Category: MHA Rounds

MHA CEO Report — Preserving Patient Access to Care

MHA Rounds

“For every complex problem, there is an answer that is clear, simple and wrong.”  – H.L. Mencken

Nurses are the heart and soul of our healthcare ecosystem. They were heroes long before the COVID-19 pandemic, they stepped up in extraordinary ways during the darkest days of that chapter in our history and they remain heroes today. Anyone who has spent time as a patient – or the family member of a patient – knows how impactful nurses can be, and how they truly become the face of our healthcare experience. In short, they deserve our admiration and support.

Our Michigan hospitals are proud to employ more than 62,000 nurses and the reality is that we are desperately trying to hire thousands more in every corner of the state. In terms of the supply of nurses, Michigan is confronting the same dynamics as the rest of the country. First, the significant number of baby boomers reaching senior status in recent years has translated to a growing exodus of nurses to normal retirement, while the unprecedented stress of the pandemic and its aftermath led many more to leave the field earlier than planned. As we engage with our leaders throughout the state, there is no question that the day-to-day work of our nurses has never been more challenging, and the rise in self-reported burnout rates is real and palpable.

On the first day of graduate school, one of my professors said something that I have subsequently heard many times throughout my career, and it is unequivocally true: “healthcare is not rocket science…. it’s much more complex than that.” This complexity is not limited to the incredible science behind our medical diagnoses and interventions, but extends to the organization and financing of that care as well. In practical terms, what this means is that absolutely nothing in healthcare happens in a vacuum – every potential lever to be pulled in the operational or public policy realm is impacted by a complex set of interwoven realities.

A case in point: recently-introduced state legislation (Senate Bills 334–336 and House Bills 4550–4552) would create mandatory minimum nurse-to-patient staffing ratios for Michigan hospitals. On the surface, such a mandate would seemingly ensure that we will have more nurses on the hospital floor, simultaneously alleviating their stress and creating better, safer care for patients. I would like to explain why this clear and simple proposal is flat out wrong.

Every single day in every single Michigan hospital, nursing leaders determine appropriate staffing levels in the emergency department, the labor and delivery unit, and in every other corner of the facility. These decisions take into account a complex set of variables, including the volume and acuity level of patients in house at that time, the training level and experience of not only the nurses, but all other members of the care delivery team, the various technologies that may or may not be available for deployment, and a wealth of in-house data and metrics that are updated multiple times per day. Seasoned nurse leaders have developed a good sense of the unique dynamics in a given community and in a given hospital, and they use their long experience to ensure the safest possible staffing models accordingly.

Here is the bottom line: even if there was a robust, immediately available supply of nurses to meet the proposed minimum staffing ratio mandate (there is objectively not), and even if there was an unlimited supply of available funding to pay for this new staffing (there is objectively not), there is simply no way on earth that it makes sense to replace the expert judgment of nurse leaders at the local level with a one-size-fits-all, inflexible model developed by politicians in Lansing. 

There is a good reason why the Michigan Organization of Nurse Leaders (MONL) is adamantly opposed to this legislation, and good reason why many nurse leaders I have spoken with in recent months have said they are personally offended by the premise behind it. Such a mandate would create an untenable situation for hospitals when a patient shows up and the facility is already at the mandated ratio: willingly ignore the law and risk penalties, fines and reputational damage, or follow the law and essentially tell the prospective patient “There is no room at the inn” and send them down the road. Of course, the hospital down the road will be in precisely the same boat. Without question, more hospitals will go on diversion, more hospitals will temporarily or permanently take beds offline, and more hospitals will make the difficult decision to eliminate entire service lines. In other words, the real losers here are patients and communities, who will lose access to care. This will be a reality in every corner of the state, and particularly alarming as we consider winters in rural Michigan and the distance between providers. Access reductions will become very serious, very quickly.

In public policy and politics, it is often instructive to examine other states that have already implemented a policy that is under consideration. To that end, California was the first state to adopt legislatively mandated nurse staffing ratios, some two decades ago. According to data from the Bureau of Labor Statistics, Michigan has a greater number of nurses per capita today than California. Despite having staffing ratios, California continues to have a shortage of 40,000 RNs, demonstrating they are suffering from the same problem as all other states in the country and the presence of legislatively mandated staffing ratios has done virtually nothing to improve the size of the workforce. Meanwhile, Michigan outperforms California in hospital quality, as Michigan has both a higher percentage of 4- and 5-star hospitals than California (49% to 35.3%) and a lower percentage of 1- and 2-star hospitals (18.4% to 38.7%), according to CMS Care Compare Hospital Overall Star Ratings.

Legislation similar to what is now being proposed here in Michigan was recently defeated in Minnesota, after the leadership of every single hospital in the state raised grave concerns about the severe negative consequences of its passage. The Mayo Clinic – world-renowned for its quality of care – publicly threatened to withdraw billions of dollars in planned investment in the state should the bill be adopted. The fact that an organization of their reputation and credibility felt so strongly about the negative ramifications of this concept should be a major red flag for policymakers in all states.

The mission of the MHA is to advance the health of individuals and communities. When we see public policy proposals that jeopardize our ability to achieve this mission, no matter how well-intended, we will do everything in our power to stand strong, to stand united and tell our story to our elected officials. Healthcare is complex, and Michiganders deserve better than ham-handed mandates coming from Lansing.

As always, I welcome your thoughts.

MHA CEO Report — Added Association Value

MHA Rounds

“It takes 20 years to build a reputation and five minutes to ruin it. If you think about that, you’ll do things differently.” – Warren Buffet

The healthcare industry is a vital cornerstone of any community, providing essential medical services to people in times of need – not to mention our role as economic engines. Behind the scenes, there’s a complex network of organizations and associations dedicated to supporting healthcare providers and ensuring their success. Among these is the Michigan Health & Hospital Association (MHA), the leading advocate for hospitals and health systems throughout the state of Michigan.

While most people recognize the MHA’s visible and impactful role in the public policy arena, many are unaware of the comprehensive business services we also provide to our member organizations. Housed within our MHA Service Corporation, these services not only help hospitals and health systems to achieve their missions of providing high quality, cost-effective care to their communities, but they also generate revenue for our association – which in turn allows us to moderate the need for membership dues increases over the years.

