Go through these two studies and write a three to five page analysis of the two healthcare facilities you have conducted the research.

In this concluding section of the paper, explain how the situations may be similar or how they are different. Things you want to compare can include but not limited to reimbursement, quality and availability of care, government regulations and how changes in healthcare system such as the Affordable Care Act (ACA) will impact healthcare management in the near future.

CASE STUDY #1: WESTCHESTER MEDICAL CENTER

INTERVIEW W/: Nurse manager from the ICU’s units

How does financing and reimbursement affect delivery of care?

There is a huge impact of the financing and reimbursement on the quality of the care delivered to the patients having some kind of insurance or the health policy. The financial and reimbursement status is taken as the regulator of the type of the care delivered to the patients in the healthcare system. Financial and reimbursement policies greatly affect the quality of the delivery of the care.

How does reimbursement differ in the delivery of outpatient vs inpatient care?

Yes, reimbursement differs in the delivery of the outpatient vs inpatient care. In case of the outpatient department the patient takes the prescription provided by the physician and has the medicine from the reliable source hence have minimum impact of the reimbursement policies on the other hand in case of in-patient care the patient is admitted in the hospital. He/she may be advised for the plenty of the diagnostic pathological tests, there is included the bed charges and other ambulatory services. Hence in case of the inpatient care there is huge impact of the reimbursement.

How do Managed Care and Integrated Systems impact the cost, access, and quality of health care delivery?

The managed care and integrated systems highly impact the cost access and quality of the healthcare delivery by utilizing the systematic plans regarding the delivery of the healthcare using the special provisions regarding the individual patient.

These evidence based practices are highly effective in reducing cost of care, along with maintaining the proper access of the care with the high quality concerns.

How has Legislative Health Policy impacted the delivery of care?

The legislative Health Policy had a great impact on the delivery of care as it governs the healthcare and insurance policies. There are various health policy reforms which have a direct impact on the quality of the care. These regulations are ensuring the good healthcare delivery to the population. Hence there is need to reform these healthcare policies time to time.

What is the future of health services delivery?

As per the future concerns of the health care service delivery, there is need to have a concern of the cost effectiveness and inclusion of novel health care technologies in the healthcare organizations. On the basis of these systematic concerns we can assure an effective health care delivery for the welfare of the mankind.

CASE STUDY #2: MONTEFIORE HOSPITAL

INTERVIEW W/: CEO Montefiore

How does financing and reimbursement affect delivery of care?

Health insurance affect health care delivery in the US that it makes providers less aware of the actual cost of health care it creates provider induced demand, this financing greatly influences how much health care is delivered.

How does reimbursement differ in the delivery of outpatient vs inpatient care?

Reimbursement varies most significantly by insurance company, more insurance companies do reimburse inpatient and outpatient serves very differently, but some smaller insurance companies may reimburse according to simple criteria, Medicare inpatient prospective payment system reimburses a weighted fee schedule of rates by diagnosis related group based upon the average cost of cost across the mations providers for that particular set of health issues, and Medicare outpatient reimbursement fits into one of two scenarios that is clinic( a freestanding primary ) and hospital( procedures performed wither at the hospital or at a clinic located within 35 miles of the hospital that own and operate the clinic) there reimbursed accordingly to the ambulatory payment classification.

How do Managed Care and Integrated Systems impact the cost, access, and quality of health care delivery?

Managed care and integrated systems has positive impact on the cost and access and quality of health care delivery.

My opinion:

How has Legislative Health Policy impacted the delivery of care?

Legislative health policy impacted the delivery of care: the health care delivery system continue to evolve by the market forces, and as do legal and regulatory changes resulting from health reform legislation.

What is the future of health services delivery?

The future of health service delivery: insurances drop individual plans because they do not comply with some of the mandates and employers cope by reducing worker hours and negotiating new health plans and the US healthcare system will continue to evolve but no one knows the destiny. The human services framework can barely be known as a framework. Or maybe it is a confounding cluster of exceedingly decentralized areas. Span of doctor bunches is growing, 37.12 percent of rehearsing doctors are still in solo or two man hones. The wellbeing design segment is getting some distance from structures that can encourage combination and coordination, with the piece of the overall industry of wellbeing upkeep associations falling and favored supplier associations. Furthermore, healing center division has been merging in numerous business sectors of the 5,000 network doctor's facilities, in excess of 3,500 have a place with some system or framework a large portion of these courses of action are centered on managerial instead of clinical joining.

Revenue Recognition - Percentage of Completion - Project Instructions, Spring 2018

One of your clients is a large regional construction company. The company has many long-term projects in the works. The spreadsheet you are given contains some information about these jobs. Some of the jobs began last year and continue into the current year, so they exist on both tabs. The projects are in various phases of construction; some of which were completed during the current year.

You've been asked by your firm to analyze the data and prepare the following:

1) Complete the revenue recognition process by adding the necessary calculations into the blank columns F-J and L-M on the Current Year and Prior Year tabs and populate the data for all rows. It is expected that you look back at the text for definitions and to remind yourself of the percentage of completion method prior to asking questions.

Current year:

Prior Yr:

Read and study all the material and the Case Study: American Investment Management Services in Week 9 before beginning the final exam. “Exhibits” are found in that Case. Then answer the following questions about the Case Study: American Investment Management Services:

#3. Noting that excess capacity is charged back to active accounts, if AIMS scaled back to 3,000,000 active households and planned only a 10% excess capacity reserve for future growth, a large proportion of cost could be eliminated. Estimate how much of total cost for 1999 could be eliminated, based on facts presented in the case.

American Investment Management Services (AIMS)

Kim Davis, Executive Vice President ofAIMS, sat in her 43rdfloor corner office overlooking the Manhattan skyline, reflecting on the challenges facing the investment services business in 2000. Profits had come easily during the longest economic expansion ofthe century. However, signs ofweakness in the economy,

financial market volatility, intense competition for high net worth customers, and the proliferationofcomplex technology-dependent products were all making her life much more complicated AIMS had recently invested in new analytic tools to help think more strategically about its operations and customers. Kim wondered how much the new analytic approach would really impact business decision-making. Was intensive customer segment analysis a real opportunity orjust another "shot in the dark?"

AIMS is one of the larger investment services providers in the U.S., approaching $500 billion in assets in 2000. Ofthis total, a little more than halfwas in mutual funds and the balance in brokerage accounts. This case deals with customer profitability assessment for AIMS' 3.9 million households, up from 1.8 million in just four years. Until I999, AIMS had no system for measuring the profitability of any specific customer.

SEGMENT A TION

AIMS spanned two separate and very different product lines (mutual funds and full-line brokerage services), but that was only one element of the complexity it faced. In addition to this product complexity, it also spanned three distinct "distribution channels" (Call Centers, Full Service Branches, and E-business), and a complex array of customers with diverse asset holdings, trading patterns, investment objectives and service requirements. There was no particularly sharp focus on what kind of households to add. The basic idea was high wealth, but that was not pushed exclusively at all. Basically, AIMS wanted to do business with the same 2 million American households (over $1 million in invested assets) that 2 I other major financial services firms were pursuing.

In I999, AIMS introduced segment analysis, starting with a four-way segmentation that mixed three different dimensions: asset holdings, trading activity and age (as a proxy for investment objectives). The first segment was any household with more than $500,000 in assets under management at AIMS ("High Net Worth," or "HNW''). Failing this test, the second segment was households trading more than 36 times in I998 ("Active Traders," or "AT"). Failing this test as well, the third segment was households where the principal customer was already retirement age (60 years old). Finally, customers failing all three of these tests comprised the fourth segment-all other, termed "Core" customers. "Core," with more than 70% of all households, was the largest segment.

The primary role of any segmentation is to facilitate analysis leading to management actions tailored to the specific needs of defined customer subgroups. No particular segmentation is ever beyond dispute. Whatever approach is chosen necessarily emphasizes some distinctions and de­ emphasizes others. But, the AIMS segmentation was particularly contentious on two grounds: I) it segmented current customers rather than a market. It is as if Procter & Gamble were to segment the detergent market based on how many pounds of Tide are purchased; 2) the sequence specific classification scheme meant that labels could be misleading: for example, the segment Active Trader applies only to households which are not each HNW. And, "Retiree" applied only to households which were not each HNW or AT.

2

AIMS

FINANCIAL RESULTS

As shown in Exhibit I, AIMS did quite well in 1999. Net margin afteJ tax was about $156 million on an underlying equity investment of about $625 million. But, 1999 represented the height of the prolonged bull market. The year 2000 was projected to be much less bullish, and most Wall Street observers envisioned the next few years to be much less rosy than the previous ten.

