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Tuesday, April 2, 2013

Blood on the tracks in Reno

Updated: Jim Miller steps down as CEO of Renown
Apr. 2, 2013 12:09 PM by Bill O'Driscoll,

Jim Miller today stepped down as president and CEO of Renown Health.

The announcement follows a review by the Renown board of directors of events that led to a recent court settlement of a lawsuit between Renown and 12 cardiologists, part of the former Sierra Nevada Cardiology Associates acquired by Renown in 2010, that resulted in Renown paying them $4 million in compensation as well as $872,000 in attorneys’ fees.

Today’s announcement also said three other Renown executives involved in the SNCA transaction – general counsel Kelly Testolin, vice president of system development Andy Pearl, and business development administrator Phil Schweber – have left effective immediately...
Wow. Testolin was one of our HealtHIE Nevada HIE Cross-functional Consent Task Force members (with which I have served), who, along with another lawyer from one of our large southern Nevada health systems, served principally to throw you-Unwashed-non-lawyers-just-don't-get-it sand in the gears over issues such as the proper interpretation of the phrases "opt-in" vs "opt out" in the new Nevada HIE law, SB43. SB43 contains the word "opt" merely twice -- each time followed by the word "out," yet these Legal Eagles concluded that such dictated that "we are clearly an opt-in state."

Renown was considered a Big Catch for our HIE, given that they so dominate northern Nevada medical care (we have only two population centers comprising 90% of Nevada population - Metro Vegas area and the smaller Reno-Carson City area).
On Jan. 1, 2000, Miller took over as president/CEO of what was then Washoe Health System, which operated Washoe Medical Center -- now Renown Regional Medical Center -- at Mill Street and Kirman Avenue just east of downtown Reno.

Miller, a Texas native raised in Southern Nevada, came to Reno in 1983 as controller at Washoe Medical Center. He worked his way up to executive vice president and chief financial officer before he was named CEO.

Over the next 13 years, Miller oversaw tremendous growth in Northern Nevada’s largest health-care system, including the opening of a health-care campus off of South Meadows Parkway in south Reno.

The biggest change came in 2006, when Washoe Health System -- the name’s origin dates to the 1870s as Washoe County Hospital -- became Renown Health, retaining its non-profit status put in place in 1985...

The company continued to growth, acquiring Sierra Nevada Cardiology Associates in 2010 and, a year later, Reno Heart Physicians, both entities at the time handling nearly all of the cardiac-care business in Reno-Sparks, according to Kent Robison, attorney for the SNCA physicians.

In November 2011, the SNCA cardiologists filed suit against Renown, with Miller as a defendant, alleging fraud by using “bait and switch” tactics in the negotiations to buy the practice.

Before that, the acquisitions had drawn regulatory attention on anti-trust grounds. Under a settlement with Renown, the Federal Trade Commission last December ordered Renown to release the SNCA cardiologists from non-compete clauses in the their contracts. Seven of them went to Saint Mary’s Regional Medical Center in Reno and five joined Northern Nevada Medical Center in Sparks...
Be interesting to see how this shakes out for our HIE work. This is not the first -- nor will it by any means be the last -- of contentious legal dustups over health care vertical integration and coercive consolidation buy-outs as Suits everywhere try to position themselves to capitalize on PPACA related economic imperatives.

Drive-by iPhone shot from my rental car.
Local NBC affiliate KRNV has the story as well.

...Renown CEO Jim Miller has stepped down and will leave the health network. Three other Renown executives involved in the SNCA transaction – general counsel Kelly Testolin, vice president of system development Andy Pearl, and business development administrator Phil Schweber – have also left effective immediately.

"There is no question that things did not go as planned," said Renown Health board chairman David C. Line, "and for that we are sincerely sorry. As an organization, we have been committed to taking whatever steps are necessary to make sure that our policies, procedures and communications are as world-class as the health care we provide. If the execution of the SNCA transaction had been as solid as our intentions, none of this would have occurred."

