Parties in Summa Health staffing dispute agree on little -AND- California's Community Clinics, Big ACA Beneficiaries, Worry About Their Future

CAL/AAEM News Service at
Wed Feb 8 13:28:03 PST 2017



January 17, 2017


Health staffing dispute agree on little 



mpaign=financedaily> Modern Healthcare



By Lydia Coutre


Leaders from Summa Health System and Summa Emergency Associates, the
independent physician group that staffed the system's emergency departments
until this month, agree on this: Contract negotiations, which ultimately
broke down days before the deadline, could have started sooner.


Both say they entered negotiations in early November fully expecting to have
SEA clinicians staffing all five of Summa's emergency departments in 2017
and years to come.


Beyond that, the two agree on little about how negotiations played out.


Upon reaching a stalemate in the last week of December, Summa solicited
proposals from other companies that could, within days, have enough doctors
available at midnight on New Year's — an unnecessary move, said Dr. Jeff
Wright, SEA president and ER physician. But Summa leaders say it was their
only option.


Officials at US Acute Care Solutions (USACS) — which has been staffing the
EDs since SEA's contract expired Dec. 31 — thought Summa and the SEA group
that has provided emergency services there for decades would reach an


Dr. Thomas Malone, Summa president and CEO, said it was a tough decision.
Realizing they were at an impasse, he brought on USACS at the last minute to
staff Summa's Barberton, Akron, Wadsworth-Rittman, Green and Medina
emergency departments.


"I don't think they thought we could do it," Malone said. "It was horribly
disruptive to the organization, unbelievably disruptive to the ED staff, to
the patients the first couple of days because they had longer waits. But
because of the hard work of the staff, mostly the nurses, the credentialing
staff (and) IT, we were able to pull that off, and every day it's been


The wait times have returned to normal, and patient volumes have remained
steady, said Valerie Gibson, chief operating officer of Summa and president
of Summa Health System hospitals.


But that hasn't appeased concerned practitioners and patients.


Summa leaders, its board and many of the system's department chairs support
the decision and stand on one side of what has become a very public and
contentious debate. Facing them is a sea of unhappy community members,
fed-up physicians — hundreds of whom have signed a no-confidence letter —
and other groups weighing in.




In late November, Summa sent SEA its initial proposed contract: a three-year
deal without financial assistance, similar to what SEA had operated under


Wright returned it with additions two weeks later. He said he wanted a
15-year contract to help with recruitment and retention, as well as
financial assistance to help SEA make up for financial losses sustained
while staffing some less busy Summa emergency departments.


Although Wright said SEA had been talking to Summa for a year or two about
the financial struggles in those EDs, no form of stipend was in the initial
contract. His counteroffer was to not staff two of the financially
underperforming departments.


Summa leaders realized the two were very far apart. A 15-year contract is
outside the industry standard of three years, said Ben Sutton, Summa's
senior vice president for strategy and performance management. And any
stipends Summa includes in contracts are assessed by a third party for
fair-market value, a process Sutton said SEA didn't initially offer.


Summa offered an extension of the contract so they could get on the same
page. Wright, thinking they'd certainly be able to work it out, declined the
offer. He saw his requested changes as wording and legal issues that the
attorneys could hammer out.


Summa leaders didn't think it was that simple. Sutton said, they were asking
for things "so far outside of the norm that there was no way that we could
even contemplate doing some of the things that they asked."


Summa offered four extensions, all of which SEA turned down, Gibson said.
Wright doesn't know an exact number, but acknowledges declining multiple


He said it didn't seem like Summa officials were "putting the effort forward
to get a contract finalized."


Malone said he's never been in an environment where people didn't extend a
contract, especially if they'd had it for as long as SEA did — about 40
years, according to Wright.


Although the short time frame worried Wright, he was more concerned that
during any extensions, Summa would find another group to take over the
contract. "It was a lack of trust," Wright said.