Our business services include in-house offerings and carefully vetted and selected partnerships. All services have been curated to give hospitals and healthcare providers robust solutions and options. Examples of services available to hospitals and other providers include the MHA’s data services, unemployment compensation program, a robust endorsed business partner program and graphic design and print services.

The MHA first began work to develop a data bank in 1975, establishing our association as a credible resource for industry data. Data-driven decision-making is essential for healthcare organizations to deliver high-quality services efficiently. More than 500 healthcare entities nationwide now use MHA data products for a variety of purposes, including strategy development, community benefit tracking and improving safety and quality of care. By harnessing the power of data, hospitals and health systems can enhance patient outcomes, optimize workflows and ultimately reduce costs.

Our unemployment compensation program has an even longer history, having existed since 1972. Much like data services, it not only serves existing MHA members in Michigan, but nationally. Collectively, it processes thousands of unemployment claims for over 700 clients every year, saving clients millions of dollars annually. By participating in this program, member organizations can navigate the complexities of unemployment compensation more effectively, saving valuable time and resources. I’m pleased to share the program was once again recognized by the National Association of State Workforce Agencies (NASWA) for the program’s commitment to utilizing the NASWA’s nationwide, web-based system for receiving new claims and responding to state unemployment agencies.

The MHA Graphic Design & Print Services division offers specialized print services, as we recognized the need to offer our members cost-effective printing solutions. The healthcare industry has a constant need for marketing materials, patient information brochures and administrative documents. This program has grown and now offers services for many organizations even outside of healthcare.

Our association has also expanded our ability to connect our member hospitals and health systems to companies that offer products and services tailored to the healthcare industry. Within the MHA Endorsed Business Partner Program, we rigorously review each potential company before endorsing a partner to ensure that they provide quality and valuable services to our membership. The MHA has the opportunity to be a liaison between our members and endorsed business partners, leveraging our events and relationships to make the right connections at the right time.

As you can see, our commitment to supporting hospitals and health systems goes well beyond advocacy and policy. By offering diverse business services, we empower healthcare organizations to thrive in an ever-evolving industry. These additional services complement our existing efforts to improve the health and wellness of individuals and communities. Together, these initiatives contribute to the enhancement of healthcare excellence in Michigan, ensuring that the state’s healthcare providers can deliver the best possible care to their patients.

I can tell you that over the years, I have heard from countless clients of our various business services, who consistently praise the outstanding customer service and value-added work provided by our exceptional team. From my perspective, our success can be largely attributed to a commitment to build genuine, trusting relationships for the long haul.  And we will not allow those relationships – or our reputation – to be compromised in any way. If you are affiliated with a healthcare-related organization (and perhaps even if not), I would strongly encourage you to reach out and explore our ability to serve you and see this difference first-hand.

As always, I welcome your thoughts.

MHA CEO Report — The Story of the MHA Program Year

MHA Rounds

“Plans are only good intentions unless they immediately degenerate into hard work.”— Peter Drucker

The theme of the 2022-2023 MHA program year was telling our story. With focus and passion, we told the stories of our hospitals and health systems, the challenges and adversity they face, and how they still provide high quality and accessible healthcare to their communities. This theme was intended to ensure that we as healthcare leaders continue to help those who don’t live and breathe healthcare understand the ways we are working to meet the most pressing needs, but also the support we need from other sectors to continue to offer strong and daily access to care for all. Our theme served to frame the four distinct pillars of our association strategic action plan, which included the financial sustainability of hospitals, workforce restoration and well-being, the behavioral health crisis and continued efforts towards achieving health equity.

I’m pleased to share we made significant progress in telling our story and achieving tangible, impactful results under each of the four strategic pillars, which is summarized in the latest MHA Annual Report. This work evolved around the ending of the COVID-19 public health emergency, a pandemic that tried our member organizations, and especially their healthcare workers, like nothing has before in most of our lifetimes. A large part of our success in making this transition and achieving so many significant outcomes was due to the MHA Board of Trustees, who I want to thank for their strong leadership and commitment to advancing the health of individuals and communities. I particularly want to express my gratitude to our outgoing Chair, T. Anthony Denton, for his steadfast leadership throughout this year.

Key to our efforts to safeguard the financial viability of hospitals is our continued focus on the state budget. Not only were we successful in continuing existing supplemental payment pools such as for Disproportionate Share Hospitals, Graduate Medical Education, Rural Access and Obstetrical Stabilization, but we also secured a Medicaid outpatient hospital rate increase. Collectively, these victories generated hundreds of millions in funding for Michigan hospitals. Long a priority of our association, the MHA also successfully advocated to ensure the Healthy Michigan Plan (our Medicaid expansion program) is fully funded. Our advocacy team continues to be one of the most respected in Lansing, as we saw several MHA-supported bills signed into law while experiencing a 100% success rate in making sure none of the 10 bills we opposed became statute.

Each of the four pillars are equally important to our membership, but it is hard to overstate just how important workforce restoration and well-being is to our healthcare leaders. This is the issue that keeps each of them up at night, whether it is finding new staff or protecting and retaining their existing workers. Our advocacy efforts secured an additional $75 million in funding to support the hospital workforce while also securing $56 million in funding to support partnerships to offer Bachelor of Science in Nursing programs at community colleges. We also continue to advocate for increased penalties for those who verbally or physically harm healthcare workers, providing them with protections they deserve as front-line caregivers, much like emergency responders receive. The MHA Keystone Center has been active in offering well-being resources, trainings, safety and security risk assessments and other offerings, continuing their long history as a leader in safety and quality not just here in Michigan, but nationally and internationally. Lastly, we recently launched a statewide healthcare career awareness campaign to entice students to pursue health career pathways.

