Lab Soft News

Johns Hopkins Pediatric Hospital in Florida Suffers Soaring Surgical Mortality Rate

The prestigious Johns Hopkins Health System acquired All Children's Hospital in St. Petersburg, Florida, in 2011 (see: All Children's Hospital Joins Johns Hopkins Medicine). This was a non-cash transaction and the first U.S. hospital outside of the Baltimore/Washington, D.C., region to become integrated with JHM. As reported recently, this move has been the source of extreme embarrassment for Johns Hopkins as reported in a recent Tampa Bay Times article (see: Top All Children’s executives resign following Times report on heart surgeries). Below is an excerpt from it:

The CEO of Johns Hopkins All Children’s Hospital and two other hospital administrators have resigned following...an investigation that found dramatic increases in the hospital’s mortality rates for heart surgeries....In a statement, the health system said All Children’s CEO Dr. Jonathan Ellen, Vice President Jackie Crain and deputy director of the hospital’s Heart Institute Dr. Jeffrey Jacobs had resigned. Dr. Paul Colombani also stepped down as chair of the department of surgery....The...mortality rate at the hospital’s Heart Institute tripled between 2015 and 2017. Last year, it was the highest of any pediatric heart surgery program in Florida.....[T]he board of Johns Hopkins Medicine, which owns and operates All Children’s,...commissioned an external review of the issues within the heart program.....The...investigation reported that four physician assistants asked for a meeting with their supervisor and Colombani in 2015 to raise concerns about the surgeries performed by Jacobs and Dr. Tom Karl. At least four other employees also raised safety concerns....In June 2016, a third surgeon who had handled many of the most complex procedures was pushed out of the program.... Jacobs and Karl began performing all of the institute’s hardest surgeries. In the next 18 months, at least 11 children died after their procedures, even as the hospital began to turn away the most difficult cases....Kevin W. Sowers,..., president of the Johns Hopkins Health System and executive vice president of Johns Hopkins Medicine, will step in and lead the hospital in a temporary capacity while a plan for interim leadership is put into place. 

One could say at this point that the Johns Hopkins strategy of acquiring a hospital outside of its home territory has been a major problem for the brand. The first idea that comes to my mind as an explanation of their problem is that "culture eats strategy," a phrase attributed to management guru Peter Drucker (see: Culture Eats Strategy For Breakfast. So What's For Lunch?). Here's a quote from this article:

...[B]oards appear to be paying only lip service to Drucker's tenet, according to a new survey by tax and accountancy firm Mazars....The study found that, despite culture being in the top three priorities for company boards, only 20% of 450 London-based directors and board members reported spending the time required to manage and improve it. Some 62% of survey respondents felt that they were primarily responsible for setting culture from the top of an organisation. However, a similar proportion (63%) either did not consider culture as part of their formal risk assessment or failed to routinely consider the risk associated with their corporate culture.

My guess is that the Johns Hopkins executives sitting in Baltimore assumed that their culture of hard work, high quality, and ethical behavior would be transmitted through the ether to their newly acquired pediatric hospital in St. Petersburg, Florida. They probably did not take the time and effort to manage and improve the local culture and are now paying the consequences for their actions in terms of a serious reputation hit. As noted above, "interim leadership" is being put into place but this will only be a temporary solution. A lot of building and damage control will be required.

Blurring of Definition of Big Medicine; Corporatization of Healthcare

Eight years ago I posted a note referring to an article in the New York Times (see: More Doctors Giving Up Private Practices) about the emergence of "Big Medicine" (see: Physician Private Practice Declines; the Last Barrier to Emergence of "Big Medicine"). In that note, Big Medicine was defined as being composed of the following organizations: (1) Big Pharma, (2) Big Payers (i.e., the U.S. government and large insurance companies); and (3) Big Providers (i.e., large consolidated regional health systems). A related concept now occurring in Big Medicine is its corporatization. As a result, physicians working in hospitals are now commonly referred to as providers and patients as customers. Here is a quote from a recent blog note that discusses the corporatization of medicine (see: Here’s what the corporatization of medicine is doing).