Even in 1999, performance was not consistent across all the customer segments. Pre-tax margin ranged from a high of48% for HNW, to only 6% for Retirees and minus 4% for Core.

The revenue breakdown across segments in Exhibit I is based on actual identification with individual customers. The expense breakdown starts with an annual "unit cost" study that uses "Activity-Based Costing" (ABC) principles. The study first assigned all operating costs from the General Ledger to specific processes or "activities." Then, the activity costs were divided by throughput measures for each activity, to create "cost per unit of activity" for each sub-stage of each process. This process is illustrated in Exhibit 2 for estimated costs for 2000. Individual unit costs were then multiplied by throughput totals for each segment and aggregated to provide total expenses per segment as shown in Exhibit I, a report format which was new at AIMS in 1999.

THE, CUSTOMER/PRODUCT PROFITABILITY INITIA TIVE

As a management report, Exhibit I was too aggregated to identify actionable issues. In 2000, AIMS undertook a project to take customer/product profitability reporting down to the individual household level to provide more useable, timely, and integrated information for decision­ making. The new system combined unit costs from the annual ABC study with current actual household activity and attributes (e.g., products held, services used, number of trades, number of rep-assisted phone calls) extracted from the Marketing Database to generate profitability by household. The data then were exported into easily queried online analytical processing (OLAP) "cubes." OLAP cubes allow profitability analysis of the intersections among customer attributes, product/service attributes, and channels ofdistribution.

Exhibit 2, which illustrates the first step in this n.ew .system (unit costs across processes), is highly s1mpltfied for purposes of the case. As shown, a "driver" was chosen to proxy the activity in each process­ telephone calls as the driver of activity in the Call Center, for example. Next, a count was made of the total estimated units of the activity for 2000 for each driver­ 7~.l million calls for the Call Center, for example. Fmally, the total cost for the process was divided by the total activity count to calculate cost per unit of activity for that process.

Some ofthe assignments ofcosts to activities and some of the activity measures are "soft," but the activity costs tagged to individual households based on actual household activity are conceptually plausible and at least directionally correct. Similarly, product-specific and service-specific revenues are driven down to a household level. Household profitability calculations are thus based on actual asset holdings, fee-based services consumed and activity usage. The actual system in use allows for 11 categories o f customer revenue and 70 categories o f process cost.

Conceptually, Exhibit 2 represents "long-run average cost" for each activity. It does not attempt to portray marginal or incremental cost because it is not intended for use in short-run cost-volume-profit (CVP) analyses. Since very little cost at AIMS is variable with short-run volume fluctuations anyway, short-run CVP analysis is really just based on revenue changes.

Almost all costs are "step costs" which go up (or down), in chunks as capacity is added to (or deleted from) the system. In a business as fast-growing as AIMS has been in recent years, capacity is typically being added every year in many places across the process value chain ahead o f usage requirements. Thus, there is almost always excess capacity in the system. And, the extent of excess capacity varies across processes, depending on where growth has been fastest and where recent expansions have been made. The analysis in Exhibit 2 divides current cost by current throughput to calculate unit cost. The analysis thus charges any excess capacity to the current users of the process. This is debatable, conceptually, but is not recognized as a practical problem at AIMS.

The expense base grew substantially faster than throughput volume between 1995 and 1999 in anticipation of even greater future growth. In 1995, ~here was about 10% excess capacity (on average) in the operating expense base. Capacity grew at a compound rate of about 26% from 1995 to 1999, versus households growth at about 21%. As a result, excess capacity in 1999 was a much larger percentage of the expense base, across branches, the call center, on-line activity, transactions processing and account maintenance activity. Kim wondered how much of operating capacity was devoted to unprofitable customers.

THE SEGMENTATION REFINEMENT

INITIATIVE

Another new initiative in 2000 to enhance customer profitability analysis involved further refining the segmentation. The goal was to better identify customer clusters that would be responsive to specific managerial actions. Kim Davis was chairing the task force coordinati~g this effort. The primary four-way segmentation was expanded to 11 categories as shown below.

AIMS

3

High Net Worth(> $500,000 ofassets under management) I. (16,000 Households)> $2,000,000 in assets under

management
2. (141,000 Households) - $500,000 to $2,000,000

Active Traders(> 36 trades per year)
3. ( 9,000 Households) - more than 200 trades 4. (12,000 Households) - 60 to 200 trades
5. (19,000 Households)- 36 to 60 trades

Retirees
6. (262,000 Households)- $100,000 to $500,000 in

assets under management
7. (607,000 Households)< $100,000

Core
8. (426,000 Households)- $100,000 to $500,000 in

assets under management
9. (1,762,000 Households) - "Boomers" (40 to 59 years

o f age)
10. (434,000 Households)- "Young Professionals"

(under 40 years o f age)
11. (192,000 Households) - All Other, including

employees

CUSTOMER PROFITABILITY ANAL YSIS

As noted earlier, although the company was very profitable in 1999 as the ten-year bull market continued, the senior management group was concerned about the tremendous range o f profitability across customer segments and about the potential for substantial profit erosion when overall markets slowed down, as was widely anticipated over the next few years. Kim challenged the management team to analyze customer mix carefully to identify problem areas and potential corrective actions.

One new management report now being produced each quarter showed income statements for each of he eleven segments broken down by deciles, starting with the most profitable 10% of households and ending with the least profitable 10%. Not surprisingly, the tenth decile in all eleven segments was unprofitable, even before considering any allocation of marketing expenses directed at acquisition of new customers. It was generally agreed that profitability analysis of current households should exclude all expenditures directly related to new households-either "prospecting" expenses in marketing

or new account set-up expenses in the back office. When the segmentation was ignored, 75% of the bottom decile customers were in the Core segment and 80% had less than $100,000 in assets under management.

The wide range ofprofitability across deciles and segments is summarized in Exhibit 3 for 1999. The aggregate loss on all unprofitable households in 1999 was $248 million. Obviously, unprofitable households are an important concern for AIMS. Kim Davis wanted to identify the roots ofthe problem as clearly as possible.

At a casual level of analysis, an unprofitable household suggests one oftwo responses:

• "Fire" them, because AIMS does not want customers on whom it loses money.

• "Do nothing," because there is usually some compensating business reason for keeping .them-the "loss leader" concept. It is possible to construct a long list of reasons to choose to

keep any one currently unprofitable household. At a deeper level of analysis, an unprofitable household suggests that AIMS change its behavior (or the household's behavior) to convert the household to profitable status. In general, there are three ways to convert unprofitable households into profitable ones:

• Raise prices.
• Substitute less expensive for more expensive

services.
• Reduce the cost of delivering some (or all)

services.
Exhibit 4 presents activity profiles o f six

individual tenth decile households chosen to highlight management problems across different segments. Each household presented in Exhibit 4 proxies for thousands of households with the same general profile. The activity profile of the "average" account is also shown for comparison.

Preliminary discussions about "improving customer profitability" focused on the 2000 forecast for representative "problem households" such as those depicted in Exhibit 4. Management wanted to consider both revenue enhancement proposals and service containment proposals.

Potential Account Profitability Enhancement Programs

l)

2) 3)

4)

5) 6) 7)

Charge $15. per rep-assisted call, over 50 calls per year (22,000 l0th Decile Households generate more than 50 calls/year)
Charge $.02 per quote over 100 per transaction Charge a minimum annual fee on brokerage assets or mutual fund assets of $200 or 20 BP, whichever is greater (a fee for the right to trade, even when trading is very inactive)

For customers who generate less than $560. revenue per year (the average), limit access to branches and customer representatives:

charge $100. for branch consultations
- route all incoming calls to the automated

answering service, bypassing account reps Charge $.75 for automated calls over 300 per year.

Charge $1.25 for on-line visits over 10 per transaction.
Set a minimum balance for all new accounts of $50,000 of assets invested (perhaps exempt persons under 35 years old), and a minimum balance of $75,000 of assets invested for persons over 45 years old.

4 AIMS

(Research indicated that AIMS only had about 40% of the invested assets of its custo)llers, on average. The other 60% was invested elsewhere.)

Each ofthese proposals was modeled on charges levied by one or another of AIMS' major competitors, including Charles Squibb, Morton Staley Dan Withers, Merry Lurch, or United Express. Other competitors such as Towncorp Bank or County Road Financial Services approached this problem by limiting their offer of investment advisory services to customers with more than $1 million in invested assets. A good question was why AIMS bothered at all with low net worth customers when so many of them were unprofitable now and likely to remain so.

Questions: Please answer in depth

1. What managerial insights about profitability per household can you extract from Exhibit 3?

2. a) Using ABC analysis, and the information in Exhibits 2 and 4, calculate the loss per household for the six customer profiles per Exhibit 4. Round your calculations to the nearest dollar. b) What are two specific management actions for each of the six customer profiles that would substantially improve the profitability? Calculate the impact of these actions to the nearest dollar.