Our work on behavioral health continues, as there remains a need to expand the number of behavioral health professionals and facilities to provide better access to care. The MHA secured both $50 million in the fiscal year 2023 state budget for expanding pediatric inpatient capacity, while adding an additional $10 million to create Psychiatric Residential Treatment Facilities to alleviate state hospital capacity issues. Much of the feedback we have received is the need to add quantitative data to the conversation to demonstrate to lawmakers and stakeholders the degree of the crisis. For several months, our team has been collecting data weekly on the number of patients waiting for a behavioral health bed in Michigan hospitals. This demonstrates the degree to which patients are having difficulty finding care, while also showing how many patients are utilizing hospital resources while the facility receives no reimbursement due to not having an acute care diagnosis billing code.

Lastly, we will not rest as our members continue to address health disparities to ensure health equity. The MHA Keystone Center works closely with the Michigan Alliance for Innovation on Maternal Health (MI AIM) to help address disparities and reduce the risk of maternal death. This past program year, their efforts resulted in 77% of Michigan birthing hospitals participating in MI AIM, 94% of which are compliant with the pre-partum assessment and 89% are compliant with the post-partum assessment. Our work with the MHA Public Health Task Force also continues as they explore strategies for collaboration that can improve data collection and public health initiatives.

Of course, there are always other items that come up that require MHA attention and effort that are not always known during the development of the strategic action plan. Responding to the shortages of chemotherapy drugs cisplatin and carboplatin and working with Michigan’s Congressional delegation is just one example of the value of association membership and how quickly we can mobilize our relationships in a time of crisis. Other wildcards include our work on licensing Rural Emergency Hospitals, tracking and increasing awareness of candida auris infections and expanding hospital bed capacity.

As we concluded our program year during our Annual Meeting on Mackinac Island, we were able to honor a true healthcare champion with our Meritorious Service Award in U.S. Sen. Debbie Stabenow. She announced earlier this year she will not seek an additional term in office and this award is the highest honor our association can bestow on an individual for their years of work towards enabling the health and wellness of individuals and communities. We have worked closely with Sen. Stabenow from her time in elected office in the Michigan Legislature to Congress and she will leave an extraordinary legacy for which the MHA family will be eternally grateful. We also had an opportunity to honor a number of other outstanding individuals for their contributions to Michigan healthcare.

Above all else, I want to take this opportunity to thank all MHA staff for their many contributions which made it another successful program year. The challenges we confront in healthcare are daunting and constantly evolving, but my confidence in our team at the MHA has never wavered, as they continue to display their exceptional commitment to their work and embody the MHA culture of member service and value creation every single day.

Now as we formally begin our 2023-24 program year on July 1, I am excited for the leadership of our new Chair Shannon Striebich. We offer our congratulations to her and look forward to working closely together. A year from now, I am confident we will once again be able to report on the successful outcomes we were able to achieve through our unity, collaboration and plain old fashioned hard work.

As always, I welcome your thoughts.

MHA CEO Report — Impact of Drug Shortages on Hospitals

MHA Rounds

“In the midst of every crisis, lies great opportunity.” — Albert Einstein

The shortage of key cancer treatment drugs carboplatin and cisplatin made national headlines in recent weeks, as hospitals implemented multiple strategies to maintain care for their patients when supply of these two drugs was remarkably low to nonexistent. While this shortage deservedly caught the attention of the nation, hospitals must navigate dozens to hundreds of drug shortages every day. This shortage is a worst-case example of how inefficiencies in the pharmaceutical supply chain can have devasting impacts on patient care.

Unfortunately, hospitals far too often must manage short supply of drugs, seek alternative sources for drugs, adjust treatment regimens and collaborate with other health systems to maximize supply. Hospitals throughout the state used all these tactics to respond to the recent crisis.

I’m proud the MHA was able to quickly raise the flag on this issue to our lawmakers as soon as we became aware of it. U.S. Senator Gary Peters (D-Bloomfield Twp.) chairs the Senate Committee on Homeland Security & Governmental Affairs and has prioritized drug shortages as a national security concern. His report from March 2023 shares a wealth of information on the subject, including all the problems associated with drug shortages and recommended solutions. His committee has been a key partner in providing accurate information about the shortage to Michigan hospitals.

In addition, U.S. Representatives Debbie Dingell (D-Ann Arbor) and Tim Walberg (R-Tipton) led Michigan’s US House delegation in sending a bipartisan letter May 24 to Food and Drug Administration (FDA) Commissioner Dr. Robert Califf to take immediate action to mitigate the effects of the nationwide shortage. I’m happy to share every member of our House delegation signed on to the letter, showing the health of our hospitals, patients and communities is truly a bipartisan issue.

Our work will continue on this issue far after the supply of these two drugs stabilizes, as the MHA supports several strategies that will address drug shortages. The first is relaxing prior authorization requirements from health insurers for alternative therapies during a shortage so they can be used widely. Federally, we believe establishing an early warning system will help avoid or minimize drug shortages so both manufacturers and providers have more time to respond to an upcoming shortage. Healthcare providers also welcome improved communication from the FDA and drug manufacturers, as there is often little to no transparency on the cause of a drug shortage. Lastly, changing the economic model to encourage drug manufacturers to stay in, re-enter or initially enter the market would be beneficial to all stakeholders. Many shortages occur with generic drugs due to a limited number of drug manufacturers.

In addition to the public policy arena, it is noteworthy that hospitals across the country – including several of our MHA members – helped to launch Civica, an entity that is helping to increase the production and availability of key generic drugs.  While not directly applicable to the current cancer drug shortage at this time, this effort is an example of the field looking to the future and doing all we can to ensure appropriate healthcare access to patients.

Finally, I’d like to lift up the MHA’s response to this crisis as a great example of the value of an association. Since we represent all acute care community hospitals in Michigan, we’re able to speak with a unified voice. The MHA has the relationships and institutional knowledge to quickly convene ad hoc groups in times of crisis to gather knowledge on the subject and what needs to be done, and then can execute and utilize our long-standing partnerships with lawmakers, both at the state and federal levels, to generate necessary awareness and action. By looking at national headlines, Michigan has been a leader in the shortage of carboplatin and cisplatin. That’s a testament to the health of our association and the culture we have helped to establish, whereby safety and quality engender collaboration and not competition within our hospital and health system membership.

As always, I welcome your thoughts.