....[T]he “corporatization of medicine,”...[occurs when] the principles of depersonalized mass production — highly effective in retail business models — ...[are] imposed on health care systems, replacing the sacrosanct doctor-patient relationship with that of a commodity and consumer. Why is this happening? In the first three quarters of 2017, the top-five insurance companies made a record $6 billion in profit, with their executives getting handsome salaries and bonuses. The top CEOs of health care systems make seven- and eight-figure salaries. And their executives make equally large sums of money. When you receive that $25,000 ER bill, keep these exorbitant salaries in mind.

Another shift that is occurring in Big Medicine is that large retail drug companies such as CVS and Walgreens are becoming significant providers of the first tier of healthcare and Big Payers such as health insurance companies have become the employers of many thousands of physicians in competition with large health systems. In other words, there is a blurring of the originally conceived categories. I discussed this phenomenon in a recent blog note (see: OptumHealth, One of the Largest Employer of MDs, Pursues Telemedicine):

The largest employer of physicians in the country, OptumHealth is emphasizing virtual care. It is a division of the largest health insurance company in the country, UnitedHealth Group (see: Top 5 Largest Health Insurance Payers in the United States). UnitedHealth Group is also pursuing virtual care with its NowClinic subsidiary.....The third largest health insurance company in the country, Aetna, has now merged with CVS which is one of largest purveyors of walk-in primary care with its MinuteClinics (see: CVS Health and Aetna merger closes). These major health insurance companies may thus control at some point in the future a substantial portion of the first tier of healthcare as well as medical referrals associated with patients seen in their clinics.

Although I believe that value-based care needs to be substituted for fee-for-service with emphasis on outcomes of care, I believe that this goal may result in a lower quality of care in this depersonalized and increasingly corporatized healthcare environment.

Three Examples of Predictive Analytics in Clinical Practice

I have posted previous notes about predictive analytics, particularly with regard to their use in the clinical labs (see, for example: Successfully Screening for Lung Cancer Based on Predictive Analytics; Diagnostic and Predictive Analytics and Their Possible Link to the Future of the LIS). However, of at least of equal importance, will be the use of predictive analytics in hospitals to improve clinical care and reduce costs. Such projects are even more important in an era of value based case with emphasis on efficiency and effectiveness. I therefore thought that it would be useful to provide some example of projects in this area (see: 3 Examples of How Hospitals are Using Predictive Analytics). Below is an excerpt from it:

Predictive analytics is increasingly key to powering hospital initiatives that maximize efficiency, realize cost savings, and help deliver superior care....The goal is often to improve operational efficiency or to proactively provide services that prevent greater problems and spending. Many hospitals have started with applications aimed at reducing readmissions and predicting which patients are at risk of developing sepsis. Other common use cases focus on optimizing staffing and resources. Here are three other examples of hospitals successfully putting predictive analytics into action.

Operating room bottlenecks: The University of Chicago Medical Center (UCMC) used predictive analytics to tackle the problem of operating room delays. Such delays are aggravating for clinicians, patients, and families, and they are wasteful since ORs are expensive to run. But delays are hard to prevent, with so many individuals and teams working on each surgical case. When one procedure ends, there is a sequence of certain tasks that must be completed before the next surgery can start. UCMC combined real-time data with a complex-event processing algorithm to improve workflows, create notifications, and streamline the handoffs from one team to the next for each step of the OR process. The effort decreased turnover time 15% to 20% ..., which was expected to save the hospital up to $600,000 annually. The new system also increased visibility into what was causing each delay and how to intervene in real time to get things back on track.

