Slow: budget danger ahead. CMS says 10-year healthcare spending to reach $4.3 trillion by 2017, but execs seek longer-term planning to curb costs.

The CMS delivered its latest projections last week, showing healthcare spending will double in 10 years, with just a small portion of the growth being blamed on aging baby boomers. Many saw gloom in the forecast, but one exec saw a bright side for home healthcare, expected to be among the fastest-growing sectors. "It shows that the industry is being valued as a promising alternative," says Amanda Thomas, left.

Nowhere to run, or hide. Current economic downturn may exacerbate hospitals' weakness with buildings, technology costs, reimbursements.

As the economy moves through what many believe is a recession, healthcare won't be immune, experts say. "I don't know much in the economy that is recession-proof, and I don't think healthcare is either," says W. David Bradford, left, a Medical University of South Carolina economics professor. Because of the current economic conditions, some systems are rethinking where they put their money.

Religious experience. Catholic Health Association's Sister Keehan lands top spot on our annual 100 Most Powerful ranking, underscoring her devotion to achieving a long-elusive goal: access to healthcare for everyone.

The hunger for reform and transparency in healthcare is palpable in this year's listing of the 100 Most Powerful People in Healthcare. The first six are all people who have helped lead efforts to increase access or protect patient privacy, including No. 3, California. Gov. Arnold Schwarzenegger, left. Find out who leads the pack.

Command performance. CMS ready to debut pay-for-performance plan, but regardless of whether it's a hit, quality comparisons could be a rising star.

Whether the CMS' pay-for-performance plan ever materializes is inconsequential. Executives say quality performance will undoubtedly play a larger role in reimbursement. Opal Reinbold, left, from Palomar Pomerado Health says the system participated in a quality incentive demonstration project because "it prepared us for how this evidence-based practice was going to be applied."

High-risk proposition. With CMS' 'value-based purchasing' model, struggling hospitals are wondering if they can afford the IT needed to make it work.

As the CMS pushes its "value-based purchasing" model, hospitals are left wondering if they'll get squeezed by a program that will require them to invest big bucks in technology. "People need to ... understand it is a way of transforming Medicare from a passive payer of claims to an active purchaser of higher-quality, more-efficient services," says the CMS' Thomas Valuck.

Profitable complications. One analysis says that in some cases infections can actually help a hospital boost its bottom line, but naysayers disagree.

While no one is saying that hospitals try to induce infections to raise their bottom lines, one analysis says that the bottom line is healthcare providers do cash in when patients get infected in their facilities. Hamot Medical Center in Erie, Pa., is one hospital that has invested in infection prevention. Steve Danch, the hospital's CEO, says infection rates dropped by "focusing on the root causes."

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.

Getting schooled in governance. N.J. enacts law that will require hospital trustees to receive certified training through class, special leadership curriculum.

Those joining hospital boards of trustees in New Jersey will soon have to go to school, according to a new law aimed at boosting their financial and governance savvy. And it could start a trend, as more and more hospitals come under greater scrutiny. "I think trustee leadership is crucial to the survival of the hospitals in New Jersey," said Fred Jacobs, left, state health commissioner.

Unlikely GPO partners unite. Could Consorta and Healthtrust's collaboration spark a trend among the nation's other top group purchasing organizations?

Consorta's deal to become the sixth equity owner in HealthTrust Purchasing Group could signal a wave of consolidation at group-purchasing organizations. HealthTrust's clinically based decisionmaking for product selection and contract compliance are what swayed Consorta's board, says Chairman Louis Fierens, left. "It's about the total value, and it is at the end of the day a fairly simple equation", Fierens says.

Prime Example. A Calif. community's inability to stop a failing not-for-profit hospital from being sold, converted has national implications.

Approval of the sale of a California hospital to a for-profit ended a contentious struggle in the community, where advocates of keeping it not-for-profit worked to stop the sale. The battle highlights the difficulties facing not-for-profits. "Everybody is interested in the best thing for their community and yet because of the difficult economics of healthcare, there are no solutions agreeable to all parties," says consultant Phil Dalton, left.

New chapter in NCFE saga. SEC's civil fraud charges against executives at failed firm offer cold comfort for the hospitals, physicians hurt by the debacle.