To ensure continuity of leadership while a national search for a chief executive is under way, the board has named healthcare industry veteran Donald C. Sibery as interim Chief Executive Officer. Sibery brings to Renown more than 35 years of experience as a health system chief executive and chief operating officer. Line was also appointed to serve as Renown’s president on a temporary basis to lend additional support to Sibery and the senior leadership team. Sheryl Feutz-Harter was appointed to the interim legal counsel role.

In announcing the changes, Line emphasized the depth of Renown’s senior leaders, who average 24 years in healthcare. "We couldn’t ask for a more capable and dedicated team," Line said.

To lend additional national perspective on emerging developments and best practices in healthcare, the board has elected as its newest member Michael Peterson, who most recently served as a top executive at Stanford Hospital and Clinics in Palo Alto, Calif., including eight years as its chief operating officer.

A Physician Collaboration Committee also will be established and be chaired by board member and physician Lesley Smith. Additional details will be announced at a later date after Dr. Smith and others have discussed how best to structure the initiative to enhance trust and facilitate the sharing of ideas and concerns between the physician community and Renown...
Jim Miller was "upset about leaving" the hospital, but Miller will be paid for the remainder of his two year contract with Renown.
$916,000 a year. Dude won't be missing any meals anytime soon (anyone know any cardiologists making $916k annually?).

From another KRNV piece:
...Board Chairman David Line says the board did not receive critical information from Renown's legal team and he says that why the board did not take action earlier. Line told News 4, "We as a board are putting processes in place. We depend on senior management team including counsel to bring us all the pertinent information so that decisions can be made. That did not happen."

News 4 asked David Line if they considered suing their legal team? Line first said that was not an appropriate question, then he said its something they are considering.
Defendant Testolin? Pass the popcorn.

I and a couple of my REC/HIE colleagues spent the day here, assessing workflow issues:

HAWC heroically, ably serves northern Nevada populations on the margins, from the homeless to the otherwise socioeconomically hapless. Wonder what they could do with an additional $916k a year?

Renown Shake-Up: Should Board Step down?

RENO, Nev. (KRNV & - Renown Medical Center is experiencing major fallout as the hospital's top four executives have all stepped down - effective immediately. This happens as the Hospital Board tries to shake off some major legal issues that have plagued Renown recently.

The health system board at Renown has been mum for several weeks, Tuesday they broke their silence - announcing the management changes. The board is not accepting any responsibility for the problems that taken place.

Board Chairman David Line told News 4 that in the case of the FTC investigation of Renown's acquisition of two local cardiology groups, Renowns' lawyers failed to inform the board the FTC had warned Renown against the acquisition.

When a group of local doctors claimed Renown had changed the terms of the contracts without telling them, Line again said he was never informed of that, even though the doctors told the board face to face what was happening. That case then went to court and Renown paid out nearly $5,000,000 in a settlement.

Line says he and the board are not to blame. The Fact Finder team asked Line: Given everything that happened have you considered stepping down. Lane told News 4, "At this point in time no. All of the board members are community based and we had the review committee come in, I told them to start looking at myself all the way on down."...

The Federal Trade Commission (“Commission”), having initiated an investigation of the acquisition by Renown Health of Reno Heart Physicians (“RHP”), and Renown Health (hereafter referred to as “Renown Health” or “Respondent Renown”) having been furnished thereafter with a copy of a draft Complaint that the Bureau of Competition proposed to present to the Commission for its consideration and which, if issued by the Commission, would charge Respondent Renown with violations of Section 7 of the Clayton Act, as amended, 15 U.S.C. § 18; and

Respondent Renown, its attorneys, and counsel for the Commission having thereafter executed an Agreement Containing Consent Orders (“Consent Agreement”), containing an admission by Respondent Renown of all the jurisdictional facts set forth in the aforesaid draft Complaint, a statement that the signing of said Consent Agreement is for settlement purposes only and does not constitute an admission by Respondent Renown that the law has been violated as alleged in such Complaint, or that the facts as alleged in such Complaint, other than jurisdictional facts, are true, and waivers and other provisions as required by the Commission’s Rules; and