Newborn antibiotics: Kaiser Permanente led the development of a risk calculator that has reduced the use of antibiotics in newborns. Antibiotics are necessary for a small percentage of newborns who are at risk for early onset neonatal sepsis, an infection that can lead to meningitis or death. Researchers developed a risk prediction model after drawing data from the EHRs of about 600,000 babies and their mothers....The effort safely reduced antibiotic use by nearly 50% in newborns delivered at Kaiser’s Northern California birthing centers in 2015....Kaiser makes the risk calculator available online (see: Neonatal Early-Onset Sepsis Calculator)

Care transitions after knee and hip replacement: Cleveland Clinic, feeling the pressures of fixed reimbursements and bundled payments, wanted to find ways to decrease the length of stay for patients receiving total hip and knee replacements. It focused on discharge delays. Often, these were caused by patients’ unexpected need for post-acute rehabilitation in a skilled nursing facility. Researchers used analytics to predict which patients would recover successfully at home and which ones required inpatient rehab. The goal was not to prevent a rehab stay, but rather to better prepare for it. Cleveland Clinic pulled on existing research and a validated prediction model, which drew on variables captured in the physician’s office prior to surgery. The propensity score was put into the clinical workflow so all providers could use it in their preoperative discussions with patients. The program was successful at taking into account patients’ needs, decreasing lengths of stay, driving down costs, and improving the system’s patient experience scores in the HCAPHS Care Transition measures.

I have nothing to add beyond these presenting these examples because they are highly illustrative of the ways in which predictive analytics can be used to improve care.

The "Proximity Advantage" Enjoyed by Retail, Walk-In Clinics Over Health Systems

I have posted a number of notes about some of the competitive advantages enjoyed by the Walgreens, CVS, and Walmart walk-in clinics (see, for example: Retail Drug Stores Emerging as Healthcare Hubs for First-Tier Primary Care); Doctor on Demand Expands Reach with Walmart Collaboration and Coupon for Care). They are competing, of course, with physician practices, multi-specialty clinics, and health systems for this first-tier business. A recent article described this competition as the "war for outpatients" (see: The War for Outpatients). I am not sure that this war metaphor is totally accurate because the physician/hospital side seems to be somewhat oblivious to what is happening. Nevertheless, below is an excerpt from the article :

[T]he common goal of emerging healthcare competitors [like CVS and Walgreens is] to dislodge the outpatient business from traditional hospitals and health systems. CVS and Walgreens are well positioned to battle for outpatients on the ground, each having about 10,000 stores. To put that in perspective, three-quarters of Americans live within five miles of a Walgreens, and 80 percent of Americans live within 10 miles of a CVS. Both companies are also well equipped to fight this battle via the Internet. Walgreens and CVS have 88 million and 62 million loyalty program members respectively, providing not only a trove of data, but also a digital relationship. Of course, CVS and Walgreens are not the only companies with their eyes on the hospital outpatient business. UnitedHealth/Optum has amassed more than 47,000 physicians in 35 of the company’s 75 target markets, all without owning a single hospital. Private equity firms invested more than $42 billion in healthcare services in 2017, with $12 billion and 75 deals devoted to nonhospital providers....And if Amazon decides to direct its 100 million Prime members toward an Amazon healthcare platform, the presence would dwarf that of any other competitor. These forces are after a piece of the $3 trillion healthcare business. 

This article caused me to reflect on what I will call the "proximity advantage" held by the rapidly expanding walk-in clinics in drug stores and Walmart. As noted above, CVS and Walgreens combined have about 20,000 stores in the U.S. which means that one of them will always be very close to the vast majority of American healthcare consumers. This proximity to consumers provides a distinct advantage over hospitals in the competition for primary care patients. In addition, these clinics are beginning to offer services to a broader range of patients. When it purchased Aetna, CVS announced  that it would begin to care for patients with chronic diseases, referring to a community-based care model (see: Merged CVS and Aetna Will Move Toward a Community-Based Healthcare Model). By way of comparison, large health systems are offering fewer primary care services because of the lower profit margins associated with them (see:  Walmart Health: A Deep Dive into the $WMT Corporate Strategy in Health Care). Here is a quotation from this article that discussed Walmart's strategy for its Care Clinics compared to hospitals:

Walmart’s retail strategy in health care is based on the hospital inefficiency in innovation and the business theory of bundling and unbundling services. The vast majority of hospital revenue is rooted in the fee-for-service business model ....Providers are thus incentivized to provide a high-volume, high-cost standard of care, squeezing money from insurance companies. In turn, those costs are passed down to consumers in the form of higher premiums. However, as hospital operational costs ballooned, health systems began to treat their departments like a public investment portfolio. They unbundled (divested from) low-end services that required all the same operating expenses but didn’t turn a profit.