3. Noting that excess capacity is charged back to active accounts, if AIMS scaled back to 3,000,000 active households and planned only a 10% excess capacity reserve for future growth, a large proportion of cost could be eliminated. Estimate how much of total cost for 1999 could be eliminated, based on facts presented in the case.

4. What are your overall recommendations to top management based on the customer profitability information?

Carilion Clinic

Case History/Background

Nestled in the Commonwealth of Virginia between Salem and Vinton is the city of Roanoke, whose population was approximately 98,000 in 2010. The metropolitan area population was about 309,000. Bisected by the Roanoke River and circled by the Blue Ridge Mountain Parkway, Roanoke is the commercial and cultural hub of western Virginia and southern West Virginia.

The community that became Roanoke was established in 1852. Early economic development of Roanoke resulted from its importance as the junction point for the Shenandoah Valley Railroad and the Norfolk and Western Railway. These railroads were essential for transporting coal from western Virginia and West Virginia. Roanoke’s service area includes a regional report, shopping malls, a regional hub for United Parcel Service, and manufacturing plants for General Electric, Yokohama tires, and Dynax, a maker of friction-based automobile parts.

Carilion Clinic

Carilion Clinic employs almost 12% of Roanoke’s population. The clinic includes 9 freestanding hospitals, 7 urgent care centers, and 220 (and increasing) practice centers, and it employs over 650 physicians in more than 70 specialties. The clinic has 1,026 licensed beds, not including 60 neonatal intensive care unit beds. The clinic had 48,659 admissions in fiscal year 2014-15.

The clinic’s joint ventures and related companies include the following:

Carilion Clinic Physicians, LLC (real estate holding company)

Carilion Emergency Services, Inc.

Carilion Behavioral Health, Inc.

In March 2010, the same month and year the Affordable Care Act became law, the clinic was ordered by the Federal Trade Commission to divest itself of an outpatient surgical center and an imaging center. Both had been acquired as it sought to re-create “The Mayo Clinic” medical delivery model.

Led by Edward G. Murphy, M.D., from 1998 to 2011, Carilion Health System became Carilion Clinic, a vertically integrated health-care system. During Murphy’s tenure the system expanded to include graduate and undergraduate medical education programs, a school of medicine (through a partnership with Virginia Polytechnic Institute and State University Virginia Tech), and, perhaps most impressively, Carilion established an accountable care organization in partnership with Aetna insurance company.

Dr. Murphy’s total compensation was almost $2.3 million in 2007. Nancy Agee, the clinic’s chief operating officer at the time, earned the next highest salary of about $800,000. When Murphy resigned in 2011, Ms. Agee was promoted to president and CEO. In fiscal 2014, Carilion Clinic net revenue was $1.5 million. Agee’s salary was $1.9 million.

CONTROVERSY IN ROANOKE

Despite its philanthropic mission and positive effect on Roanoke, Carilion Clinic has not always enjoyed a good relationship with its community.

   In May 1988, the U.S. Justice Department’s Antitrust Division sought to prevent the merger of Roanoke’s two hospitals: Memorial Roanoke Hospital and Community Hospital of Roanoke Valley. The lawsuit sought to block the merger because of the monopoly it alleged would result. Less than one year after the suit was filed, the Fourth Circuit U.S. Court of Appeals found for defendants Memorial Roanoke Hospital and Community Hospital of Roanoke Valley.

   The merger between defendant hospitals would not constitute an unreasonable restraint of trade under the Sherman Act $1. The merger would strengthen the competition between the hospitals in the area because defendant hospitals could offer more competitive prices and services.

In the two appeals that followed, courts found for defendant hospitals, which then merged and were named Carilion Health System. The decision provided legal basis for what is now the Carilion Clinic.

IN A MARKET: WHAT CONSTITUTES A MONOPOLY?

A monopoly occurs when one or more persons or a company dominate an economic market. This market domination results in the potential to exploit or suppresses those in the market or those trying to enter it (supplier, provider, or consumer).

   During the 19th century, the U.S. government began prosecuting monopolies under the common law as “market interference offenses” to block suppliers from raising prices. At the time, companies sometimes sought to but all supplies of a certain material or product in an area, a practice known as “cornering the market”.

   In 1887, Congress passed the Interstate Commerce Act in response to railway companies’ monopolistic practices in small, local markets. This legislation protected small farmers who were being charged excessive rates to transport their products. Congress addressed monopolistic practices further by passing the Sherman Antitrust Act of 1890, which limited anticompetitive practices of businesses. The act blocked transfer of stock shares to trustees in exchange for a certificate entitling them to some of the earnings. The Sherman Act was the basis for the Clayton Antitrust Act of 1914, the Federal Trade Commission Act of 1914, and the Robinson-Patman Act of 1936, which replaced the Clayton Act.

   Antitrust or competition laws address three main issues:

Prohibit agreements or practices that restrict free trade and competition among business entities.

Ban abusive behavior by a firm dominating a marker, or anticompetitive practices that tend to lead to such a dominant position.

Supervise the mergers and acquisitions of large corporations, including some joint ventures.

The Herfindahl-Hirschman Index (HHI)helps implement these laws by providing a mathematical method to determine market “density”, or the concentration of the market. Antitrust laws and methods of calculating market density, such as HHI, are imperfect and can leave gaps that may be exploited.

   Since its establishment, the mission of the Federal Trade Commission has remained largely unchanged. Laws affecting private enterprise and government agencies have not. It is possible this mal juxtaposition underlies many of the difficulties in the healthcare industry.

VERTICAL INTEGRATION: THE MAYO CLINIC MODEL

The Mayo Clinic is the leading example of vertical integration in the delivery of healthcare in the United States. Founded in Rochester, Minnesota, in 1863, the Mayo Clinic began as the medical practice of William Worrall Mayo and his two sons, who were also physicians. It grew to include a comprehensive array of specialties. Mayo developed different levels of care across the health services continuum. The result was a vertically integrated health system. Mayo physicians are salaried at market levels, and they control the management structure.

   Mayo Clinic is headquartered in Rochester, Minnesota; it has satellite clinics elsewhere in the United States. In addition, Mayo and various medical centers worldwide have consulting and referral relationships. Mayo provides excellence and dedication in delivery of services with a constant, and self-admittedly stubborn, commitment to core values, which include that the needs of the patient come first, the integration of teamwork, efficiency, and mission over profit.

   Mayo has been long recognized for high performance, research and innovation. It has ranked at or near the top of “Honor Roll” hospitals through the history of U.S. News and World Report’s best-hospital rankings. In 2015 - 2016, Mayo clinic had more number one rankings than any U.S. hospital or system. Eight specialties ranked number one: diabetes and endocrinology, gastroenterology and gastrointestinal surgery, geriatrics, gynecology, nephrology, neurology and neurosurgery, pulmonology, and urology.

FORESHADOWING A MAYO CLINIC CLONE

Even before Murphy took the helm in 2001, Carilion Health System actions had stirred significant, but manageable, controversy in the community. Much of the controversy resulted from the antitrust case in 1988. After the court ruled that the merger did not violate federal law because it posted no threat of monopoly, the hospital continued its previous work in the community.

   After becoming CEO, Murphy began to vertically integrate the Carilion Health System. His formal plan was presented in fall 2006. Part of evolving to a Mayo-style organization included acquiring physician practices in the community; some were closed after acquisition.

WHO IS EDWARD G. MURPHY, M.D.?

Edward. G. Murphy earned his BS from the University of Albany, New York, and his medical degree (with honors) from Harvard University Medical School. Although he never practiced medicine. Murphy was a clinical professor at the University of Albany School of Public Health and an adjunct assistant professor at Rensselaer Polytechnic Institute School of Management. Before leaving New York state he was also a member of the New York State Hospital Review and Planning Council, and he served on its executive committee as the vice chair of the fiscal policy council.

   From 1989 to 1991, Murphy served as the vice president of clinical services at Leonard Hospital, a 143-bed facility north of Albany, New York. In 1991, he was promoted to president and CEO of Leonard Hospital until it merged with St. Mary Hospital fo form Seton Health system in 1994. Murphy became president and CEO of that new health system and stayed with Seton until 1998, when he relocated to Roanoke to head Carilion Health System.

   During his tenure at Carilion Clinic, Murphy managed the growth of that two-hospital health system into a vertically integrated model of healthcare delivery anchored by a 500-physician specialty group practice that included nine not-for-profit hospitals, undergraduate medical programs, an array of tertiary referral services, and a multistate laboratory service. In 2007, Murphy announced plans for the Virginia Tech Carilion School of Medicine, which opened in 2010. In 2010, Murphy was paid $2.27 million ($1.37 million in salary and $900,000 in benefits).