MHA CEO Report — Attracting Healthcare Talent

MHA Rounds

“Individual commitment to a group effort – that is what makes a team work, a company work, a society work, a civilization work.” — Vince Lombardi

Talent acquisition is always top of mind for all business leaders. Demand for workers now outpaces supply throughout the U.S., but particularly here in Michigan due to our demographic realities, including an aging baby-boom generation entering retirement in significant numbers. A recent presentation by Michigan Senate Fiscal Agency Chief Economist David Zin summarizes these challenges, as Michigan has the eleventh highest median age in the country, a metric which has been increasing rapidly in recent years.

This challenge is clearly felt by Michigan hospitals and health systems, as many retirement decisions made by healthcare workers accelerated during and because of the pandemic. The use of contract agencies for nurses exploded while hospitals also reduced the number of staffed beds in their facilities due to worker shortages. The financial repercussions of these shortages had Michigan hospitals spending more than $1 billion more on contract labor and recruitment and retention expenses in 2022 than in 2020, according to a MHA workforce report.

Although current staffing levels have stabilized somewhat in the state, the demand remains high. According to a March 2023 survey of 95% of the MHA membership, there were over 27,000 job openings in Michigan hospitals, including nearly 8,500 open nursing positions.

While the number of open positions may be surprising, healthcare is historically the largest private-sector employer in Michigan. The next iteration of the Economic Impact of Healthcare in Michigan report publishes May 2, which demonstrates the massive role healthcare plays in the state. Michigan healthcare organizations provided nearly 568,000 direct healthcare jobs in fiscal year 2021, with Michigan hospitals providing roughly 219,000 – or nearly 40% – of those jobs. Once wages, salaries and benefits and tax revenue are factored in, healthcare contributes nearly $100 billion to the state’s economy each year.

The value that our hospitals provide to the health and wellness of a community is obvious and is reason enough to warrant our strong support. But in addition, the magnitude to which our Michigan economy depends on healthcare can easily be overlooked. Hospitals are often the largest employer in their respective communities and serve as critical lynchpins of economic vibrancy. This is why it is so important for hospitals to engage with business and policy leaders to ensure alignment across the state in our efforts to attract and retain talent.

Healthcare careers are not only stable and well compensated, but also provide a set of transferrable skills which rarely become obsolete. We recognize that healthcare careers, particularly clinical positions, can be stressful and emotionally draining. We can’t sugarcoat the challenges associated with caring for all types of patients in organizations that operate 24/7/365.

But the MHA is here to help. In an effort to support the emotional well-being of healthcare workers, in 2021 the MHA Keystone Center launched a partnership with the Duke Center for Healthcare Safety and Quality team led by Bryan Sexton, PhD. More than 5,000 clinical and non-clinical staff from 144 organizations joined in the first 10-week Well-being Essentials for Learning Life-Balance cohort, and our work here is ongoing. We are also advocating for policy change at the state and federal level that would increase the penalties for those who commit acts of violence against our caregivers.

Through our successful advocacy work, the Michigan Legislature appropriated $75 million in funding for the recruitment, retention and training of hospital workers in Public Act 5 of 2023. This funding supplements an earlier $225 million appropriation made in Public Act 9 of 2022 and has played a large part in minimizing further losses to the healthcare workforce. The MHA was named as the fiduciary for both of these funding pools – evidence of the strong bipartisan trust in our association.

Allowing clinicians to work at the top of their license and removing administrative work is another tactic that can help attract healthcare talent. Enacting policy change that reduces rates of healthcare worker violence and expands access to behavioral health treatment are others. The work of the MHA and our members is to make sure healthcare workers have all the tools available to do their work improving and saving lives without unnecessary mandates and other interference that contributes to the challenges healthcare professionals experience.

These workforce challenges and the need for more workers also illustrates the need for local control for hospitals to determine staffing models that best represent the needs of their patients and communities. A one-size-fits-all approach doesn’t work when comparing a rural critical access hospital to an urban Level I trauma center. Successful staffing models incorporate input and feedback from nursing teams and the unique needs of the local community.

There are also a variety of other approaches the MHA and our partners at the American Hospital Association are advocating for to attract healthcare talent. This ranges from increased investment in nursing schools, nurse faculty salaries and hospital training time; enacting protections for healthcare workers against violence and intimidation; supporting apprenticeship programs for nursing assistants; and supporting expedition of visas for foreign-trained nurses.

There is no silver bullet that will fix workforce shortages. The current issue facing hospitals, as well as many other industries, is the reality that the available supply of workers simply doesn’t meet the demand. Michigan continues to be aggressive in efforts to attract businesses to the state. We must recognize our state is in competition with others for a finite amount of available healthcare workers.

Yet things can be done to grow the pie and attract more students into the healthcare talent pipeline. For example, the MHA will be focused this summer on raising awareness about the variety of jobs and career pathways that exist within health systems, and encouraging future and existing workers to consider a career in healthcare where they can truly change lives, whether they’re at the bedside or behind a computer screen.

Healthcare is the ultimate team sport, with the utmost objective – saving lives, and preserving the health and welfare of people. I hope you will join us in this endeavor and invite as many people as you can to the party.

As always, I welcome your thoughts.

MHA CEO Report — A Healthy Michigan is an Insured Michigan

MHA Rounds

“Life is what happens while you are busy making other plans.” — John Lennon

The United States celebrated last month the 13th anniversary of the signing of the Affordable Care Act (ACA). Simply put, when then-President Obama signed the legislation March 23, 2010, it was one of the most monumental healthcare policy changes in our lifetime. Since its passage, it has provided millions of Americans with health insurance, provided access to care for millions of residents with preexisting conditions and incentivized the launch of innovative models of care that have improved patients’ lives and saved billions of healthcare dollars.

The MHA was pleased to celebrate the anniversary by having MHA Executive Vice President Laura Appel join U.S. Rep. Elissa Slotkin and others in a virtual press conference discussing the positive impact the ACA has had on Michiganders.

The mission of the MHA is to “advance the health of individuals and communities.”  We have long supported the ACA, as the availability of robust health insurance coverage is crucial to achieving this mission. The benefits of the ACA can be measured by the more than one million Michiganders now covered by our Medicaid expansion program – the Healthy Michigan Plan – and more than 320,000 Michiganders who now receive coverage through the Health Insurance Marketplace created simultaneously by the act. Combined, these new developments have helped to significantly reduce the number of uninsured individuals in Michigan, which consistently numbered well over one million people in the years prior to the ACA’s passage.