Make up you own mind on this issue but I think that, in a few years, health systems are going to be highly dependent on CVS, Walgreens, Walmart, and UnitedHealth/Optum for patient referrals. Such referrals will begin to dry up as the health systems cut back on the number of PCP's and primary care services. I will write more about this issue in upcoming blog notes.

Questions Raised about the American Cancer Society's Corporate Partners

The EVP and CMO of the American Cancer Society has resigned, reportedly over the organization's corporate relationships (see: Cancer Society Executive Resigns Amid Upset Over Corporate Partnerships). In 2009, I posted a note stating that the American Academy of Family Physicians had received a six-figure grant from Coca-Cola and also that the American Academy of Pediatric Dentists took a $1 million payment from Coca-Cola In 2003 (see: American Academy of Family Physicians Cozies Up to Coke). Below is an excerpt from the article about the ACS:

A top official of the American Cancer Society has resigned in part because of concern over some of the organization’s fund-raising partnerships....Dr. Otis W. Brawley, an executive vice president and chief medical officer, resigned his post...after 11 years at the society. His departure was largely attributed to his dismay over some commercial partnerships, including with Herbalife International, the controversial supplements company, people close to him said. While he would not comment publicly, others said that he had become uncomfortable with the society’s growing reliance on donations from businesses with questionable health credentials that he and others suspect are seeking to burnish their images....[Such] donations and fund-raising partnerships have become more important in recent years as the organization’s fund-raising has declined. Fund-raising income has gone down every year since its peak of just over $1 billion in 2007. In 2017, donations reached only $736 million, although the society made up for some of the loss by selling properties. Critics in and outside the 105-year-old organization have also protested its recent partnerships with Long John Silver’s, a seafood chain best known for its batter-fried fish; and Tilted Kilt, a sports pub showcasing “Kilt Girls” in skimpy red plaid.

I have a personal rule of thumb about the behavior of large organizations such as the American Cancer Society that one would assume should have a laser-like focus on health promotion and cancer prevention. My rule is that the primary goal of such organizations is nearly always to protect and support their major stakeholders (i.e., executives) above the interests of constituents or followers who derive no fiduciary benefits from the organization. In the case of the ACS, the latter would be physicians and healthcare consumers. Below is some information about CEO companion at the ACS in 2010 (see: Eye-Popping Pay); it's probably much higher this year.

The head of the American Cancer Society since 1992, John Seffrin made $1.3 million in total compensation and benefits in fiscal 2009. His payout in fiscal 2010 was boosted to $2.2 million. This puts him at #2 on CharityWatch's list of Top 25 Compensation Packages. According to the Society's 2010 tax filing Seffrin was paid $1.5 million for a supplemental SERP. SERP is usually an acronym for "supplemental executive retirement plan." So this begs the question: Why is Seffrin receiving a retirement payout before he's retired? Greg Donaldson, the Society's VP of Corporate Communications, told CharityWatch that the $1.5 million was a retention benefit rather than a retirement benefit that was approved by the Society's compensation committee in 2001 to "preserve management stability" and for "succession planning."

Here's what you need to consider regarding the mission of the ACS. First, does the ACS provide meritorious services regarding cancer eduction and care. Your answer is probably yes. Secondly, in order to provide such services, is it logical and appropriate for the ACS to pay its executives multi-million dollar salaries and then have the pressing need to accept donations from organizations like Herbalife, fast food restaurants, and sports pubs to maintain their budget. Keep in mind that such organizations will use the ACS logo in their marketing materials which could theoretically promote unhealthy behavior.

Reducing Healthcare Costs with Virtual Visits; Tangible Evidence Provided

I have suggested in the past notes that deploying virtual visits (telemedicine) in a health system can reduce costs but did not provide any tangible evidence to support the idea (see: Telemedicine Used in New Healthcare Settings Like Coaching). However, in a recent webinar, executives from Spectrum Health make the point that deploying virtual visits does result in substantial savings for the health system; they also provide concrete evidence for this assertion (see: Spectrum Health Uses Site-to-Site Telehealth Consults to Avoid Transfers and Reduce Costs).