Murphy’s other roles in the Roanoke community included memberships on the boards of Healthcare Professionals Insurance Company and Trust; Luna Innovations, Inc; and Hometown Bank. He is past chair of the Art Museum of Western Virginia. He also served in an influential position with the council on Virginia’s Future, which works to frame the growth and progress of the state, including businesses, people, and the health of the population.

   Murphy left Carilion to become chairman of Sound Physicians, a national provider of Intensivist and hospitalist services. In 2012, he became the operating officer of Radius Ventures, a venture capital firm that invests in health-related companies.

VERTICAL INTEGRATION: BECOMING A “CLINIC”

Murphy was always clear about his plans for Carilion Health System. In an August 2006 interview, “Right now...our core business is hospital services. In the new model, the core business will be physician services; the hospital will become ancillary. In a 2007 interview for Health Leaders Magazine, Murphy explained, “I’ve been enamored of this model of healthcare delivery for a long time.”

   In Fall 2006, Murphy, his staff, and the leadership board of Carilion Health System announced their plan to create a new model for Carilion management characterized by teamwork and salaried physicians and other caregivers focused on patients across the spectrum of care. Murphy explained:

   The essence of the clinic model is that hospitals stop becoming independent businesses and start becoming ancillary services to the physician practice….If hospitals eventually want to provide better and more cost-effective healthcare, it’s a necessary shift.

The transformation was planned for seven years with an 18-month phase -in of its new name, Carilion clinic. Plans for Carilion Clinic included a 50-50 partnership with Virginia Tech University in Blacksburg, Virginia, to establish a private, not-for-profit clinical research institute and a new medical school. Further, from 2007 to 2012 Carilion clinic would add four or five fellowships for physicians to support its mission.

Ground was broken for the much-anticipated university in early 2008. On July 20, 2009, the Virginia State Council for Higher Education approved the Virginia Tech Carilion School of Medicine as a postsecondary institution. It’s first class matriculated in fall 2010.

THE WALL STREET JOURNAL EXPOSE

Usually, an organization is pleased if the Wall street Journal publishes an article about it. That is, of course, unless the story ignites a firestorm that leads to separate citizen and physician coalitions working against the organization and raises the specter of a word from Carilion Clinic’s prehistory: monopoly.

“Nonprofit Hospitals Flex Pricing Power. In Roanoke, Va., Carilion’s Fees Exceed Those of Competitors: The $4,727 Colonoscopy” was published on the front page of the Wall Street Journal August 28, 2008. The author, John Carreyrou, explored Carilion’s history, including the 1989 antitrust case, its expanding”market clout,” and the strides toward its goal of vertical integration. The article suggested that some of the means used were questionable.

   Carreyrou asserted that skyrocketing healthcare costs in Roanoke were partially caused by, or possibly even led by, Carilion Clinic.

   In a press release, Carilion Clinic denied monopolistic practices or exploitative pricing and claimed it faced robust competition from Lewis-Gale Medical Center located in nearby Salem, Virginia. Carilion Clinic defended its pricing practices by noting it must cross-subsidize emergency departments and care for the uninsured.

   Unsettling to some, however, was Carilion’s practice of suing patients for unpaid medical bills. After Carilion obtains a court judgement, a lien is placed against the patient’s home. A lien on real property puts a “cloud” on the title, which prevents the owner from conveying the property with a clear title until the lien has been satisfied. Responding in the Wall street Journal, Murphy stated,

   Carilion only sues patients and places liens on their homes if it believes they have the ability to pay … If you’re asking me if it’s right in a right-and-wrong sense, it’s not...But Carilion cannot be blamed for the country’s “broken” healthcare system.

Murphy asserted that Carilion efforts to protect its financial interests meet legal requirements, but may be morally flawed. This position appears inconsistent with Carilion’s mission that ‘Patient Care Comes First.”

WHERE WERE THE LOCAL MEDIA?

As reported by Carreyrou, Carilion Clinic complained several times to editors of the Roanoke Times regarding reporter Jeff Sturgeon’s coverage of the system. Shortly after the complaints, and mainly in response to a May 2008 article by Sturgeon, Carilion greatly reduced advertising in the Roanoke Times. About the same time, Sturgeon, the paper’s longtime health issues writer, was reassigned.

Even after Sturgeon’s reassignment, Carilion continued to be frontpage news in the Roanoke Times. Reporter Sarah Bruyn Jones covered community reaction to the Wall Street Journal article and the impetus it gave to local coalitions. Her articles included the following: “Carilion Critics Draw Hundreds to Meeting” (September 2008); “Fed Agency Looks into Carilion Purchase” (September 2008); “Carilion Footprint Expands in Deal” (August 2008); and “Carilion to Buy Cardiology Practice” (August 2008). Jone’s reporting put Carilion practices at the forefront for Roanoke’s citizens, but, as noted by Carreyrou, Carilion growth seemed unstoppable.

THE BACKLASH

The August 2008 Wall Street Journal article resulted in a community uproar and fueled physician's’ efforts to air their concerns about Carilion, including its anti competitive actions and unfair pricing, and their desire to have open referrals for patients from outside Carilion’s health network. Citizen and physician coalitions met in hotel conference rooms and community centers to discuss the “unfair practices and behaviors” ifof Carilion Clinic. One, the citizens Coalition for Responsible Healthcare, sponsored a petition that read as follows:

   To Dr. Murphy and the Carilion Health System Board of Directors:

   Please reconsider your Carilion Clinic plans. I want to keep my right to choose my doctor, even if he or she is an independent physician. Please rethink spending $100 million of my community’s money on a Clinic model that could ruin our hospitals! Monopolies are never good for healthcare.

The Coalition’s website offered copies of the Wall Street Journal article, video recordings of their meetings, information about a new forum program, and membership form for those who wished to join their efforts.

   The citizen coalitions stated they intended to focus on the negative impact of Carilion’s transformation to a physician-led clinic that they asserted will increase costs and drive out many local physicians. Murphy’s plan was to bring into Carilion as many physicians as possible; all of whom will be salaried. The concerns of citizen coalitions stemmed from the scope of the effort, which resulted in closure or sale of many physician practices. Unaffiliated physicians asserted they could not compete. Further, Carilion’s system of internal referrals, added to the purchase of existing practices, gave many specialists no choice but to leave, or stay and fight.

   Despite the controversy, Carilion has shown no signs of slowing: it has stayed the course outlined in Fall 2006.

CARILION’S RESPONSE

On August 28, 2008, less than 24 hours after publication of Carreyrou’s Wall Street Journal article, Carilion responded. Statements published in newspapers and posted on Carilion’s website, as well as press releases, stated the allegations and conclusions drawn from them were misleading and misinformed.

   In response, Carilion directed readers’ attention to the Virginia Hospital and Health care Association PricePoint Website. It showed that Carilion’s prices are comparable to surrounding hospitals and are generally lower than its closest competitor, Lewis-Gale Medical center in neighboring Salem, Virginia. To support their position on pricing,Carilion stated “Medical care in hospitals is more expensive … having staff and technology at the ready has its costs. Also mentioned was Carilion’s Lifeguard helicopter, which is subsidized service. Carilion provided $42 million in charity care in 2007 and an additional $25 million in free care (bad debt written off), thus illustrating its dedication and support of its service area. Carilion supports research and education substantial resource commitments that add major costs to the organization and provide subsidize services tiot the community.

   In explaining the policy to sue patients, Carilion stated that efforts are made to qualify patients for public programs, as needed. Further, Carilion said only “a small fraction of the nearly 2 million” patient billings each year go to court.

   Court filings are a final resort, and we try to be flexible. If the judgement includes a lien on an individual’s property, we do not foreclose on the lien. The lien is satisfied if and when the property is sold.

In response to concerns about its internal referral practice, Carilion stated that referrals are sent from physician to physician in the system with the intention of sending patients to better, more-qualified physicians who have earned the referral. The “earn, not force” mentality contributes to the goal of well-coordinated care and service, which is the first choice of patients.

Carilion’s press release closed by describing a wasteful and poorly organized U.S. healthcare system that is hoped to improve with the vertically integrated clinic model of providing care. The hope is that comprehensive, high quality, and cost-effective care will put the patient first. The reader of the press release is reminded that what happened at Mayo could be replicated at Carilion.

CURRENT SITUATION IN ROANOKE

As noted, Carilion Clinic has a medical school partnership, an expanding physician practice with a robust specialty list, and its own accountable care organization, which continues to show progress and increased membership.

