The Envision Healthcare (EVHC) case examines the operations of one of EVHC's divisions, EmCare, a national physician services outsourcing company. The case describes EmCare's controversial use of out-of-network billing for a significant share of its revenues. As the company faced increasingly negative scrutiny for these practices, the case highlights the different perspectives and vantage points- both good and bad- of this strategic decision, and delves into the question of ethical practices as it relates to out-of-network billing. Students will explore the legal, societal, and economic implications of EmCare's business model, grappling with questions of business ethics and responsibility to customers. As EVHC contemplates reducing the out-of-network billing practices of its divisions including EmCare, the company faces important questions around financial viability, which serve as an opportunity for students to develop recommendations and novel approaches to EVHC's strategic quandary. Ethical challenges are common to healthcare organizations as they develop and implement strategy. Organizations must deal with questions of profitability and performance against the backdrop of making self-guided decisions around social responsibility and ethical practices. The case provides relevant context regarding emergency medicine, out-of-network billing, and payer-provider-hospital relationships. With this background, students are encouraged to consider the gamut of considerations, some of which are not so obvious, when weighing strategic decisions that bear in mind social and ethical implications.
Beginning in 2013, Humana Inc., headquartered in Louisville, Kentucky, pursued a major organizational transformation, from being an insurance company focused on paying claims to becoming a health and well-being company focused on improving the health of its beneficiaries. The company set a "Bold Goal" of improving the health of the communities it served by 20% by 2020. To achieve this new goal, Humana undertook a multiyear redesign and investment of people, processes, and products in order to gain the trust of consumers and providers, and to partner with communities to improve health. The case focuses on community initiatives, where Humana was developing its new role as "convener of conversations," providing leadership infrastructure and partial funding to spark community planning with a wide range of stakeholders and to design and monitor interventions that were tailored to local health improvement. At the same time, Humana remained a publicly-held corporation accountable to its shareholders for revenue growth and financial return. The case protagonist, Andrew Renda, MD, MPH, Director, Bold Goal Measurement, must design and implement a business plan, including leading and lagging performance metrics, that would measure Humana's progress toward its Bold Goal in ways that supported continued investment in community health improvement in Humana's local markets, while satisfying its traditional business constituents. This case can be used in courses on strategy, community health improvement, the corporate role in public health, and other courses exploring the intersection of business and society. It also offers a rich opportunity to explore the research design and measurement challenges associated with evaluating the impact of public health interventions on local communities.
In July 2016, Jennifer Brown, a graduate student at Southwest State School of Public Health, had been asked to staff an Ethics Advisory Group (EAG) meeting at Mountain Health Insurance Company, a large, regional nonprofit health insurance company where she was employed as a summer intern. The mission of Mountain Health was "to improve the health of the people we serve and the health of society." Jennifer had been working with the ethics program director, Robert Jones, to review and update the program's ethical guidelines to reflect emerging ethical challenges in the financing and delivery of health care. This meeting was the first time that Jennifer had been given the responsibility of identifying the ethical issues that EAG should consider and what values should be applied in determining how Mountain Health should address them.
As Angela Laramie compiled her thirteenth annual report on sharps injuries (SIs) among hospital workers for the Massachusetts Department of Public Health's Occupational Health Surveillance Program, she noted that the prevalence of injuries had remained at the same level for six years in a row. From 2002 through 2009, the SI rates had trended downward as hospitals implemented sharps injury prevention plans, but starting in 2009, the decline in rates and number of sharps injuries appeared to have stalled. Angela hoped to evaluate the reasons for the apparent lack of progress over the last few years, and to reassess the state's approach: were the data they had been collecting adequate to meaningfully capture the sources and incidence of SIs in Massachusetts hospital workers? Did it clearly indicate where interventions should be targeted? Were there other data that could help her better understand the flat trend line? What did the data tell her, and what more should she know?
In the seven years since Don Blanchon was hired as the Chief Executive Officer of Whitman-Walker Health, it had transitioned into a primary care-based community health center and a patient-centered medical home serving a diverse population in a rapidly changing area of Washington, DC. The Affordable Care Act of 2010 would, in Blanton's view, increase access to providers for WWH's patient population, thereby increasing the competition. The implications of this change left senior management with unresolved strategic questions. Should WWH pursue a "hybrid FQHC model," a new location, new services, or a future strategic partnership with a large health system? What should the next direction be for WWH, and how should it get there?