Spectrum is a large health system operating in central Michigan with a patient catchment area extending hundred of miles to the north. Spectrum executives have learned that substantial savings are realized by treating patients in their home communities via telemedicne visits rather than forcing them to travel to the major hospital of the system in Grand Rapids. Incidentally and obviously, savings are also incurred by the patents who participate because they don't need to pay the costs of a long overnight trip. In the webinar, the savings realized are demonstrated.

Emphasis was placed in the webinar on virtual visits for "specialty" care by which is meant medical specialties like wound care and sleep disorders. During a patient visit with a PCP, a tele-consultation is initiated in areas such as these. The virtual visit is supported with a telecart provided by AmericanWell. The very interesting point was also made during the webinar that specialists have been more accepting and enthusiastic about telemedicine than primary care providers (PCPs) at Spectrum Health because the specialists are accustomed to being conferred with during a primary care encounter. Virtual care is thus an effective and efficient way to deploy specialty care in smaller community hospital or physicians' offices that are part of a multi-hospital group (see: Telehealth tips, torn from the playbook of Intermountain's massive virtual hospital).

Doctor on Demand Expands Reach with Walmart Collaboration and Coupon for Care

I continue to be interested in what is happening with first-tier (i.e., primary) healthcare. It's being shaken up by retail drug store, walk-in clinics like MinuteClinic, urgent care centers, and virtual care. With for-profit companies now deeply embedded in the mix, aggressive marketing of services is being introduced and now a coupon is being used to attract customers to virtual care. Details were provided in as recent article (see: Doctor on Demand expands through Walmart collaboration) with an excerpt below:

Walmart and the parent company of Mucinex are partnering with Doctor On Demand, a virtual care provider headquartered in California that has spread nationwide and is steadily expanding....RB, the English-based health and hygiene company, announced that consumers who purchase their products Mucinex, Airborne or Digestive Advantage at Walmart stores or through walmart.com would receive a limited-time offer for a medical video visit with a Doctor on Demand physician at no cost. Doctor on Demand already has a number of direct contracts with large employers including Walmart, Wells Fargo, Comcast, American and United Airlines. Employees at these companies are able to use Doctor on Demand services.

Virtual care is a big part of the future of healthcare. It is not replacing face-to-face physician visits, but represents a less expensive, more convenient consumer care experience, exactly the direction the healthcare industry has been told to head. In-office visits are more expensive and time-consuming, Doctor on Demand said. Plus, 30 percent of adults don't have a primary care physician. The Centers for Medicare and Medicaid Services and private health plans are increasingly reimbursing providers for telehealth. Doctor on Demand works with national health plans such as UnitedHealthcare and Humana and others, which pay less for the virtual services than in-patient care. Medicare will begin allowing monitoring from homes starting in 2020 and other changes are coming that will further open up the business.

It's also interesting that Walmart may be taking a hard look at the virtual services provided by Doctor of Demand with this coupon offer. Walmart itself is pursuing a novel market strategy around the unbundling and consumerization of healthcare distinct from that of Amazon and CVS Caremark (see: Walmart Health: A Deep Dive into the $WMT Corporate Strategy in Health Care). Walmart has developed a primary care network within its stores called Walmart Care Clinics. I suspect the company may also be trying to decide whether to introduce virtual care services into its clinics for more complex cases by contracting with Doctors on Demand. In the above cited article, the Walmart strategy was explained in the following way:

Walmart’s retail strategy in health care is based on the hospital inefficiency in innovation and the business theory of bundling and unbundling services. The vast majority of hospital revenue is rooted in the fee-for-service business model: rather than make money for improving health ..., providers are paid more for the number of services provided ....Providers are thus incentivized to provide a high-volume, high-cost standard of care, squeezing money from insurance companies. In turn, those costs are passed down to consumers in the form of higher premiums. However, as hospital operational costs ballooned, health systems began to treat their departments like a public investment portfolio. They unbundled (divested from) low-end services that required all the same operating expenses but didn’t turn a profit.