Many have raised questions about the involvement of Dr. Vivian von
Gruenigen, Summa's chief medical officer, in the negotiations. Her husband
is CEO of the group tapped to replace SEA. Summa officials say they ensured
that anyone with conflicts of interests, including von Gruenigen, was
excluded from the selection process for the new company.


In the crunch of the final week, SEA and Summa officials share different
versions of the verbal and written offers from each. But ultimately, they
could not bridge the gap, and USACS was put in place.




The fallout from doctors, community members and beyond was swift.


About 215 attending staff members signed a letter of no-confidence in Malone
and another such letter with a couple hundred signatures came from medical
residents, said Dr. Hitesh Makkar, vice president of medical staff at Summa.


An anonymous survey circulating has garnered 350 to 400 votes of
no-confidence, said Makkar, a partner and physician with Respiratory,
Critical Care, Sleep Associates (RCSA), whose contract with Summa also was
not renewed.


This decision, though made last summer, is under public scrutiny following
the ED contract negotiation breakdown. Summa maintains that these were
separate decisions.


Summa moved to an exclusive contract with its employed group but would
include others who align with the system, Malone said.


Dr. Charles Fuenning, another partner with RCSA, said the move indicates
that Summa officials wish to move to a wholly employed physician model and
don't appear to be interested in collaborating with independent physicians.


Malone disputes this, saying they'll work with any independent group that
wants to work with Summa and join its affordable care organization.


Fuenning and Makkar are investors in Western Reserve Hospital, which is
co-owned by Summa Health and Western Reserve Hospital Partners, who are in
an ongoing legal battle.


Malone said the ED decision was an unfortunate and separate situation, but
now independent docs who are shareholders at Western Reserve "are trying to
make it more disruptive than it needs to be."


Makkar and Fuenning both say they did not bring attention to their contract
issue following the ED decision and say the contract disputes are separate
from their involvement with Western Reserve.


Malone said the SEA residency program director canceled upcoming interviews
for medical students interested in next year's residency. He said they
"maliciously" attempted to impact the residency. "I've never seen this kind
of behavior from physicians before," Malone said.


Wright doesn't know who canceled the interviews, but said it would have
"probably been someone in the residency office, which would have been one of
our physicians."


Wright said SEA physicians had no way of knowing whether medical students
traveling there would have anyone to meet with.




Summa's board and department chairs have issued letters of support for the
administration's decision.


Summa and USACS say the EDs have been fully staffed since midnight on New
Year's and the wait times are back to normal, while Wright says he's heard
otherwise from former colleagues.


Gibson emphasizes that the decision was a contract dispute and had nothing
to do with quality of care. SEA physicians were high-level, board-certified
doctors that Summa would love to have back — provided they come through
USACS, which has been reaching out to physicians.


Dr. David Scott, USACS chief administrative officer, said they're in
negotiations to hire some docs back.


Summa is working with physicians to make sure they understand the decision
and feel engaged in the system's vision, Sutton said.


"We made the right decision," Malone said. "As I've gone through this again
and again, no matter how much press we get on it, the board is confident in
the new group and we're not turning back."


Dr. Eric Espinal, Summa's chief of cardiothoracic surgery, said that with
this much of an upset, it's clear that communication should have been
better. At the end of the day, the Summa administration and the physicians
want the same thing, he said.


"We want a financially viable institution, we want our nurses and the
families who depend on all of these employees to be happy and enjoy coming
to work, and we want our patients to be confident that they're well taken
care of," Espinal said. 




January 19, 2017


California’s Community Clinics, Big ACA Beneficiaries, Worry About Their



6spwhRXAG8Noom_7wXiTSBNu__1nx1TU&_hsmi=40959445> California Healthline



By Eryn Brown


Paula Wilson has seen some tough times in her 23 years as the CEO of Valley
Community Healthcare, a clinic that provides care for the poor in North
Hollywood, Calif. But nothing was quite like November 9, the day after the
U.S. elections, when walking around the office “was like coming into a
funeral,” she said.