"Alameda Health System" (AHS) describes a county-owned safety net health system adapting to the implementation of the Affordable Care Act and an increasingly competitive health delivery environment. It takes the perspective of senior management, specifically the Chief Medical Officer for the system, who has been in his job for just over one year. The case begins in late 2014, when the CEO of 9 years announced that he was leaving AHS to become CEO of a Detroit health system. He was leaving behind a senior management team that had been in place for 1-2 years, and had turned over several times throughout his tenure. At the same time, the system was experiencing a financial downturn, brought on in part by the loss of many low-income, formerly county indigent patients who selected subsidized private health insurance plans on the new state health exchange that contracted primarily with AHS's two largest competitors. AHS also had yet to integrate clinically or administratively with two community hospitals, both of which were in poor financial health, recently acquired as part of a strategy to diversify the AHS payer mix. The system faced operating challenges common to many publicly-owned safety net hospitals, including: a unionized workforce; an independent, mission-driven medical staff that had grown weary of administrative turnover; a poorly functioning revenue collection system; unprofitable contracts with managed care plans; relatively few commercially insured patients or contracts; long wait times for care; lack of telephone and transportation access to providers; and a low-income population with multiple poorly managed chronic diseases, including mental illness and substance abuse, as well as a high rate of violent crime. The case requires that students understand key aspects of the ACA and can synthesize other relevant environmental and organizational trends in order to recommend and evaluate the actions that senior management should take.
In early 1996, Charlton Memorial, St. Luke's, and Tobey Hospitals were contemplating a full asset merger, something that had never been done before in Massachusetts. The logistics of the merger and its impact on the finances of the hospitals were among the many unknowns that the boards of trustees and management were facing. But, as Ron Goodspeed, MD, CEO of Charlton at the time, explained, "We had a fundamental desire to make it work. We expected hurdles - we knew there would be difficulties - but that is not a reason to back away...We took one step at time, taking care of hurdles as they appeared."
Southcoast Health System consists of three hospitals in southeastern Massachusetts: St. Luke's in New Bedford, Charlton Memorial in Fall River, and Tobey in Wareham, as well as numerous affiliated entities. But how did the merger that created the Southcoast system came about? "Basically, we merged because we wanted to, not because we needed to," said John Day, President and CEO of Southcoast Health System (formerly the CEO of St. Luke's Hospital). "We wanted to avoid a divide and conquer situation. As community hospitals, we needed to be able to serve the long-term interests of our communities." "We decided it was ridiculous to be competing with each other," added Ron Goodspeed, MD, President of Southcoast Hospitals Group and Executive Vice President of Southcoast Health System (formerly the CEO of Charlton Memorial). A mix of events and environmental conditions set the stage for the three hospitals to consider merging. One of the most critical of these was a turnover in Charlton's CEO position. Meanwhile, the health care environment was becoming increasingly volatile and competitive, and the focus in the business community was shifting away from city-specific planning and toward developing the larger southeastern area of the state. The predominant goal of the management and boards at all three hospitals was to find a way to best serve the interests of their communities. They decided on a full asset merger: building a single executive management team and board of trustees to oversee the organization.
Mr. J, the Manager of the Health Department in District X, South Africa, was hopeful that he could bring increased resources and better health to the area. District X, one of about 50 districts in 9 provinces in South Africa, was a largely rural area saddled with high levels of poverty, poor infrastructure, and high mortality rates; medical needs were high but almost half of the positions in the health department were unfilled, and turnover among staff was high. In South Africa, there was a push to improve primary care and to decentralize management to local levels in order to respond to local needs more effectively, but the processes for planning, reporting and budgeting were extremely complex and did not seem to support that goal. Mr. J wondered what additional skills he needed in order to work the system, and was also thinking about how the system itself could be improved.
On November 15, 1996, Stanford's Board of Trustees and the University of California (UC) Board of Regents voted to merge their two academic medical centers; on November 1, 1997, the merger became official. However, less than two years later, in October 1999, the merger came to an abrupt end. Was the merger an ill-conceived "snakebit venture" or a reasonable response to the environmental and economic pressures of the time that fell apart in its execution? Would the same ills have befallen Stanford and UCSF regardless of the merger?
This case considers the challenges, benefits, and costs of hospital participation in a widely recognized surgical quality improvement benchmarking program. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) issues performance reports twice a year to participating hospitals, creating benchmarks based on data submitted by over 500 hospitals. NSQIP claims that participation reduces surgical complications. The protagonist, the Chief of General Surgery at a large academic medical center, faces skepticism about the value of the report on two fronts: from some surgeons on his staff and from a statistician he consults. Some of the hospital surgeons find the data difficult to interpret, and question their utility in focusing quality improvement interventions. The statistician has reservations about the validity of the statistical results as a basis for action. The chief must decide if and how the NSQIP report can be used to improve quality. In the coming era of value-based purchasing initiatives for hospitals, the chief also needs to be concerned about how payers might interpret this data as they develop payment systems that reflect available measures of surgical quality.
