with a dynamic curriculum of fitness games and challenges, on-site teacher training, and in-class education on nutrition and other health-related topics. 

Last week, Flintstone Elementary School became the first school in Maryland to become part of Project Fit America.  Today, New Creek Elementary School in neighboring Mineral County, West Virginia, became the first school in that state to join the program.  Next week, Bishop Walsh School in Cumberland will have its kick-off festivities.

WMHS and Maryland Physicians Care, the managed care organization that WMHS co-owns with several other hospitals, provided the funding to bring this innovative program to three schools in our service area.  Our hope is that the concept will be successful and these schools will serve as a model for the rest of Allegany County and Mineral County schools.  Based on the early reactions from the children and their teachers, I think this has been a good investment for the future.

Students from New Creek Elementary School demonstrate
the sport hoop challenge at today's kick-off festivities

Friday, October 19, 2012

WMHS Captive Insurance Company

This week, several folks from WMHS and I are attending the annual meeting of the Western Maryland Insurance Company, our Captive  based in the Cayman Islands that provides our liability insurance.   When we were looking for a new liability insurance carrier in 2004, the most prominent carrier in Maryland had just left the state and there were limited options for coverage.  It ended up that our premium for that year was $3.9 million to cover the health system and 15 physicians.  We knew we had to find a more affordable alternative.

As a result, WMHS began pursuing an off-shore Captive similar to hundreds of US health systems with Captives in the Cayman Islands.  The WMHS Captive was formed in 2005; and in the 8 years that we have been a part of the Captive, we have saved close to $10 million in insurance premiums that would have been paid to insurance companies year after year.  Those retained earnings remain a part of the Captive, along with all other invested monies.  None of this money is paid to anyone else and it directly benefits the Captive and WMHS.  In addition, our Captive now covers the health system and nearly 60 providers.  Can you imagine the cost on an annual basis that we would have been paying to an insurance company?

The Captive requires a meeting to occur on an annual basis outside of the US and it is scheduled a year in advance since it requires the attendance of many actuaries, auditors, attorneys and other service providers.  Also, every two years, the Captive leadership is required to meet with the Cayman Monetary Authority.  The Monetary Authority is similar to the insurance commissioner for a State. The expenses for the meetings in the Cayman Islands are covered by the Captive.  The timing of this year’s annual meeting is unfortunate based on what has been happening recently.  We would have changed the date of the meeting if we could but it was not possible.   In fact, we have already scheduled the date for next year.

The bottom line is the Captive has been a godsend for WMHS as we strive to manage the rising costs of providing healthcare services.