Her staff worried that a repeal of the Affordable Care Act, long promised by
Republicans, would obliterate their jobs. Patients fretted it would
jeopardize their care.


Nearly a third of the clinic’s 25,000 patients were newcomers, many of them
recently covered through the expansion of Medi-Cal ushered in by the
Affordable Care Act. Thanks to the expansion, Valley Community Healthcare
had been growing rapidly, opening one new site, adding on to others, and
offering patients new dental and mental health services.


What would happen if this new source of financial support were taken away?


Wilson didn’t have an answer that day, and she still doesn’t. But she’s
hanging on to a cautious hope. “Pretty much that whole first week was
getting a grip and assuring people: We’ve been here 46 years and we’re not
going anywhere,” she said. “We’ve fought the fight before, and we’ll do it


In the absence of details about the impact and timing of a possible ACA
repeal, Wilson’s brand of determination is all community clinics can count
on for now.


Republicans, newly empowered by Donald Trump’s ascendance to the White
House, have made clear they plan to repeal large parts of the landmark
health care law in short order. The timing of any replacement is still
uncertain, though political pressure has been growing recently for any void
left by a repeal to be quickly filled with a new plan.  For the time being,
however, consumers are unlikely to see big changes in their health care.


Community clinics are key providers of primary care services for the poor.
CaliforniaHealth+ Advocates, which represents the state’s clinics, estimates
that they serve 6.2 million Californians — an increase of more than a
million in less than five years. Today, more than 3.5 million community
clinic patients are covered by Medi-Cal, California’s version of Medicaid,
the federal health insurance program for people with low incomes.


More than half of patients who signed up for Medi-Cal after the advent of
the ACA have gotten their primary care at community clinics, according to a
December 2015 report by the California Health Care Foundation. (California
Healthline is an editorially independent service of the California Health
Care Foundation.)


Historically supported by Democrats and Republicans alike, community clinics
worked hard to implement Obamacare reforms, and they benefited as a result.
Many, like Valley Community Healthcare, helped enroll patients and expanded
their services, taking advantage of special ACA funding that enabled them to
improve their facilities and systems of care.


The same scenario has played out nationwide at many of 1,400 federally
backed community health centers — a type of community clinic — according to
two studies published recently in the journal Health Affairs.


One of the studies, which used data from 2012 to 2015 to track visits to
community health centers, showed that in states that adopted the Medicaid
expansion, the centers saw more patient visits, including those for mental
health treatment, and lower rates of uninsured patients — a financial boon
for clinics that typically operate on thin margins.


The second study, which examined data from 2011 to 2014, found that in the
Medicaid expansion states, patients were more likely to receive asthma
treatment when it was needed, have their body mass index assessed, get pap
smears and keep their blood pressure relatively stable.


Proponents of the health reform law in California had hoped the expansion of
community clinics would provide primary care for more patients, thus
reducing expensive emergency room visits at safety-net hospitals.


“Health centers have been the poster child of positively embracing the ACA.
They’ve gone along with everything,” said Blue Shield of California
Foundation CEO Peter Long, whose organization supports the clinics. But
without clarity about where funding will come from in the future, or how
much of it there will be, it’s possible that clinics will “go into
hunker-down mode,” he added. That could mean limiting hours, reinstating
waiting lists for new patients and cutting promising new programs.


Implementing Obamacare “put a lot of stress on their systems,” Long said.
“To unwind it would be equally hard.”


Wilson and other clinic CEOs say they’re trying to anticipate worst-case
scenarios and plan accordingly, but that’s hard when Congress hasn’t
specified what changes it is planning, or when to expect them.


“Right now it’s all crystal ball gazing,” said Steven Wallace, associate
director of the UCLA Center for Health Policy Research. “‘Repeal and
replace’ is a great slogan, but ‘replace’ is really hard to figure out.”


Community clinic leaders say they’re focusing on several funding challenges.
First is a potential rollback of the ACA’s Medicaid expansion program, which
extended new coverage to about 20 million people in the U.S., including more
than 5 million in California, said Carmela Castellano-Garcia, CEO of
CaliforniaHealth+ Advocates.