Three decades after the hospital merger controversy began in Roanoke, Virginia, the economic and healthcare environments have changed, the population is increasing, and healthcare costs are rising. When the antitrust case was brought in 1988, Roanoke had among the lowest health insurance premiums in Virginia; now, they are among the highest.

Discussion questions to be answered

1) Identify the problems Carilion Clinic faces as it seeks to become a comprehensive, vertically integrated healthcare provider.

2) Briefly explain the summary of the case

3) Identify the most important factors/facts of the Case study

4) Explain the critical issues that is the most important health administration problem/issue to be solved and if applicable, identified secondary problems.

5) Identify the recommended solution of the case. At least three realistic alternative solutions.

6) Identify the relevant concepts and tools for example, methods, techniques, principles,theories, and or models.

Carilion Clinic

Case History/Background

Nestled in the Commonwealth of Virginia between Salem and Vinton is the city of Roanoke, whose population was approximately 98,000 in 2010. The metropolitan area population was about 309,000. Bisected by the Roanoke River and circled by the Blue Ridge Mountain Parkway, Roanoke is the commercial and cultural hub of western Virginia and southern West Virginia.

The community that became Roanoke was established in 1852. Early economic development of Roanoke resulted from its importance as the junction point for the Shenandoah Valley Railroad and the Norfolk and Western Railway. These railroads were essential for transporting coal from western Virginia and West Virginia. Roanoke’s service area includes a regional report, shopping malls, a regional hub for United Parcel Service, and manufacturing plants for General Electric, Yokohama tires, and Dynax, a maker of friction-based automobile parts.

Carilion Clinic

Carilion Clinic employs almost 12% of Roanoke’s population. The clinic includes 9 freestanding hospitals, 7 urgent care centers, and 220 (and increasing) practice centers, and it employs over 650 physicians in more than 70 specialties. The clinic has 1,026 licensed beds, not including 60 neonatal intensive care unit beds. The clinic had 48,659 admissions in fiscal year 2014-15.

The clinic’s joint ventures and related companies include the following:

Carilion Clinic Physicians, LLC (real estate holding company)

Carilion Emergency Services, Inc.

Carilion Behavioral Health, Inc.

In March 2010, the same month and year the Affordable Care Act became law, the clinic was ordered by the Federal Trade Commission to divest itself of an outpatient surgical center and an imaging center. Both had been acquired as it sought to re-create “The Mayo Clinic” medical delivery model.

Led by Edward G. Murphy, M.D., from 1998 to 2011, Carilion Health System became Carilion Clinic, a vertically integrated health-care system. During Murphy’s tenure the system expanded to include graduate and undergraduate medical education programs, a school of medicine (through a partnership with Virginia Polytechnic Institute and State University Virginia Tech), and, perhaps most impressively, Carilion established an accountable care organization in partnership with Aetna insurance company.

Dr. Murphy’s total compensation was almost $2.3 million in 2007. Nancy Agee, the clinic’s chief operating officer at the time, earned the next highest salary of about $800,000. When Murphy resigned in 2011, Ms. Agee was promoted to president and CEO. In fiscal 2014, Carilion Clinic net revenue was $1.5 million. Agee’s salary was $1.9 million.

CONTROVERSY IN ROANOKE

Despite its philanthropic mission and positive effect on Roanoke, Carilion Clinic has not always enjoyed a good relationship with its community.

   In May 1988, the U.S. Justice Department’s Antitrust Division sought to prevent the merger of Roanoke’s two hospitals: Memorial Roanoke Hospital and Community Hospital of Roanoke Valley. The lawsuit sought to block the merger because of the monopoly it alleged would result. Less than one year after the suit was filed, the Fourth Circuit U.S. Court of Appeals found for defendants Memorial Roanoke Hospital and Community Hospital of Roanoke Valley.

   The merger between defendant hospitals would not constitute an unreasonable restraint of trade under the Sherman Act $1. The merger would strengthen the competition between the hospitals in the area because defendant hospitals could offer more competitive prices and services.

In the two appeals that followed, courts found for defendant hospitals, which then merged and were named Carilion Health System. The decision provided legal basis for what is now the Carilion Clinic.

IN A MARKET: WHAT CONSTITUTES A MONOPOLY?

A monopoly occurs when one or more persons or a company dominate an economic market. This market domination results in the potential to exploit or suppresses those in the market or those trying to enter it (supplier, provider, or consumer).

   During the 19th century, the U.S. government began prosecuting monopolies under the common law as “market interference offenses” to block suppliers from raising prices. At the time, companies sometimes sought to but all supplies of a certain material or product in an area, a practice known as “cornering the market”.

   In 1887, Congress passed the Interstate Commerce Act in response to railway companies’ monopolistic practices in small, local markets. This legislation protected small farmers who were being charged excessive rates to transport their products. Congress addressed monopolistic practices further by passing the Sherman Antitrust Act of 1890, which limited anticompetitive practices of businesses. The act blocked transfer of stock shares to trustees in exchange for a certificate entitling them to some of the earnings. The Sherman Act was the basis for the Clayton Antitrust Act of 1914, the Federal Trade Commission Act of 1914, and the Robinson-Patman Act of 1936, which replaced the Clayton Act.

   Antitrust or competition laws address three main issues:

Prohibit agreements or practices that restrict free trade and competition among business entities.

Ban abusive behavior by a firm dominating a marker, or anticompetitive practices that tend to lead to such a dominant position.

Supervise the mergers and acquisitions of large corporations, including some joint ventures.

The Herfindahl-Hirschman Index (HHI)helps implement these laws by providing a mathematical method to determine market “density”, or the concentration of the market. Antitrust laws and methods of calculating market density, such as HHI, are imperfect and can leave gaps that may be exploited.

   Since its establishment, the mission of the Federal Trade Commission has remained largely unchanged. Laws affecting private enterprise and government agencies have not. It is possible this mal juxtaposition underlies many of the difficulties in the healthcare industry.

VERTICAL INTEGRATION: THE MAYO CLINIC MODEL

The Mayo Clinic is the leading example of vertical integration in the delivery of healthcare in the United States. Founded in Rochester, Minnesota, in 1863, the Mayo Clinic began as the medical practice of William Worrall Mayo and his two sons, who were also physicians. It grew to include a comprehensive array of specialties. Mayo developed different levels of care across the health services continuum. The result was a vertically integrated health system. Mayo physicians are salaried at market levels, and they control the management structure.

   Mayo Clinic is headquartered in Rochester, Minnesota; it has satellite clinics elsewhere in the United States. In addition, Mayo and various medical centers worldwide have consulting and referral relationships. Mayo provides excellence and dedication in delivery of services with a constant, and self-admittedly stubborn, commitment to core values, which include that the needs of the patient come first, the integration of teamwork, efficiency, and mission over profit.

   Mayo has been long recognized for high performance, research and innovation. It has ranked at or near the top of “Honor Roll” hospitals through the history of U.S. News and World Report’s best-hospital rankings. In 2015 - 2016, Mayo clinic had more number one rankings than any U.S. hospital or system. Eight specialties ranked number one: diabetes and endocrinology, gastroenterology and gastrointestinal surgery, geriatrics, gynecology, nephrology, neurology and neurosurgery, pulmonology, and urology.

FORESHADOWING A MAYO CLINIC CLONE

Even before Murphy took the helm in 2001, Carilion Health System actions had stirred significant, but manageable, controversy in the community. Much of the controversy resulted from the antitrust case in 1988. After the court ruled that the merger did not violate federal law because it posted no threat of monopoly, the hospital continued its previous work in the community.

   After becoming CEO, Murphy began to vertically integrate the Carilion Health System. His formal plan was presented in fall 2006. Part of evolving to a Mayo-style organization included acquiring physician practices in the community; some were closed after acquisition.

WHO IS EDWARD G. MURPHY, M.D.?

Edward. G. Murphy earned his BS from the University of Albany, New York, and his medical degree (with honors) from Harvard University Medical School. Although he never practiced medicine. Murphy was a clinical professor at the University of Albany School of Public Health and an adjunct assistant professor at Rensselaer Polytechnic Institute School of Management. Before leaving New York state he was also a member of the New York State Hospital Review and Planning Council, and he served on its executive committee as the vice chair of the fiscal policy council.

   From 1989 to 1991, Murphy served as the vice president of clinical services at Leonard Hospital, a 143-bed facility north of Albany, New York. In 1991, he was promoted to president and CEO of Leonard Hospital until it merged with St. Mary Hospital fo form Seton Health system in 1994. Murphy became president and CEO of that new health system and stayed with Seton until 1998, when he relocated to Roanoke to head Carilion Health System.