The history of health insurance coverage in America is interesting and complex, and there were two major turning points in the 20th century that preceded the ACA. First, to combat inflation amid World War II, Congress passed the 1942 Stabilization Act. Designed to limit the ability to raise wages, the act led employers to instead offer health benefits for the very first time. Because health benefits did not count as income, they were not taxable to the employees. With a flip of the proverbial switch, employers were in the health insurance business and have never looked back. Second, in 1965 then-President Lyndon B. Johnson signed into law the enabling legislation to create the Medicare and Medicaid programs, which have provided coverage to important populations including seniors, those with disabilities, low-income and more.

Today the majority of Michiganders – over six million – are covered by employer-sponsored private insurance. But both Medicare and Medicaid have grown, accounting for approximately two million enrollees in each program respectively.  This growth is driven by different factors: for Medicare, we obviously have an aging population, increasingly fueled by the baby-boom generation. And for Medicaid, we have seen both organic growth in the traditional program, as well as significant growth in the Medicaid expansion program.

Whether public or private, we celebrate health insurance coverage because it directly benefits people, as they are more likely to see a primary care practitioner, seek recommended tests and screenings, receive appropriate prenatal care and generally access a wide array of healthcare services in such a way that their issues can be identified and resolved as early as possible. Not only does this mean better outcomes, but it also saves healthcare costs in the long run. And of course, having insurance coverage provides financial peace of mind for families when an unanticipated serious illness or catastrophic injury occurs.

The truth is that better insurance coverage is a positive for hospitals as well, as it helps to reduce the amount of uncompensated care that we must absorb. However, simply having an insurance card is no guarantee that an individual will have the appropriate level of coverage, as the rise in high-deductible and “skinny” insurance plans still result in significant and growing out-of-pocket expenses for consumers. These plans in turn have created more bad debt and uncompensated care for hospitals because consumers often purchase these plans based strictly on price without full knowledge of their co-pays, deductibles, which providers are considered in-network and what care may not be covered at all. On this note, the subject of surprise medical bills has been in the spotlight in recent years, culminating with the implementation of the federal No Surprises Act in January 2022. There is no doubt hospitals own our share of this issue – and we are committed to doing all we can to improve. But as a wise health policy observer commented to me at the time, the situation for far too many Americans can be summarized as “surprise, your health insurance stinks.” The total unpaid costs of patient care for Michigan hospitals in 2020 exceeded $3.4 billion, and the anecdotal evidence points to this challenge continuing ever since.

Back to the public policy front, one key issue on our radar screen now is the pending expiration of the COVID-19 public health emergency (PHE). Michigan has an additional 355,000 residents enrolled in traditional Medicaid and 367,000 additional Healthy Michigan Plan enrollees since the PHE began, and many of them will be at risk of losing coverage when the PHE ends and the Medicaid “redetermination” process begins.

In many Michigan counties, more than 30% of the population uses Medicaid for its healthcare benefit. The goal of the MHA and our partner stakeholder groups is to work with the Michigan Department of Health and Human Services (MDHHS) to ensure as many people as possible either maintain their Medicaid coverage or transition to an appropriate plan on the insurance exchange if they do not now have employer-sponsored coverage. This will continue to ensure that community members avoid interruptions in their care and will allow us to maintain many of the health outcome gains achieved over the past 13 years.

The MDHHS has created tools and resources for providers and partners aimed at educating their patients about the need to ensure their contact information is updated so they properly process their redetermination paperwork. The MHA has worked closely with our member hospitals and health systems to share these resources. This may be the first time for many beneficiaries that they must renew their coverage, and some may not even be aware they’re on Medicaid. Hospitals are the main touchpoint for many beneficiaries and hence play a very significant role in helping to facilitate this process for vulnerable patients.

The ACA, like any other major public policy change, has been far from perfect. But reflecting on the success in providing coverage to more Michiganders, we must express our gratitude for those at both the federal and state levels for the gains we’ve made over the past 13 years. In Michigan, we’ve received bipartisan support over the years for expanded coverage. Despite all the challenges hospitals and health systems have experienced in recent years, the gains made from the ACA have been a big reason why Michigan hospitals can continue to serve their communities throughout all areas of the state.

And on the broader issue of health insurance coverage, we would be remiss if we did not acknowledge that insurance is only one element that contributes to – but does not on its own ensure – access to care. Our efforts in the health equity domain have shown clearly that language and cultural barriers, transportation, housing, food insecurity and many other factors contribute to the ability of many Michiganders to get the care they need. But at the end of the day, having insurance is a critically important first step. No one plans to get sick or injured – but when “life” happens, that coverage is nothing short of a blessing.

As always, I welcome your thoughts.

MHA CEO Report — The Challenges for Rural Hospitals

MHA Rounds

“The country is lyric, the town dramatic. When mingled, they make the perfect musical drama” — Henry Wadsworth Longfellow

Having just returned from the annual American Hospital Association (AHA) Rural Health Care Leadership Conference, where I was joined by a strong contingent of MHA members and staff, the future of our rural hospitals has been top of mind.

When I was in graduate school at the University of Michigan many years ago, I recall clearly our discussions related to rural health. In short, we were taught that rural America was statistically older, poorer and sicker than the rest of the country – and this demographic and socioeconomic reality led to all kinds of challenges for those responsible for the health of rural populations and the viability of rural hospitals.

Fast forward to the most recent (2020) census and this dynamic remains true. In addition, we discovered that between 2010 and 2020, rural America actually lost population for the first time in history. Here in Michigan, the latest projections indicate that while the total state population will grow moderately over the next 20 years, the population in rural Michigan will remain flat or even decrease.