Trouble revisited National Century Financial Enterprises last month, when the Securities and Exchange Commission sued four former execs for the accounting fraud that caused the financial firm's collapse in 2002. The investigation worries some, but others, like Kathy Patrick, left, an attorney representing former NCFE investors, says there is "legitimate business to be done in the purchase of healthcare receivables."

Technical difficulties. Recent health IT security breaches are unlikely to improve the public's perception about the safety of personal data.

Consumers who claimed in recent surveys that they were "more afraid of cyber crimes than physical crimes" may have had reason for caution. A spate of well-publicized information thefts and security breaches at healthcare organizations have eroded trust in technology, says Carol Diamond, left, of the Markle Foundation, and that could have an adverse effect on acceptance of electronic medical records.

Charitable obligations. Both sides declare victory in uninsured billing settlements. Will more systems settle rather than fight it out in court?

Some not-for-profits involved in uninsured billing lawsuits have decided to settle the cases rather than pay hefty legal fees to fight in court. But hospitals contend offering discounts to the uninsured won't make much of a difference since most don't pay anyway. Attorney John Phillips, left, says the fact poor people don't have the money to pay is really the impetus behind these lawsuits.

Charity with an arm twist. Senate hearing starts the ball rolling on tougher community benefits standard, greater federal oversight of not-for-profits.

A Senate hearing last week helped boost not-for-profit hospitals' chances of facing a new standard for reporting community benefits. At stake for hospitals are billions in tax breaks. The standard for exemption hasn't been modified since 1969, and "has not kept up with the substantial unfunded health needs of communities," says Nancy Kane, right, a member of MedPAC.

Charitable intentions. CHA, VHA unveil community-benefit guidelines developed to help not-for-profit hospitals justify their tax exemptions.

With new guidelines from the CHA and VHA on reporting community benefits, not-for-profit hospitals are being advised to drop bad debt and Medicare shortfalls from their accounting of how they fulfill their mission. While the AHA doesn't agree, some experts do. MedPAC member Nancy Kane, right, says bad debt "is a tough one, but I don't think a lot of bad debt is a community benefit.

Patients push for price data. Lawsuits, regulations could cause consumers nationwide to start seeking more transparency from hospitals on outpatient fees.

Lawsuits over hospital outpatient fees, including a case at Virginia Mason Medical Center, could prompt consumers nationwide to seek more information about their bills. The issue highlights the turf battle between physician- or corporate-owned clinics and competing hospital facilities, and how they're marketed. "We absolutely agree that patients need full information", says Virginia Mason's Sarah Patterson, left.

One question: credit or debit? As health savings accounts gain in popularity, insurers and the financial services industry want to bank the cash.

The Blue Cross and Blue Shield Association has a new sideline-banking. By chartering its own bank, the Blues is joining other insurers that have moved into financial services to adapt to the changes being wrought by health savings accounts. And other insurers have been faster to make the move. The Blues "is certainly late to the game" of banking, says analyst Katy Henrickson, left.

Extreme planning. Experts say New York's plan to restructure its healthcare system may prompt other states to consider doing the same.

In what could be a model for other states, New York's Commission on Health Care Facilities in the 21st Century last week recommended revamping the state's healthcare system, including closing nine hospitals. David Sandman, left, the executive director of the commission, says New York needs "to spend smarter and obtain better value.

And then there were three. With consolidation leaving three major players in each sector of the medical device industry, what happens to competition?

Consolidation in the medical device industry has reduced the major players in each sector to three. While some laud the trend, saying one supplier can bundle products at a deep discount to hospitals, others say savings are often illusory. Cook Group President Kem Hawkins, left, sees the amalgamation as the ordinary course of business, and isn't "any more rampant now than at other times in the past".

Influenza economics. Providers and suppliers who usually reap big profits during flu season might find that a pandemic could backfire on their bottom lines.

Health and Human Services Secretary Mike Leavitt, right, spoke about avian influenza at the National Press Club in Washington last week. President Bush's plan involves asking Congress to invest billions of dollars in development, production and stockpiling of antiviral drugs and vaccines in case the flu strain becomes a pandemic. HHS hopes to stockpile enough of vaccine to inoculate 20 million Americans.