   During his tenure at Carilion Clinic, Murphy managed the growth of that two-hospital health system into a vertically integrated model of healthcare delivery anchored by a 500-physician specialty group practice that included nine not-for-profit hospitals, undergraduate medical programs, an array of tertiary referral services, and a multistate laboratory service. In 2007, Murphy announced plans for the Virginia Tech Carilion School of Medicine, which opened in 2010. In 2010, Murphy was paid $2.27 million ($1.37 million in salary and $900,000 in benefits).

Murphy’s other roles in the Roanoke community included memberships on the boards of Healthcare Professionals Insurance Company and Trust; Luna Innovations, Inc; and Hometown Bank. He is past chair of the Art Museum of Western Virginia. He also served in an influential position with the council on Virginia’s Future, which works to frame the growth and progress of the state, including businesses, people, and the health of the population.

   Murphy left Carilion to become chairman of Sound Physicians, a national provider of Intensivist and hospitalist services. In 2012, he became the operating officer of Radius Ventures, a venture capital firm that invests in health-related companies.

VERTICAL INTEGRATION: BECOMING A “CLINIC”

Murphy was always clear about his plans for Carilion Health System. In an August 2006 interview, “Right now...our core business is hospital services. In the new model, the core business will be physician services; the hospital will become ancillary. In a 2007 interview for Health Leaders Magazine, Murphy explained, “I’ve been enamored of this model of healthcare delivery for a long time.”

   In Fall 2006, Murphy, his staff, and the leadership board of Carilion Health System announced their plan to create a new model for Carilion management characterized by teamwork and salaried physicians and other caregivers focused on patients across the spectrum of care. Murphy explained:

   The essence of the clinic model is that hospitals stop becoming independent businesses and start becoming ancillary services to the physician practice….If hospitals eventually want to provide better and more cost-effective healthcare, it’s a necessary shift.

The transformation was planned for seven years with an 18-month phase -in of its new name, Carilion clinic. Plans for Carilion Clinic included a 50-50 partnership with Virginia Tech University in Blacksburg, Virginia, to establish a private, not-for-profit clinical research institute and a new medical school. Further, from 2007 to 2012 Carilion clinic would add four or five fellowships for physicians to support its mission.

Ground was broken for the much-anticipated university in early 2008. On July 20, 2009, the Virginia State Council for Higher Education approved the Virginia Tech Carilion School of Medicine as a postsecondary institution. It’s first class matriculated in fall 2010.

THE WALL STREET JOURNAL EXPOSE

Usually, an organization is pleased if the Wall street Journal publishes an article about it. That is, of course, unless the story ignites a firestorm that leads to separate citizen and physician coalitions working against the organization and raises the specter of a word from Carilion Clinic’s prehistory: monopoly.

“Nonprofit Hospitals Flex Pricing Power. In Roanoke, Va., Carilion’s Fees Exceed Those of Competitors: The $4,727 Colonoscopy” was published on the front page of the Wall Street Journal August 28, 2008. The author, John Carreyrou, explored Carilion’s history, including the 1989 antitrust case, its expanding”market clout,” and the strides toward its goal of vertical integration. The article suggested that some of the means used were questionable.

   Carreyrou asserted that skyrocketing healthcare costs in Roanoke were partially caused by, or possibly even led by, Carilion Clinic.

   In a press release, Carilion Clinic denied monopolistic practices or exploitative pricing and claimed it faced robust competition from Lewis-Gale Medical Center located in nearby Salem, Virginia. Carilion Clinic defended its pricing practices by noting it must cross-subsidize emergency departments and care for the uninsured.

   Unsettling to some, however, was Carilion’s practice of suing patients for unpaid medical bills. After Carilion obtains a court judgement, a lien is placed against the patient’s home. A lien on real property puts a “cloud” on the title, which prevents the owner from conveying the property with a clear title until the lien has been satisfied. Responding in the Wall street Journal, Murphy stated,

   Carilion only sues patients and places liens on their homes if it believes they have the ability to pay … If you’re asking me if it’s right in a right-and-wrong sense, it’s not...But Carilion cannot be blamed for the country’s “broken” healthcare system.

Murphy asserted that Carilion efforts to protect its financial interests meet legal requirements, but may be morally flawed. This position appears inconsistent with Carilion’s mission that ‘Patient Care Comes First.”

WHERE WERE THE LOCAL MEDIA?

As reported by Carreyrou, Carilion Clinic complained several times to editors of the Roanoke Times regarding reporter Jeff Sturgeon’s coverage of the system. Shortly after the complaints, and mainly in response to a May 2008 article by Sturgeon, Carilion greatly reduced advertising in the Roanoke Times. About the same time, Sturgeon, the paper’s longtime health issues writer, was reassigned.

Even after Sturgeon’s reassignment, Carilion continued to be frontpage news in the Roanoke Times. Reporter Sarah Bruyn Jones covered community reaction to the Wall Street Journal article and the impetus it gave to local coalitions. Her articles included the following: “Carilion Critics Draw Hundreds to Meeting” (September 2008); “Fed Agency Looks into Carilion Purchase” (September 2008); “Carilion Footprint Expands in Deal” (August 2008); and “Carilion to Buy Cardiology Practice” (August 2008). Jone’s reporting put Carilion practices at the forefront for Roanoke’s citizens, but, as noted by Carreyrou, Carilion growth seemed unstoppable.

THE BACKLASH

The August 2008 Wall Street Journal article resulted in a community uproar and fueled physician's’ efforts to air their concerns about Carilion, including its anti competitive actions and unfair pricing, and their desire to have open referrals for patients from outside Carilion’s health network. Citizen and physician coalitions met in hotel conference rooms and community centers to discuss the “unfair practices and behaviors” ifof Carilion Clinic. One, the citizens Coalition for Responsible Healthcare, sponsored a petition that read as follows:

   To Dr. Murphy and the Carilion Health System Board of Directors:

   Please reconsider your Carilion Clinic plans. I want to keep my right to choose my doctor, even if he or she is an independent physician. Please rethink spending $100 million of my community’s money on a Clinic model that could ruin our hospitals! Monopolies are never good for healthcare.

The Coalition’s website offered copies of the Wall Street Journal article, video recordings of their meetings, information about a new forum program, and membership form for those who wished to join their efforts.

   The citizen coalitions stated they intended to focus on the negative impact of Carilion’s transformation to a physician-led clinic that they asserted will increase costs and drive out many local physicians. Murphy’s plan was to bring into Carilion as many physicians as possible; all of whom will be salaried. The concerns of citizen coalitions stemmed from the scope of the effort, which resulted in closure or sale of many physician practices. Unaffiliated physicians asserted they could not compete. Further, Carilion’s system of internal referrals, added to the purchase of existing practices, gave many specialists no choice but to leave, or stay and fight.

   Despite the controversy, Carilion has shown no signs of slowing: it has stayed the course outlined in Fall 2006.

CARILION’S RESPONSE

On August 28, 2008, less than 24 hours after publication of Carreyrou’s Wall Street Journal article, Carilion responded. Statements published in newspapers and posted on Carilion’s website, as well as press releases, stated the allegations and conclusions drawn from them were misleading and misinformed.

   In response, Carilion directed readers’ attention to the Virginia Hospital and Health care Association PricePoint Website. It showed that Carilion’s prices are comparable to surrounding hospitals and are generally lower than its closest competitor, Lewis-Gale Medical center in neighboring Salem, Virginia. To support their position on pricing,Carilion stated “Medical care in hospitals is more expensive … having staff and technology at the ready has its costs. Also mentioned was Carilion’s Lifeguard helicopter, which is subsidized service. Carilion provided $42 million in charity care in 2007 and an additional $25 million in free care (bad debt written off), thus illustrating its dedication and support of its service area. Carilion supports research and education substantial resource commitments that add major costs to the organization and provide subsidize services tiot the community.

   In explaining the policy to sue patients, Carilion stated that efforts are made to qualify patients for public programs, as needed. Further, Carilion said only “a small fraction of the nearly 2 million” patient billings each year go to court.

   Court filings are a final resort, and we try to be flexible. If the judgement includes a lien on an individual’s property, we do not foreclose on the lien. The lien is satisfied if and when the property is sold.

In response to concerns about its internal referral practice, Carilion stated that referrals are sent from physician to physician in the system with the intention of sending patients to better, more-qualified physicians who have earned the referral. The “earn, not force” mentality contributes to the goal of well-coordinated care and service, which is the first choice of patients.

Carilion’s press release closed by describing a wasteful and poorly organized U.S. healthcare system that is hoped to improve with the vertically integrated clinic model of providing care. The hope is that comprehensive, high quality, and cost-effective care will put the patient first. The reader of the press release is reminded that what happened at Mayo could be replicated at Carilion.

