Local COVID-19 Epicenter in Detroit Metropolitan Area Causing Profound and Pervasive Reorganization of Clinical, Educational, Research, and Financial Programs of a Large Academic Gastroenterology Division with a GI Fellowship and Primary Medical School Affiliation.

AIM: To report revolutionary reorganization of academic gastroenterology division from COVID-19 pandemic surge at metropolitan Detroit epicenter from 0 infected patients on March 9, 2020, to > 300 infected patients in hospital census in April 2020 and > 200 infected patients in April 2021. SETTING: GI Division, William Beaumont Hospital, Royal Oak, has 36 GI clinical faculty; performs > 23,000 endoscopies annually; fully accredited GI fellowship since 1973; employs > 400 house staff annually since 1995; tertiary academic hospital; predominantly voluntary attendings; and primary teaching hospital, Oakland-University-Medical-School. METHODS: This was a prospective study. Expert opinion. Personal experience includes Hospital GI chief > 14 years until 2020; GI fellowship program director, several hospitals > 20 years; author of > 300 publications in peer-reviewed GI journals; committee-member, Food-and-Drug-Administration-GI-Advisory Committee > 5 years; and key hospital/medical school committee memberships. Computerized PubMed literature review was performed on hospital changes and pandemic. Study was exempted/approved by Hospital IRB, April 14, 2020. RESULTS: Division reorganized patient care to add clinical capacity and minimize risks to staff of contracting COVID-19 infection. Affiliated medical school changes included: changing "live" to virtual lectures; canceling medical student GI electives; exempting medical students from treating COVID-19-infected patients; and graduating medical students on time despite partly missing clinical electives. Division was reorganized by changing "live" GI lectures to virtual lectures; four GI fellows temporarily reassigned as medical attendings supervising COVID-19-infected patients; temporarily mandated intubation of COVID-19-infected patients for esophagogastroduodenoscopy; postponing elective GI endoscopies; and reducing average number of endoscopies from 100 to 4 per weekday during pandemic peak! GI clinic visits reduced by half (postponing non-urgent visits), and physical visits replaced by virtual visits. Economic pandemic impact included temporary, hospital deficit subsequently relieved by federal grants; hospital employee terminations/furloughs; and severe temporary decline in GI practitioner's income during surge. Hospital temporarily enhanced security and gradually ameliorated facemask shortage. GI program director contacted GI fellows twice weekly to ameliorate pandemic-induced stress. Divisional parties held virtually. GI fellowship applicants interviewed virtually. Graduate medical education changes included weekly committee meetings to monitor pandemic-induced changes; program managers working from home; canceling ACGME annual fellowship survey, changing ACGME physical to virtual site visits; and changing national conventions from physical to virtual. CONCLUSION: Reports profound and pervasive GI divisional changes to maximize clinical resources devoted to COVID-19-infected patients and minimize risks of transmitting infection.

Expenditures and Quality: Hospital- and Health System-Affiliated Versus Independent Physicians in Virginia.

OBJECTIVES: The American Medical Association has reported that 2016 was the first year in which fewer than half (47.1%) of all practicing physicians owned their own practice. Across the United States, there has been consolidation of physicians and hospital and health systems, resulting in questions about the effect of this on healthcare expenditures. The aim of this study was to compare the expenditures per patient between hospital- and health system-affiliated physicians and independent physicians. METHODS: The author used Virginia's new statewide all-payer claims database to analyze expenditures and quality for 3 years for hospital- and health system-affiliated physicians versus independent physicians. The database had all claims statewide for Virginians with individual or group commercial insurance coverage: 1.95 million patients in 2013, 2 million in 2014, and 2.1 million in 2015. The average annual expenditure for each physician was adjusted for average patient condition burden (risk) and differences in geographic input costs using regression analysis. Measures of primary care quality were obtained from the claims data using evidence-based measures from national health quality organizations. RESULTS: Hospital- and health system-affiliated physicians had annual expenditures per patient ranging from 10.3% to 14.6% higher than independent physicians. Most of the measures of primary care quality were not significantly different. CONCLUSIONS: Virginia patients, employers, and managed care companies incurred higher per-patient expenditures with hospital and health system physicians than with independent physicians.

Combining forces to manage the continuum of care.

Many healthcare organizations are pursuing affiliation strategies to effectively manage population health. Healthcare organizations should take the following key steps in setting such a strategy: Ensuring the strategy aligns with the organization's mission Identifying potential partners. Outlining expectations for the affiliation. Assessing affiliation structure options.

The cost of doing business in academic radiology departments.