Health System Transfers Its Pharmacies to Walgreens; Manages Regional Retail Clinics

One interesting aspect of the emergence of retail clinics in drug stores is the business model being used by these companies for staffing these clinics with medical personnel. CVS staffs its MinuteClinics with nurse practitioners (NPs) who, incidentally, have an average hourly pay of $52. Staffing clinics with NPs rather than physicians obviously places limits on the type of patients who can be treated in the there. Another model, being pursued by Walgreens, is to select a regional healthcare provider to manage and staff the clinics. The details of such an arrangement were provided by a recent article (see: MCLAREN HEALTH CARE SEES NEW WALGREENS CLINICS AS ITS FRONT DOOR). Below is an excerpt from the article:

McLaren Health Care...inked a deal...with Walgreens to hand over 14 of its pharmacy locations to the national chain and open a still-undetermined number of McLaren retail clinics inside Walgreens stores. Intertwining their operations gives Walgreens an opportunity to expand its partnerships with prominent local and regional health systems as its competitors vie for market dominance through mergers and acquisitions, and it gives McLaren a chance to deepen ties to the communities it serves. This possible deepening of ties with consumers is forefront in the minds of McLaren's leaders as they begin the process of selecting the number and locations of retail clinics to be opened in the near term, says Barton P. Buxton, EdD, president and CEO of the McLaren Health Management Group."If we do what we call a 'global gateway' offering, we want to make sure we can care for that patient to whatever end they need care," Buxton tells HealthLeaders. "So making sure that we have our locations in such a place that they match the clinical offerings is important."

If a walk-in retail clinic provides only low-acuity services such as vaccinations and routine physicals, there is little need for a patient referral strategy to a local hospital for more complex care. Two years ago, I discussed the Walgreens strategy of leasing clinic space to local providers in the states of Oregon and Washington (see: Two Models for Hospital Integration of Walk-In Drug Store Clinics). The Walgreens deal with McLaren Health Care is another example of this strategy with the added twist that McLaren is getting out of the pharmacy business by transferring 14 of its pharmacies to Walgreens as part of the arrangement. If some or all of the these walk-in clinics are staffed by physicians, they will probably operate closer to urgent care centers than MinuteClinics. I have blogged extensively about urgent care centers (see: Rapid Growth of Urgent Care Clinics; Cost Competition for Hospital ERs; Another Type of Urgent Care Facility Flourishing for Orthopedic Problems). I have also previously blogged about Beaumont entering the urgent care business in partnership with Atlanta-based WellStreet Urgent Care. (see: Beaumont Health System Launches Multiple Urgent Care Centers in Metro Detroit). 

I was struck of the insight of the McLaren CEO suggesting that their strategy was to pursue "global gateways," which is to say "install" front doors for their health system in Walgreens drug stores. The other interesting aspect of this news is that both McLaren and Walgreens are leading with their particular expertise, healthcare delivery and retail drug in that order. Time will tell whether CVS/MinuteClinic will succeed by exercising total control over their walk-in clinics. This may limit their ability to provide care to patients with more complex medical problems. Moreover, if they do need physician input for some patients, they can always outsource such services to a company specializing in virtual care employing physicians.

Life Insurance Company, John Hancock, Embraces Wellness with Success

Both health and life insurance companies have discovered how wellness programs can be used to attract and reward policyholders who pursue a healthy lifestyle (see: Wearable Health Monitoring Devices: a Means to Lower Insurance Costs?; Apple Watch "Gifted" to Insurance Policy Holders; Any Gotcha's with the Deal?). John Hancock is moving in this same direction as described in a recent article (see: John Hancock wants to turn life insurance into a wellness game). Below is an excerpt from it:

The financial services company [John Hancock] said Wednesday that it will attach a free version of its wellness program, Vitality, to all life insurance policies. Through the program, customers can log fitness and health information with the company in exchange for discounts at places like Amazon and REI. For an extra $2 per month, customers receive a free Fitbit or an Apple Watch for $25. If they hit certain targets, they don't have to pay more for the devices and can receive up to 15% off annual premiums. The insurer says that the wellness program is changing the way people think about its products.....John Hancock hopes that encouraging and rewarding healthy behavior will help customers live longer. The company can then make more money investing premiums while deferring the payment of claims. In the meantime, it gets a trove of data on policyholders, while deepening its relationship with clients. The information John Hancock collects could make it easier to direct life insurance customers toward other company products, such as retirement plans.....John Hancock....first partnered with Vitality, a wellness firm, in 2015. Since then, about 40% of customers have opted to add Vitality to their life insurance policies....Vitality users check in an average 40 times per month, according to Tingle. They have the opportunity to sync their wearable devices, or can go into an app to log workouts, doctor visits and meditation sessions. 