CURRENT SITUATION IN ROANOKE

As noted, Carilion Clinic has a medical school partnership, an expanding physician practice with a robust specialty list, and its own accountable care organization, which continues to show progress and increased membership.

Three decades after the hospital merger controversy began in Roanoke, Virginia, the economic and healthcare environments have changed, the population is increasing, and healthcare costs are rising. When the antitrust case was brought in 1988, Roanoke had among the lowest health insurance premiums in Virginia; now, they are among the highest.

Discussion questions to be answered

1) Identify the problems Carilion Clinic faces as it seeks to become a comprehensive, vertically integrated healthcare provider.

2) Briefly explain the summary of the case

3) Identify the most important factors/facts of the Case study

4) Explain the critical issues that is the most important health administration problem/issue to be solved and if applicable, identified secondary problems.

5) Identify the recommended solution of the case. At least three realistic alternative solutions.

6) Identify the relevant concepts and tools for example, methods, techniques, principles,theories, and or models.

Case F: Controlling Performance Management Jacob Victory

1. What is your interpretation of what happened in this case? Assume for the moment that Josh was successful at improving performance and that this was why he was being transferred.

The New Vice President
“He is not a nurse,” smirked the pediatric nurse director. “He’s going to be a piece of cake,” mocked the other with mischief
gleaming in her eye. They were referring to Josh Webber, their new boss who was starting
that morning as the new vice president of the pediatric division. Josh was not new to the organization. He was a young and eager executive and had paid his dues working for five years as the right hand of the Visiting Nurse Service of America’s (VNSA) president and CEO. Thereafter, he was promoted to operations director of the organization’s highly profitable rehabilitation ser- vices division and then promoted to director of performance management, where he worked for more than a year with the pediatric division’s administra- tor and her team to improve the division’s business and clinical performance.
Josh, holding a box of files and walking confidently with his polished shoes tip-tapping on the tiles outside of his new administrative suite’s en- trance, had heard the exchange between the nurse directors. The comment struck Josh as odd because the two directors had worked closely with him over the last year and recent improvements in the division’s operational per- formance had been highly praised by VNSA leadership.
“Time to don your game face, Josh!” he thought to himself. Sighing gently, Josh put on a toothy grin, turned the corner and greeted the two di- rectors enthusiastically as he entered the suite. The nurse directors didn’t miss a beat and greeted Josh with a warm, “Welcome aboard, Josh!”
The Maternal and Pediatric Service Line
The maternal and pediatric service line was only one part of the VNSA, the nation’s largest for-profit home health agency.
Under the current CEO’s tenure, the VNSA had become a national home care agency. It employed 30,000 nurses, rehabilitation therapists, social workers, and home health aides, and served almost 500,000 patients in six states annually. The agency earned a healthy margin on its annual $5 bil- lion revenue base and, with a conservative management team at its helm, the VNSA was only geared to become bigger and more influential in enforcing federal long-term healthcare policy. Its many divisions and programs focused primarily on the home-bound frail elderly, especially those in the long-term care population who made up the Medicare, Medicaid, and dually eligible marketplace. At an annual growth rate of 8 to 10 percent, the VNSA was a force in the market, offering short-term, skilled nursing and professional services via its adult, pediatric, community mental health, long-term care, rehabilitation therapy, and palliative and hospice programs. It also operated a lucrative managed care company that offered myriad managed care plans to a large market base of elderly and long-term care patients; more than 200,000 members were covered under these plans.
Yet, while the organization’s primary focus was on long-term care and the geriatric population, the agency’s roots had been laid by its maternal and pediatric division, VNSA’s first program, which had been founded more than 170 years ago. Now composed of ten pediatric programs, the division annually served more than 35,000 mothers, newborns, and children via numerous programs that focused on short-term skilled care, pediatric care management, and evidence-based preventive services and family-focused programs. Deemed the largest organization of its kind in the nation, VNSA’s stated mission was to serve the most vulnerable populations, especially those who lacked access to healthcare. Almost 90 percent of the patients served lived below the poverty line and were insured by Medicaid or enrolled in Medicaid managed care plans. Most of these patients had complex illnesses and, more often than not, came from socioeconomically compromised environments. A typical patient profile included a 15-year-old mother with C-section wound care complications; a two-month-old boy with a brain tumor who recently had his left arm amputated; a 14-year-old girl with the mental capacity of a 3-year-old experiencing severe cardiac and respiratory complications and multiple rehospitalizations—and the list continued on for thousands of similar patients. VNSA’s charitable care and community benefit programs were a hallmark of its mission, and the maternal and pediatric service line was at the mission’s core.
With annual revenues of $50 million, the pediatric division was histori- cally under-reimbursed and had a loss of $18 million every year. Seven of its ten programs were grant-funded, and two were funded by VNSA’s board of directors’ Charitable Care Benefit Fund. The program that relied on tradi- tional insurance mechanisms for reimbursement was responsible for nearly all of the division’s deficit.
Despite the annual losses, the VNSA board of directors considered this division untouchable. A subset of VNSA board members and community pediatricians also composed the pediatric division’s advisory board, and these individuals and the division’s chair—a full board member and an influential member of society—were key fixtures with respect to their commitment, sup- port, and advocacy for the maternal and pediatric services the division pro- vided to the communities it served. From a branding perspective, VNSA’s executive management shared in the board’s view and actively used the ma- ternal and pediatric division in the agency’s public relations efforts to market the company as one that focused on community benefit, despite its for-profit status. Moreover, the division was the lead recipient of VNSA’s philanthropic endeavors. Millions of dollars were raised for the program, but not enough to reduce the deficit. Yet because VNSA was a highly disciplined agency in which most of its business leaders annually exceeded their business and clini- cal targets, the pediatric division stuck out like a sore thumb. In internal man- agement meetings, executive leadership notably demanded that the division’s management minimize its financial deficit and had directed a harsh eye and even harsher commentary toward the division because it had not historically met its budgeted business targets. Its clinical outcomes were average at best, although its customer satisfaction ratings were consistently among the high- est of all programs in the agency.
Not surprisingly, the administrators of the pediatric division turned over frequently. In the last six years, there had been four vice presidents be- cause the burnout rate was high. Other issues stemmed from a lack of insti- tutional support in providing the division with adequate business oversight. The program directors in the division were either nurses or social workers who had been promoted up the ladder; these directors maintained the per- spective of frontline clinicians, and focused primarily on ensuring that the sick children were served. Being labeled a “community benefit” program (a euphemism for “a program that makes no money”) and watching their se- nior leaders leave because they were “routinely beat up on at meetings,” as one nurse director put it, made the program’s leaders wary of every new vice president who was brought in to lead the division. “How long will this one last?” was a frequent question.
Josh was wondering the same thing.
Who Is on Deck?
Six pairs of eyes stared at Josh. All six of his direct reports sat in front of him, one next to another. “Welcome to Josh’s Leadership Assimilation,” said the regional head of VNSA’s organizational development (OD) human resources division. “In the next three hours you will learn about Josh, his management style, his goals, and his objectives for the next year,” he continued. Standing in front of the room, Josh stared back and, being a visual person, thought that he was “looking at the living and breathing version of the division’s organization chart.”
The next three hours were eye-opening. The OD representative had asked the group to describe Josh. Words such as young, a man, articulate, competitive, takes-no-prisoner type, poised, ambitious, seemingly courteous, soft-spoken, deep thinker, all-business were only some of the terms used. Then the group was asked what they wanted to know from Josh. Most wanted to know
•   how “hands-on” he planned to be in managing their divisions,

•   how available he wanted them to be when he needed them,

•   how he was going to manage a group of clinicians when he had no
clinical training, and

•   how and why he obtained his current promotion.
Only two in the group genuinely wanted to know how he was going to help them perform better, while the other four scoffed. Lorann Stutters, a director who ran two disease-based programs for adolescents, blatantly asked, “We know you’ve been brought here to ‘fix’ this division; how long do you plan to spend here before you position yourself for your next job?”
Did she really just say that? Josh thought to himself. He endured three hours of people venting about the history of the program; of questions about his intentions for the business; of sly glances that questioned his every answer; and of probing questions that had more venom than substance. Only two of the directors remained mostly quiet and asked thoughtful questions about the strategic positioning of the division.
After the meeting, Lucas Red, the OD representative leading the meet- ing, gave Josh a piece of paper that listed the five key impressions the directors had of Josh; this information had been collected prior to the meeting.
1. Josh is a male under 35 years of age, but he looks like he just turned 20. 2. Josh is too ambitious. 3. Josh knows how to present a complex idea in a simple, succinct way. He
is a good public speaker. 4. Josh is the “golden boy,” having served as the CEO’s special assistant. It
is obvious how he got this promotion. 5. Josh is a nonclinician; how can he possibly understand patient care issues?
“This is going to be a fun ride, Josh,” he said to himself, trying to nurse his bruised ego. Josh walked back to his office, sat down, and started to draw an organizational chart.