The operating environment has never been more difficult for healthcare organizations, for reasons we have documented at length in prior CEO Reports. This statement is particularly true for rural hospitals – 100 of which from across the country have actually closed since 2005. Many more have had to make the difficult decision to terminate service lines or otherwise scale back their operations to keep their doors open. What is driving these challenges?  A few items come immediately to mind:

  • An older and poorer population translates into a higher percentage of government payors (Medicare and Medicaid), which traditionally do not fully cover the true cost of care.
  • The traditional volume-based reimbursement model that has been one of the cornerstones of American healthcare does not serve rural providers – which often lack sufficient volume – particularly well. The pitfalls of the volume-based model were on full display during the worst days of the COVID-19 pandemic, particularly when non-emergent procedures were suspended.
  • Recruiting physicians today most often involves recruiting a spouse as well; in other words, there must be a good job match for both parties to spur a relocation. Physician recruitment is more difficult in rural communities for the simple fact that there are fewer potential jobs for that spouse. In addition, the on-call coverage demands can be particularly significant in rural areas, because the number of available rotating on-call clinicians is simply fewer. I would be remiss if I didn’t mention the Merritt Hawkins firm, which is one of our original MHA Service Corporation Endorsed Business Partners, and is dedicated to working with our members to create solutions to some of the most vexing challenges of the day.
  • Lastly, it is no secret the country is in the middle of a behavioral health crisis, with a lack of available placements leading to behavioral health patients boarding in emergency departments throughout the state, awaiting placement in a more appropriate setting. Hospitals are experiencing higher costs caring for these patients, increasing security to protect other patients and staff, while receiving little to no reimbursement since these patients have yet to be admitted to an inpatient psychiatric unit. This lack of access is even worse in rural areas. For example, the Upper Peninsula only has one licensed child psychiatrist for the entire region.

The reality is that when we think about rural Michigan and the more densely populated areas of the state, we are all inextricably linked. There is no “us and them.” People from the big city travel every day to rural communities for conferences and events, meetings, sales calls, deliveries, vacations and visits with friends and family (and people from rural communities come to the big city for the same reasons). While we want to ensure the vibrancy of a hospital in a rural community so that the residents have access to quality healthcare, we should all want the same thing, because we never know when we might be on one of those sales calls or vacations and need that same access. This is not just theoretical, as I have countless stories about this phenomenon playing out in real life, and I suspect you do as well.

Moreover, hospitals are one of the largest – if not the largest – employers in many rural Michigan communities, playing a crucial role in the economic vibrancy of the state. Healthcare careers provide stable, good paying jobs and positively impact lives every day. Not only are hospitals important for access to care, but also as economic drivers. 121,000 total workers are associated with the healthcare sector in rural Michigan, including 81,000 direct jobs. These direct healthcare workers received $7.6 billion in total wages, salaries and benefits and contributed $1.4 billion in local, state and federal taxes. In addition, the existence of a hospital nearby is one very important item for businesses of all kinds when considering investment in a new factory, office or headquarters.

So, the vibrancy of our rural hospitals should be a priority. What is the MHA doing about it? As it turns out, we have done a lot. Beyond our advocacy on the traditional Medicaid and Medicare budgets, certificate of need, medical liability, workforce funding and many, many other public policy issues that affect all our members, here are just a few of our rural advocacy highlights:

  • We fought hard to secure passage of the Healthy Michigan Plan (our Medicaid expansion program) and have advocated for full funding in every budget cycle since. For the reasons cited above, this is particularly impactful for our rural hospitals.
  • We worked to pass, implement and protect the Critical Access Hospital program, which has created an important lifeline for 37 Michigan hospitals. And the MHA was successful in changing existing statue at the end of 2022 to make adoption of the new Rural Emergency Hospital designation possible for our members.
  • We have worked very hard to protect the 340B drug pricing program, which is vital to many rural hospitals and their ability to provide access to care to all in their communities. Our work includes advocacy with both the state legislature and Congress, and even in the federal courts, where the MHA has filed amicus curiae briefs related to recent 340B cases.
  • The MHA successfully advocated for two new supplemental Medicaid payment pools that specifically benefit our rural members with implementation of the rural access pool in fiscal year (FY) 2012 and the obstetrical stabilization fund in FY 2015. Our advocacy efforts were also successful in securing Medicaid outpatient rate increases in FY 2020, the first increase in two decades, followed by an additional increase in FY 2021. These increases resulted in a 63% increase for critical access hospitals and a 21% increase for all other hospitals compared to Jan. 1, 2020, rates.
  • We successfully advocated for an extension of both the Medicare-dependent Hospital and Low-volume Adjustment programs during the 2022 Congressional lame-duck session, which provide critical support to many rural hospitals.
  • Finally, we have successfully advocated for passage and implementation of state legislation that modernizes the scope of practice for certified registered nurse anesthetists and allows flexibility for each hospital to choose the anesthesia care model that best fits its location, staffing and resources to offer safe and effective patient care.

Our advocacy is also focused on ensuring our members can tell their story and connect with lawmakers, both at the state and federal levels. The MHA hosted its first ever Rural Advocacy Day last September in Lansing to facilitate conversation between rural hospital leaders and members of the Michigan Legislature. The MHA also accompanied members in February for the National Rural Health Association’s Rural Health Policy Institute event. MHA members met with Michigan’s congressional delegation and staff during the trip to discuss rural health issues facing Michigan hospitals. And if you haven’t yet had the opportunity to listen to the Rural Health Rising podcasts, I encourage you to tune in to our friend JJ Hodshire, the CEO of Hillsdale Hospital and an MHA Board member, as he does a fantastic job shining a light on a wide range of rural health issues – with an impressive set of special guests – in real time.

Successful advocacy and storytelling require teamwork. As mentioned above, for years we have partnered closely with the AHA and the National Rural Health Association. We have also enjoyed a close partnership with the Michigan Center for Rural Health (MCRH), and I am pleased to share Hunter Nostrant, CEO of Helen Newberry Joy Hospital, is a member of both the MHA Board of Trustees as well as the MCRH Board.

The mission of the MHA is to advance the health of individuals and communities, and in that context, we have always strived to represent all our members and communities. Each hospital is vital to the health of our great state. While the path forward may be difficult, I’m encouraged by the many rural hospital leaders – some of the nicest, and most talented people that I have met – that have developed innovative and strategic ways to address these challenges and position themselves to be able to care for their communities for years to come.