Some also worry that shifting Medicaid to a block grant system, an idea
President-elect Trump has endorsed, would result in cuts to services; or
that Congress could decline to reauthorize “330 funding” — an additional $5
billion community clinics receive each year from the federal government.
That stream of federal dollars is set to expire in September of 2017.


That funding, in addition to payments from the Medi-Cal expansion, allowed
the Los Angeles Christian Health Centers to add medical, mental health,
dental and case management staff and open two new sites.


The clinic, headquartered on Skid Row in downtown Los Angeles, also launched
a fundraising campaign to revamp and enlarge its flagship facility. But CEO
Dr. Lisa Abdishoo now worries that some financial assumptions made in
planning the expansion may no longer apply after Trump takes office on
Friday. “We’re trying not to panic, but now we have to question the
sustainability of some of the growth,” she said.


Health care advocates have advised community clinics that they may need to
“look at 2009 levels” to plan for post-ACA operations, Abdishoo said. That
year, Los Angeles Christian Health Centers served 6,600 patients a year,
compared to 10,000 today.


Jane Garcia, CEO of La Clínica De La Raza, a 32-site clinic network in
Alameda, Contra Costa and Solano Counties, said her organization could lose
ground on hard-fought cost reductions if people’s insurance is taken away
and they revert to their old behavior of seeking care only when they are
very sick.


“Patients who don’t have coverage hesitate to come in and see the doctor,
and they hesitate to seek preventive care,” Garcia said. “That’s the kind of
thing that was starting to have an impact on bending the curve on cost


ACA-related grants allowed La Clínica’s health centers to improve case
management and collaborate more effectively with partners such as Sutter
Health, which also saved money by reducing the number of patients seeking
primary care in emergency rooms. La Clínica would probably have to cut such
administrative efforts were the ACA repealed, Garcia said.


Pamela Richardson, a 60-year-old patient of Valley Community Healthcare who
suffers from an iron absorption disorder called hereditary hemochromatosis,
was unable to get health insurance before Obamacare prohibited insurers from
excluding people with preexisting medical conditions. The clinic helped her
sign up for coverage through the Medi-Cal expansion.


Once Richardson was covered, she got long-delayed primary care, which
revealed that she had “scary high” blood pressure and a lump in one breast
(which proved benign). “When you don’t have insurance you don’t get breast
exams. You don’t have pap smears,” she said. “I wish people had a little
more patience with Obamacare. Once you get what’s wrong with you under
control, the cost would come down.”


Wilson, Castellano-Garcia and others said they plan to make precisely that
case — that community clinics represent a good value — once state and
federal officials begin mulling an ACA replacement in earnest.


A November 2016 study in the American Journal of Public Health showed that
Medicaid spending was 24 percent lower for patients who received a majority
of their primary care from federally qualified health centers — a type of
community clinic — than for patients who got care in other settings. The
savings extended across all services, the study’s authors reported.


In rural Shasta County, where a majority voted for Trump, one in three
people has Medi-Cal coverage. Dean Germano, CEO of Shasta Community Health
in Redding, said he has already launched conversations with staffers of
Republican U.S. Rep. Doug LaMalfa who he considers “a friend of the health


“Our mission is to make people like him realize what [repeal] will mean for
people on the ground,” Germano said. “If the system goes through a major
shock, what would happen to jobs? It would have a major impact on rural


Another clinic CEO, Kim Wyard of Northeast Valley Health Corporation in San
Fernando, said she takes heart because Congress will have to do something to
replace what it is taking away. Just blowing everything up isn’t an option,
she said.


“We need a safety net, and if more patients are uninsured, we’ll need it
more,” Wyard said. “We’re cost-effective,” she added. “Our new president
wrote ‘The Art of the Deal.’ He likes a deal. I don’t think there’s a better
deal than health centers.”




Jeff Wells
Deputy Editor, CAL/AAEM News Service


Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service

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