Dr. John Niff, co-chair of the Medical Advisory Panel (MAP) to Hillside Hospital, waited for his colleagues to join him to review the recommendations for The New Hillside Hospital that the panel had developed over the past six months. When Bill Hurst, Hillside's CEO, had first suggested creating a committee of doctors (the MAP) to develop recommendations for clinical programs at the hospital, Niff was skeptical. But as the clinicians worked together to identify problems and set priorities, they developed their management skills as well as a greater appreciation for the challenges facing the hospital. Trust between management and physicians grew as the hospital implemented some of the panel's recommendations. Although the MAP's list of recommendations had not yet been formally accepted by the Board, all participants reflected on the benefits already gained through this process.
Bill Hurt, the new CEO of Hillside Hospital, knew that the forecast was grim. The hospital's service volumes and market share were dropping precipitously. The direct causes of the problems were numerous, but an indirect cause-and major barrier to addressing the declines-lay in the poor relationship between Hillside's management and its physicians. To engage the physicians in problem-solving, he considered a consultant's suggestion: turning the clinical planning process over to the physicians, with management involved only at their request. This approach was risky but Bill thought sometimes you got power by giving it up.
This case presents organizational challenges facing a physician champion of the Patient-Centered Medical Home (PCMH). Dr. Julian Kuffler, working with his employer, the Mount Desert Island Hospital System (MDI), hoped to persuade the primary care physicians in the system to embrace the PCMH care model. Physician resistance was strongly opposed to some of the key principles of PCMH, such as managing the health of a defined population, standardizing chronic care management protocols, delegating patient care tasks to non-physician members of a care team, and to having strong physician leadership at the system level. At the same time, MDI was a small rural "critical access hospital" with declining admissions, predominantly outpatient-based revenues, and deteriorating finances. MDI leadership viewed high quality primary care to be essential for MDI to be able to attract the best health system partner with which it could affiliate to become part of a larger, more financially viable organization. MDI leadership also hoped to find a partner that could also support its participation in new population health arrangements such as accountable care organizations.
Ruth Ann Norton, executive director of the National Coalition to End Childhood Lead Poisoning (CECLP), founded the Green & Healthy Homes Initiative (GHHI) in order to leverage newly available federal funds from the American Recovery and Reinvestment Act of 2009 (ARRA) for weatherizing low-income housing. Unfortunately, by June 2011, the ARRA funding was winding down, and Norton was looking for other, sustainable sources of financing to keep the GHHI program alive.
When Dr. Marwan started as director of Ramses Hospital in Cairo in 2008, charged by the Minister of Health with improving performance, he found the hospital had been neglected for decades. A Ministry of Health quality audit had recently given the hospital the worst score of the five hospitals designated as critical to the greater Cairo area. Dr. Marwan vowed that Ramses Hospital would come in first in the next round of quality audits. Without improving its quality scores, the hospital would be unable to pass the accreditation process required for hospital participation in a new universal social health insurance scheme. In addition-and just as critically-Dr. Marwan needed to develop a longer-term strategy for obtaining the considerable additional resources required to upgrade the long-neglected facility.
Dale Morse, MD, MS, could feel the tension rising in the room. He was chair of a special meeting of the Advisory Committee on Immunization Practices (ACIP) called for July, 2009, that would make recommendations to the Centers for Disease Control (CDC) on whether to prioritize vaccine distribution to protect the population against a possible H1N1 influenza pandemic in the fall. Dr. Morse was particularly concerned that if ACIP did not set priorities now, he and other state and local public health officials could be faced with a vaccine shortage amid high demand-a situation he described as a potential public health disaster.
In October 2008, Dr. Richard Mgaga, Head of the Malaria Control Programme in Uganda reviewed the monthly malaria statistics report for the district of Apac, which in April of 2008 had undergone a pilot indoor residual spraying (IRS) program using DDT in a campaign to prevent mosquitoes from biting and spreading malaria. The campaign was halted by a court injunction requested by organic farmers, exporters and environmentalists in May 2008, and the injunction was upheld by the High Court in June. In early August, the Uganda Health Ministry began spraying a pyrethroid insecticide in place of DDT. Meanwhile the Ugandan Attorney General was challenging the High Court's decision. Dr. Mugaga was under pressure by the Presidential Malaria Initiative (PMI) to undertake a full program of IRS in 300,000 households in the northern districts of Uganda, including Apac. However, he was unsure whether to proceed, given the opposition and apparent problems that surfaced when the Apac pilot was implemented.
This case provides an introduction to the structure and dynamics of nonprofit hospital governance in the U.S. A hospital CEO two years into her position is grappling with how to make her board a more effective governing body. The hospital's competitive position was eroding due in part to resistance by its independent medical staff to recruiting new physicians into the service area. In addition, some of the physicians had opened freestanding diagnostic and treatment facilities that reduced hospital revenues. But the board was reluctant to take this issue on. At the same time, the CEO felt that too much board attention was spent second-guessing her new hires and other operational decisions that she felt were her responsibility.