This study identifies the major sources of overhead fees/costs and subsidies in academic radiology departments (ARDs) in the US and determines the differences between them based on geographic location or the size of their affiliated hospital. ARDs in the Northeast had the highest level of financial support from their affiliated hospitals when compared to those in the South/Southwest; however, a greater number of Midwest ARDs receive high levels of funding for teaching from their medical schools when compared to the northeast. Significantly fewer ARDs affiliated with hospitals of less than 200 beds receive subsidies for their activities when compared to those affiliated with larger hospitals. Differences in levels of overhead costs/ subsidies available to ARDs are associated with either geographic location or the size of the affiliated hospital. The reasons for these differences may be related to a variety of legal, contractual, or fiscal factors. Investigation of existing geographic and affiliate size fiscal differences and their causes by ARDs may be of benefit.

Predictors of hospital CEO affiliation with a professional association.

Based on a 2008 cross-sectional survey of 582 hospital CEOs in the United States, this study reports the findings of two logistic regression models designed to identify CEO and hospital characteristics associated with Member and Fellow status in the American College of Healthcare Executives (ACHE). The purpose of the study was to understand the personal and organizational characteristics of those CEOs who choose to be Members and Fellows of a professional association such as ACHE. The results showed that most (74 percent) of the respondents considered ACHE to be their primary professional association. The results also revealed that a master's degree in health administration [beta = .88, t(427) = 5.35, p < .0001], male gender [beta = .59, t(427) = 3.01, p = .002], and financial incentives provided by the parent hospital [beta = .25, t(427) = 2.73, p = .006] were statistically positively linked with Member status in ACHE. A master's degree in health administration [beta = .81, t(424) = 5.79, p < .0001], male gender [beta = .39, t(424) = 2.25, p = .02], and age [beta = .02, t(424) 2.32, p = .02] were also statistically positively associated with Fellow status in ACHE. Notably, organizational factors such as size, geographic location, for-profit status, and financial strength of the hospital do not seem to play an important role in the CEOs' decision to become a Member or Fellow of ACHE. The implication of these findings is that membership and fellowship at a professional association are influenced by characteristics of the individual, and incentives provided by employers can encourage employees to get involved with their professional associations.

Physician-hospital relationships: from historical failures to successful "new kids on the block".

Trends in healthcare reveal that increasing numbers of physicians prefer to work directly with hospitals-whether through employment models, new or revived partnership structures, or other such "deals". Meanwhile, hospital executives are vigorously seeking ways to create win-win arrangements that satisfy both parties-models that will ensure medical coverage for the hospital, along with revenue gains and cost savings when possible. Add to this a competitive environment, physician shortages, and high regulatory activity and healthcare reform, and the path to clinical, operational, and financial viability in the context of a hospital/physician partnership can be a challenging one. Models such as The physician enterprise and co-management agreements are gaining popularity, each with distinct benefits. With market forces dynamically changing, along with accountable care, it is time for hospitals, health systems, and physicians to prioritize their partnering relationships, a strategy that is now key to achieving success in the future...and that's a trend that's likely to continue far into the years ahead.

Funding source and author affiliation in TASER research are strongly associated with a conclusion of device safety.

BACKGROUND: Controversy exists regarding the safety of electrical stun guns (TASERs). Much of the research on TASERs is funded by the maker of the device and, therefore, could be biased. We sought to determine if funding source or author affiliation is associated with TASER research conclusions. METHODS: MEDLINE was searched for TASER or electrical stun gun to identify relevant studies. All human and animal studies published up to September 01, 2010, were included. Reviews, editorials, letters, and case reports were excluded from the analysis. Two independent reviewers blinded to this study hypothesis evaluated each article with regard to conclusions of TASER safety. RESULTS: Fifty studies were reviewed: 32 (64%) were human studies and 18 (36%) were animal studies. Twenty-three (46%) studies were funded by TASER International or written by an author affiliated with the company. Of these, 22 (96%) concluded that TASERs are unlikely harmful (26%) or not harmful (70%). In contrast, of the 22 studies not affiliated with TASER, 15 (55%) concluded that TASERs are unlikely harmful (29%) or not harmful (26%). A study with any affiliation with TASER International had nearly 18 times higher odds to conclude that the TASER is likely safe as compared with studies without such affiliation (odds ratio 17.6, 95% CI 2.1-150.1, P = .001). CONCLUSIONS: Studies funded by TASER and/or written by an author affiliated with the company are substantially more likely to conclude that TASERs are safe. Research supported by TASER International may thus be significantly biased in favor of TASER safety.

Offering salvation. Ascension, equity firm forge deal they say could save Catholic hospitals.