A couple of points jumped out at me in this article. The first is that 40% of John Hancock clients opted to participate in the company's wellness program with tracking via a wearable like Fitbit or Apple Watch. This group logs on to the Vitality web site an average of 40 times per month. I understand that the John Hancock clients undoubtedly comprise a skewed sample of the U.S. population -- they are relatively affluent and risk averse. However, such a high level of participation in the wellness program suggests that the company has found a sweet spot to encourage health monitoring and a healthy lifestyle for its customers. The second point is that John Hancock is harvesting useful health data which will allow it to provide additional benefits and rewards in the future to customers.

I was also struck by the increasing starkness of the division between the "haves" and the "have-nots" in this country from a health perspective. The Trump administration continues to try to scrap the Obamacare program which has provided basic health insurance coverage for lower wage earners. Meanwhile, the more affluent segment of our population is participating in programs that encourage wellness, thus widening the health gap with the less fortunate (see: U.S. one of world's worst on health divide between rich, poor).

Beaumont Health System Launches Multiple Urgent Care Centers in Metro Detroit

I have posted a number of previous notes about the growth of walk-in clinics located in retail drug stores (see: Details about CVS' MinuteClinic POCT Strategy; Details about CVS' MinuteClinic POCT Strategy) and also urgent care centers (see: Rapid Growth of Urgent Care Clinics; Cost Competition for Hospital ERs; Another Type of Urgent Care Facility Flourishing for Orthopedic Problems). I have also commented how hospital ER bills can mushroom by the addition of facility and out-of-network fees, often a surprise to patients (see: CMS Requires Hospitals to Post Prices for Medicare Patients; Useful Step?). As a result, walk-ins and urgent care centers are becoming very important as part of the first tier of healthcare delivery. Some health systems are beginning to fight back. A recent article discussed how Beaumont Health plans to open dozens of urgent care centers in the metro Detroit (see: Beaumont to invest $30M in dozens of urgent care centers). Below is an excerpt from the article:

Beaumont Health said...that it plans to invest about $30 million in urgent care centers in Metro Detroit by the end of 2019. The Royal Oak-based health care system is partnering with Atlanta-based WellStreet Urgent Care to jointly operate 30 Beaumont Urgent Care facilities. ....Beaumont executives said the new centers come in response to patients and employers requesting trusted and convenient access to health care at lower costs...." According to Beaumont, about 40 percent of urgent care patients do not have a primary care physician. The urgent care centers would be able to connect those patients with physicians in Beaumont's network and set up appointments there. Additionally, at least 30 percent of emergency room visits could be treated by urgent care centers, which would save on health-care costs...."Patients as consumers are looking for on-demand access points to health care," ...[a Beaumont spokesperson] said.....The centers will be meant to service patients with coughs, sore throats, skin irritations, mild intestinal illnesses and fevers as well as minor lacerations and orthopedic injuries. Providers will be able to access a patient's Beaumont electronic medical record for coordinated care. Unlike many urgent care centers, those in the Beaumont network will have an X-ray and lab on premise for less complicated diagnostics.

I was wondering how long it would take for the large health systems to fight back against the estimated 7,100 urgent care centers (2016) in the U.S. with their own branded facilities (see: 7 statistics on urgent care centers, EDs & retail clinics). At least one of them, Beaumont Health, has gotten the message. It's partnering with Wellstreet Urgent Care which owns urgent care enters in the Atlanta area, Piedmont Urgent Care. It's interesting that Beaumont has chosen to partner with a company already active in the urgent care business. Beaumont executives may feel the need to tap into the expertise of their partner in this new endeavor.