As always, I welcome your thoughts.

MHA CEO Report — Medical Liability and Denney Damages

MHA Rounds

“I have gained this by philosophy; I do without being ordered what some are constrained to do by their fear of the law.” ― Aristotle

In last month’s CEO Report, we focused on the new political environment in Lansing, with a host of first-time lawmakers taking office, Democrats assuming majority control of both chambers of the legislature and a host of new leaders in key roles. The playing field has changed in a palpable way.

As healthcare leaders, the list of emerging challenges may seem endless today, ranging from unprecedented labor shortages, inflation, cybersecurity and much more. But as the new legislative session ramps up, we also can’t turn a blind eye toward issues from years past which have the potential to rear their ugly head once again. Medical liability is at the top of that list and merits our close attention.

One of the MHA’s signature achievements over the past thirty years was the passage of sweeping medical liability reforms in the early 1990s. Our leadership and collaboration with our friends in organized medicine and other partners helped to directly address a situation that had become untenable for Michigan: runaway verdicts in medical liability cases were threatening the financial viability of hospital-based service lines (and even entire hospitals). Doctors, particularly those in high-risk specialties, were leaving the state in droves and our recruitment efforts faced an extraordinarily high hurdle.

Since the passage of our reforms, which brought reason and predictability to the system, medical liability has been relatively stable for nearly three decades, even as the caps on noneconomic damages continued to grow with inflation. And over the years, the MHA has been extremely vigilant, advocating to preserve these reforms both in the legislative arena and in the courts, where we have filed countless amicus curiae briefs on behalf of our members and the healthcare field. However, a recent decision by the Michigan Supreme Court is bringing these concerns back to the forefront of our minds.

The case of Estate of Langell v McLaren Port Huron, heard by the Michigan Supreme Court in 2022, ultimately affirmed a Court of Appeals decision that a plaintiff’s estate can recover all earning potential that a decedent would have been able to earn and provide if a person who died due to medical malpractice had lived. This is now the law, even if that person was not responsible for the support of anyone else. The Court of Appeals cited the precedent established in Denney v Kent Road Commission. Since that decision, what a decedent’s estate can recover is referred to as “Denney damages.” Cases that once settled for $250,000 are now expected to be resolved for $700,000.

With “Denney damages,” the liability for healthcare organizations increase as earnings can be counted for any victim of medical malpractice, even those who have yet to establish any known talents, educational attainments or trainings typically used to calculate such earnings.

It is important to note that while we engage on this topic in the public policy arena, our ultimate priority is the safety and wellbeing of patients. Our hospitals and providers take the life of each patient in their care extremely seriously and there is nothing a hospital wants to avoid more than a medical error. To that end, we have “put our money where our mouth is” by establishing the MHA Keystone Center, which has become a true leader in this space, both in Michigan and nationally. The Keystone Center, which also operates a federally certified Patient Safety Organization, collects and analyzes data on medical errors and “near-misses,” serving as a North Star in our collective efforts to improve patient safety and quality. Our successes have been well-documented in peer-reviewed medical journals. Blue Cross Blue Shield of Michigan has provided significant funding to the MHA Keystone Center over the years, and so has the federal government through a series of contracts, as they have seen and valued the tangible improvements we have made and will continue to make.

Back to the issue at hand: our hospitals and providers are committed to doing right by patients, through the provision of the highest quality care possible. And for nearly three decades, Michigan’s medical liability laws have proven our system can fairly handle cases of medical malpractice that compensate patients and families fairly while maintaining hospital liability at sustainable levels that do not threaten the viability of an organization due to a single error. The system works and it is our intention to keep it that way.

As always, I welcome your thoughts.

MHA CEO Report — New Control in Lansing

MHA Rounds

“I don’t like that man. I must get to know him better.” ― Abraham Lincoln

As I put the proverbial pen to paper, the Michigan Legislature has completed the 2021-2022 legislative session and I am very pleased to report that in the lame-duck session, we successfully advanced several MHA-supported bills – and not a single MHA-opposed bill was signed into law. Another job extremely well done by our MHA Advocacy team as we protect access to affordable, high-quality healthcare for all.

Now shifting to the New Year: 2023 will usher in a monumental shift in power in Lansing as Democrats will control all aspects of government in the state for the first time during my 32-year tenure at the MHA. Following last November’s election results, Democrats not only retain power in all areas of the executive branch and a majority in the judicial, but both chambers of the legislative branch flipped to Democratic control. The last time Democrats had control of the Governor’s office and both chambers of the state legislature was 1984.

This change was due to a multitude of factors, including redistricting, ballot proposals, a trickle-down impact from the top of the ballot, candidate viability and record turnout. Earlier this year, the Michigan Independent Citizens Redistricting Commission established new district maps, which had previously been handled by the majority party in the state legislature in conjunction with the governor. Michigan saw a significant increase in the number of competitive districts due to their nonpartisan work. The Michigan midterm election saw record turnout again, with 4.5 million votes cast, including 1.8 million absentee ballots. This is a 2.4% increase from the prior record set in 2018 with 4.3 million votes. Turnout was partially driven by three ballot proposals as well as over 14,000 same day voter registrations, primarily from young Gen Z voters.

The MHA has a long history of being nonpartisan, but moving from divided government to one-party control will always bring about a change in the political dynamics and associated priorities. Our advocacy culture has long been to establish and maintain relationships regardless of leadership role or party affiliation so that in times of need, you have allies you can rely on. Both new Speaker of the House Joe Tate (D-Detroit) and Senate Majority Leader Winnie Brinks (D-Grand Rapids) have established track-records of working closely with the healthcare community to help us fulfill our mission of advancing the health and wellness of individuals and communities. Our MHA Advocacy team as well as our member hospitals and health systems consider them friends. And of course, our close partnership and personal friendships with Gov. Whitmer extend back to her time in the state legislature when she was recognized with an MHA Special Recognition Award at the 2014 MHA Annual Meeting. Our bonds with the governor and her administration grew even stronger as we confronted the COVID-19 pandemic together.