As more Catholic hospitals have become acquisition targets by for-profit companies, the nation's largest Catholic system wants to keep more facilities in the fold. Ascension Health has teamed with a private-equity firm to do just that. But "can a for-profit enterprise that is owned by a private-equity firm pursue and live the ministry of Jesus in providing healthcare?" asks Seton Hall law professor Kathleen Boozang, left.

Association of Multiple Hospital Affiliations With Clinician Service Use, Breadth of Procedures, and Costs.

Importance: Little is known about whether a clinician having multiple hospital affiliations (ie, 1 clinician working across multiple teams and organizations) is associated with clinician practice style and cost. The measurement of this association requires adjusting for selection into multihospital affiliations based on both observable and unobservable clinician characteristics. Objective: To evaluate the association of multiple hospital affiliations with clinician service use, breadth of procedures used, and costs. Design, Setting, and Participants: This cohort study used Medicare Part B data from 2016 through 2017 in a fixed-effects panel data design to compare service use, procedure breadth, and costs between clinicians with multiple affiliations (treatment group) and clinicians with a single affiliation (control group), with adjustment for volume, patients, and clinician characteristics. The study also controlled for unobserved (time-invariant) clinician characteristics using individual clinician fixed effects. Clinicians with Medicare claims, a reported National Provider Identifier, and affiliation data within Medicare Physician Compare were included for a total sample of 1 073 252 observations (633 552 unique clinicians) for medical services and 358 669 observations (210 260 unique clinicians) for drug prescribing. Statistical analyses were performed from February 1 to October 15, 2021. Main Outcomes and Measures: Service use is the total number of medical (or drug) services that clinicians render to their Medicare beneficiaries within a given year, procedure breadth is the total number of unique Healthcare Common Procedure Coding System codes that are associated with clinicians' medical (or drug) services within a given year, and costs represent the total standardized amount paid by Medicare for the medical (or drug) services. Additional measures were multiple-hospital affiliations, Accountable Care Organization affiliation, and controls across clinician and patient characteristics. Results: The medical service sample consisted of 633 552 clinicians (248 359 women [39.2%]; mean [SD] of 19.6 [12.5] years of experience), and the drug service sample consisted of 210 260 clinicians (74 875 women [35.6%]; mean [SD] of 21.6 [12.3] years of experience). For medical services, clinicians with multiple practice affiliations used a mean 8.2% (95% CI, 7.5%-8.9%; P < .001) more medical services per patient, drew on a mean 5.4% (95% CI, 5.1%-5.7%; P < .001) wider set of procedures within their medical care, and incurred a mean 8.6% (95% CI, 7.9%-9.2%; P < .001) more in medical costs. Pertaining to drug services, clinicians with multiple practice affiliations used a mean 2.9% (95% CI, 1.9%-3.9%; P < .001) more drug services per patient, drew on a mean 1.0% (95% CI, 0.5%-1.4%; P < .001) wider set of procedures within their medical care, and incurred a mean 2.7% (95% CI, 1.6%-3.7%; P < .001) more in drug costs. Significant results were also found across extensive and intensive margins of hospital affiliation, and supplemental analysis further indicated heterogenous treatment associations across clinician specialties. Conclusions and Relevance: This cohort study found that a clinician having multihospital affiliations was associated with greater service use, procedure breadth, and costs across both medical and drug services. These findings suggest that clinician affiliations ought to be considered as part of health care delivery design and potential cost-containment strategies.

After the fact: the case for posttransaction antitrust review of health plan mergers.

When health insurance administrators contemplate mergers or consolidations of their plans, the transactions are generally subject to federal or state antitrust review. Regulators have traditionally examined proposed transactions for their posttransaction market power and the anticipated operating efficiencies and then decided whether to permit the transaction. Given the somewhat speculative nature of preand posttransaction market power and efficiency projections, antitrust policymakers should consider allowing the mergers or consolidations of health insurance plans to proceed while regulators subject the process to posttransaction review and enforcement.

Physician integration is back--and more important than ever.

Current affiliation strategies tend to focus on joint ventures and employment. Careful planning and organizing of a joint venture can mitigate their associated legal, tax, regulatory, and cultural risks. The success of an employment model depends upon a compensation structure that aligns the incentives of physicians and the hospital. Fora successful affiliation program, hospitals should determine needs and trends, implement strategic planning, and conduct due diligence.

When less means more. By combining under one Medicare provider number, some hospitals can reap bigger disproportionate-share supplements.

Navigating the byzantine rules governing disproportionate-share supplements presents hospitals with a special challenge. But some have discovered a little-known secret: By combining two or more hospitals under a single Medicare provider number, some can increase their level of reimbursement. "We had to do something to stem the losses that were occurring in both institutions at that time," says Bob Reh, left.