NATIONAL FARM AND GARDEN, INC., BACKGROUND

(Everyone reads.)

National Farm and Garden, Inc. (NFG) was incorporated in Nebraska in 1935 and has been a leading supplier of farming equipment for more than sixty years. Over the last five years, however, demand for NFG’s flagship product, the Ultra Tiller, has been declining. To make matters worse, NFG’s market lead was overtaken by the competition for the first time two years ago.

Last year, NFG expanded its product line with the Turbo Tiller, a highly advertised and much anticipated upgrade to the Ultra Tiller. The product launch was timed to coincide with last year’s fall tilling season. Due to the timing of the release, the research and development process was shortened, and the manufacturing department was pressed to produce high numbers to meet anticipated demand. All responsible divisions approved the product launch and schedule. In order to release the product as scheduled, however, the manufacturing department was forced to employ the safety shield design from the Ultra Tiller. When attached, the shield protects the user from the tilling blades; however, it is necessary to remove the shield in order to clean the product. Because of differences between the Ultra and Turbo models, the Turbo’s shield is very difficult to reattach after cleaning and the process requires specialized tools. Owners can have the supplier make modifications on site or at the sales location, or they can leave the shield off and continue operation. All product documentation warns against operating the tiller without the shield, and the product itself has three distinct warning labels on it. Modifications are now available that allow for the shield to be removed and replaced quite easily, and these modifications are covered by the factory warranty. However, most owners have elected to operate the Turbo Tiller without the safety shield after its first cleaning.

Over the last year, a number of farm animals (chickens, cats, a dog, and two goats) have been killed by Turbo Tillers being operated without the guard. Two weeks ago, a seven-year-old Nebraska boy riding on the back of an unshielded tiller fell off. When the tiller caught the sleeve of his shirt, his arm was permanently mangled and required amputation. One of the child’s parents owns the local newspaper, which ran a story about the accident on the front page of the local paper the next day. NFG’s CEO has called an emergency meeting with the company’s divisional vice president, director of product development, director of manufacturing, director of sales, and vice president of public relations to discuss the situation and develop a plan of action.

Divisional Vice President

You are the divisional vice president and have been with the company for many years. Historically, you have not been a pushy individual and generally prefer to stay in the background. When there are major decisions to be made or crises to address, you are frequently not available. The CEO recently put you on a sixty-day action plan to improve your division’s output; failure to achieve this plan will result in your termination, even though you are just a few years shy of retirement. Therefore, you now find it necessary to satisfy not only your own objectives, but the CEO’s very high expectations as well. This has caused great turmoil within all divisions because you place increasing pressure on your subordinates.

As the divisional vice president, you are focused on coordinating all departments. You are responsible for output from the sales, manufacturing, and field service engineering departments. The research and development (R&D) department, which must sign off on all new products before they are approved for production, is not under your supervision.

Recently, you received a memorandum from the director of R&D outlining some potential problems with the development and testing of the Turbo Tiller. The memo was copied to you, the director of manufacturing, and the director of sales. You agreed with the director of manufacturing not to share the contents of the memo with your CEO because you felt that bringing this small concern to his attention would cause unnecessary problems for each division. Moreover, the CEO is known for his abrasive personality and has a history of yelling at bearers of bad news.

The CEO has called an all-hands emergency meeting at 7:00 a.m. tomorrow. You are expected to bring all knowledge of this situation with you for discussion and creation of a comprehensive action plan.

Director of Product Development

You are the director of product development. Although you have a master’s degree in mechanical engineering from Stanford University, you are originally from the inner-city area of Chicago, where you grew up in the school of “hard knocks.” From previous experience, you tend to be rather uncompromising about products that are engineered within your organization. Your engineering team has been very successful in the past, and you are quite proud of the many new successful products your department has developed.

You originally fast-tracked the Turbo Tiller product due to constant pressure, particularly from the director of sales. However, on further investigation, you have become concerned about the implementation of the product’s safety shield. Consequently, you recently sent a memorandum to the director of manufacturing, director of sales, and the divisional vice president outlining the fact that consumers could sue National Farm and Garden under the state’s strict liability doctrine, which holds manufacturers, distributors, wholesalers, retailers, and others in the chain of distribution of a defective product liable for the damages caused by the defect, regardless of fault. Moreover, plaintiffs could cite the state’s concept of defect of manufacture when the manufacturer fails to (1) properly assemble a product, (2) properly test a product, and (3) adequately check the quality of the product component parts or materials used in manufacturing. You now believe that NFG has violated all three of these concepts of “defects of manufacture.”

Having received no response to this memo, you are contemplating whether to escalate the issue by going to the CEO. The only reason you have not already done so is the CEO’s historic temper when confronted with negative situations.

The CEO has called an all-hands emergency meeting at 7:00 a.m. tomorrow. You are expected to bring all knowledge of this situation with you for discussion and creation of a comprehensive action plan.

Director of Manufacturing

You are the director of manufacturing. A graduate from the University of Alabama with a B.S. in industrial manufacturing, you have worked for NFG for twenty years. You are required to provide reports to top management on a weekly, monthly, and quarterly basis. Top management creates the exact measures of performance that you provide; although you have a say in what these reports focus on, you often disagree with their exact focus. Your overall performance is evaluated based more on numbers of units produced than on quality. Despite this, you enjoy working for the company. You consider the group like family, and especially appreciate the effort the CEO has made to make you feel valued and supported.

You are aware of the difficulties that the Ultra Tiller guard poses when used on the Turbo Tiller. Due to the Turbo Tiller’s larger size, the guard is nearly impossible to replace after removal. Re-attachment of the shield requires a professional machine shop and additional assistance. However, with your knowledge of statistics, you know that, even without the shield in place, the chances of an animal or a person being injured by the Turbo Tiller are small. Thus, you agreed with the divisional vice president to bury a memo sent by the director of R&D stating related concerns. You both felt that the risks were small enough and that raising these concerns to your superiors would only cause headaches and paperwork. Furthermore, you need to stay on schedule in order to reach your volume goals if you are to earn your bonus.

You have also received several e-mails from the manager of the field service engineering department about reports of farmers operating the Turbo Tiller without the guard. When you requested statistical data regarding the number and location of occurrences and any related accidents, the field service engineering manager replied with field data indicating that more than 85 percent of all Turbo Tillers are eventually operated without the guard.

The CEO has called an all-hands emergency meeting at 7:00 a.m. tomorrow. You are expected to bring all knowledge of this situation with you for discussion and creation of a comprehensive action plan.

Director of Sales

You are the director of sales and have been with NFG for more than ten years. You were recruited from a competing firm and have more than twenty-five years of sales experience in the industry. Because of sagging sales, you face extreme pressure from above to meet your numbers. However, you feel that sales forecasts have been set unrealistically. Furthermore, these aggressive forecasts create churning within your department as your sales staff consistently complains that their quotas are unrealistic. Although you are adamant that declining sales are industry and product offering issues, you are reluctant to raise these concerns to the CEO because of his history of anger directed at messengers bearing bad news. You have witnessed this phenomenon firsthand as the CEO literally screamed at a coworker who brought a problem to his attention. On the other hand, the CEO has promised you a new BMW if your department reaches its numbers this year. Of course, you enthusiastically promised to achieve these results.

The Turbo Tiller has been a much-anticipated addition to your stagnant product portfolio, but you were concerned that it would be delayed due to red tape and wrote daily e-mails to the R&D manager about getting it to market on a timely basis. You have received a memo from the R&D manager about some legal concerns over the Turbo Tiller. However, you feel that these concerns are manufacturing’s problem, not your department’s. Furthermore, because the director of manufacturing received a carbon copy of the memo, you are sure that the concerns will be addressed appropriately.

You have organized training on this product for your sales staff that included proper operating procedures and the dangers of standing within five feet of the tilling blades. In addition to these training sessions, you arranged a separate class on how to address and downplay these concerns with customers.

The CEO has called an all-hands emergency meeting at 7:00 a.m. tomorrow. You are expected to bring all knowledge of this situation with you for discussion and creation of a comprehensive action plan.

Here is the question. please help me to answer this:

1) List the key stakeholders in this scenario.

2) What actions will you take with the family of the injured boy?

3) What actions will you take to move customers from the old tiller to the new version?

4) Are there any other actions you think that should be done?