As a result of term limits, the new legislative session will also welcome an astounding 59 first-time legislators to Lansing. Since the Nov. 8 election, we have been busy establishing new relationships and introducing ourselves to many new faces. Most lawmakers only know healthcare through the prism of a consumer, so it is never too early to begin the education process related to this highly complex field. As part of this process, we hosted the Building Bridges event with our partners at the Small Business Association of Michigan, the Michigan Education Association, Michigan Association for Justice and Business Leaders for Michigan that helped us pursue these goals while also offering new legislators the opportunity to connect with their peers and learn how best to serve in Lansing.

Now I have no magic crystal ball so I can not predict what types of legislation we may see introduced and prioritized over the coming months. Having not held a dual-chamber majority for nearly 40 years, we anticipate there is no shortage of issues for Democrats to work on. There is no question we will continue to express the importance of access to care, which Democrats have traditionally strongly supported. Based on public comments and prior legislative track records, it is reasonable to expect continued activity on improving behavioral health, public health, health equity and addressing pharmaceutical pricing. American Rescue Plan Act funds also remain available and we strongly believe these funds should be appropriated quickly to make a difference in addressing the financial and staffing challenges that our member hospitals throughout the state, regardless of size, are experiencing. Those are positives. In reality, we need to also be prepared to address legislative proposals that we find more concerning – such as nurse to patient staffing ratio mandates which sound good in theory but would be impractical if not impossible to implement in practice.

The truth of the matter is that the Democrat majority is very slim, so we expect Republicans will still play an impactful role in healthcare funding and policy development. We certainly appreciate the work they’ve done for hospitals and healthcare over recent years and look forward to continuing those relationships during the new session.

I hope all our elected officials who will take office in January will reflect on the wise words of Abraham Lincoln above and include among their New Year’s resolutions to pause, set aside whatever preconceived notions they may have about the people across the aisle from them and make an earnest effort to truly get to know them. Will this guarantee that we come together and see eye-to-eye on all the issues? Of course not.  But hopefully, such an approach will lead to more civility in the political process and better public policy for all Michiganders.

The bottom line: 2023 presents new challenges and opportunities for all who work in Lansing. While many of the players in town may have changed, the playbook for successful advocacy has not. On behalf of our member hospitals, I’d like to express my gratitude for those finishing their years of service, congratulate all those who will be serving in office this upcoming year and look forward to working together to achieving a healthier Michigan.

As always, I welcome your thoughts.

MHA CEO Report — Pediatric Capacity Crisis

Member News, MHA Rounds

“Every child begins the world again.” ― Henry David Thoreau

In all of my life experiences to date, none have been so challenging in every sense as those times when my young children were hospitalized in the NICU, fighting for their very lives. We were incredibly fortunate to have positive outcomes with both of them, thanks to the efforts of our Michigan hospitals and the incredible people who work there every day.

I share this perspective because there is a crisis throughout Michigan that truly hits home with me. I know the angst and exhaustion being felt by far too many parents right now – emotions that are also being acutely felt by our heroic caregivers. In short, it feels like déjà vu in Michigan’s children’s hospitals, but instead of a surge of COVID-19 patients stressing capacity to the limits, our facilities are strained by a high number of pediatric patients suffering from respiratory illnesses largely driven by RSV. Similar tactics that have been implemented in prior years, such as initiating incident command systems, have been in operation to ensure appropriate direction and communication is occurring throughout those systems impacted by this crisis.

Hospitals operating at capacity is nothing new and the staffing challenges that continue to result in Michigan operating with 1,700 fewer staffed beds than we had prior to the pandemic are well documented. What we’re seeing today is the real impact of what those staffing challenges mean: longer wait times in the emergency department, lack of available beds for patient transports (particularly in rural Michigan) and pediatric ICUs operating at beyond 100% capacity.

There are few professionals in the world that have proven to be more resilient than healthcare workers, whether they are physicians, nurses, respiratory therapists, environmental service workers…the list goes on and on (and I am proud to say that the MHA Keystone Center has played an important role with the launch of our WELL-B initiative that continues to provide resiliency tools for our clinicians and other team members). But as residents of our communities, we can no longer take our healthcare workers and the access to care they provide for granted. These workers, and their organizations, need help.

Thankfully, the Michigan Legislature provided funding earlier this year through Public Act 9 to improve the recruitment, retention and training of healthcare workers. So far, over 69,000 healthcare workers have benefitted from that funding and it has helped to stabilize existing staffing levels. Hospitals are also exploring innovative ways to grow the talent pipeline, such as investment in higher education partnerships and other apprenticeships. However, while impactful, this funding is a finger in the dyke. Without additional attention, the problem will persist.

Addressing the strain on our children’s hospitals is a multi-pronged approach, and in addition to the aforementioned work of our MHA Keystone Center, we are also deriving input and guidance from our MHA Council on Children’s Health, led by Laura Appel, executive vice president for government relations and public affairs, as well as our system chief medical officer (CMO) group, led by our own CMO Gary Roth, DO.

While the MHA will continue to pursue legislative and regulatory solutions to the staffing crisis, there are actions anyone can undertake to help our healthcare workers caring for very sick children across Michigan, particularly as COVID-19, RSV and the flu converge to drive hospitalizations.

First and foremost, ensure that both you and your children are up to date on all the relevant vaccinations that are now readily available. The MHA is a long-time supporter of I Vaccinate which is a good source of information on vaccines, and our MHA Senior Vice President of Public Affairs and Communications Ruthanne Sudderth continues to be our point person with this organization. Second, practice proper hygiene, including handwashing and staying home when sick. Third, seek the appropriate setting for care; visit the hospital for emergencies but contact your primary care physician or an urgent care facility for testing or care for mild symptoms. Lastly – and very importantly – be sure to express some grace and appreciation for any healthcare worker you meet. As we approach the winter and holiday season, they are here to provide exceptional care to all who need it and deserve to be treated with respect both on and off duty.

If you have not done so already, please join me in sharing this messaging within your networks. Our hospitals need the support from our partners in healthcare, the business community and in Lansing and Washington, DC to weather this storm. Respiratory illnesses will always be here, but there are many small actions we can take to care for the health and wellness of our communities well into the future.

As always, I welcome your thoughts.