The Commission having thereafter considered the matter and having determined that it had reason to believe that Respondent Renown has violated the said Act, and that a Complaint should issue stating its charges in that respect, and having thereupon issued its Complaint and its Order to Suspend Enforcement of Renown Non-Compete (“Order to Suspend Enforcement”), and having accepted the executed Consent Agreement and placed such Consent Agreement on the public record for a period of thirty (30) days for the receipt and consideration of public comments, and having duly considered the comments filed thereafter by interested persons pursuant to Commission Rule 2.34, 16 C.F.R. § 2.34, now in further conformity with the procedure described in Commission Rule 2.34, the Commission hereby makes the following jurisdictional findings and issues the following Decision and Order (“Order”)...


IT IS FURTHER ORDERED that Renown Health shall notify the Commission at least thirty (30) days prior to:

A. Any proposed dissolution of Renown Health;
B. Any proposed acquisition, merger or consolidation of Renown Health; or
C. Any other change in the Renown Health, including but not limited to assignment and the creation or dissolution of subsidiaries, if such change might affect compliance obligations arising out of the Order.


IT IS FURTHER ORDERED that, for the purpose of determining or securing
compliance with this Order, and subject to any legally recognized privilege, and upon written request with reasonable notice to Renown Health, Renown Health shall permit any duly authorized representative of the Commission:

A. Access, during office hours of Renown Health and in the presence of counsel, to all facilities and access to inspect and copy all books, ledgers, accounts, correspondence, memoranda, and all other records and documents in the possession or under the control of Renown Health Related To compliance with this Order, which copying services shall be provided by Renown Health at the request of the authorized representative(s) of the Commission and at the expense of Renown Health; and

B. Upon five (5) days’ notice to Renown Health and without restraint or interference from Renown Health, to interview officers, directors, or employees of Renown Health, who may have counsel present, regarding such matters.
FACT FINDER: Legal Case Costs Renown $ 15 million
...Sierra Nevada Cardiology sued  Renown claiming the hospital cheated them by changing the terms of the doctors contracts and cutting their pay, after an agreement was in place.

Reno cardiologist Dr. Kosta Arger was one of the doctors who sued.  He's also a former Renown board member.

"It was clear the administration decided at some point to change the contract without informing us," Arger said.

The hospital's board of directors won't tell News 4 why they decided to settle the case in the middle of a four week trial. But it's clear Judge Brent Adams was frustrated with the sworn testimony provided by the Renown president and CEO.  First, questioning him about what the judge called a phony letter from a high ranking Renown administrator.

"You ( Referring to Miller ) don't know who created it,  you don't know who gave the authority for it, you don't know why it was prepared, you don't know to whom it was sent.  What's going on ?"  Judge Adams asked Miller.    The judge then commented on Miller's evasiveness on the stand at another point , saying: "Mr. Miller, not every decision in a hospital is someone else's decision.  Some decisions, somewhere, must be made by you," The judge told Miller.

Several Renown Board members were in the courtroom watching it unfold.

"My view of it was the Renown defense had hoped Mr. Miller would clarify and clinch things for them. And as it turned out it was an embarrassment for them.  And that point they realized they had to throw in the towel," Dr. Arger said.

Sources tell the Fact Finder Team that just two days after Miller's testimony, Renown's board of directors held an emergency meeting on Superbowl Sunday.   And 24-hours after that a settlement was in place, with Renown agreeing to pay the Sierra Nevada Cardiology Group five million dollars. That's money the doctors say Renown guaranteed them when the hospital acquired their practice, but never paid.

But that five million dollars is just the tip of the iceberg in money spent.  The Federal Trade Commission conducted a thorough investigation in conjuction with the Nevada Attorney General's office and found those deals gave Renown 88 percent of the cardiologists in the market.  A monopoly, in violation of the law...
Some sorry stuff, this is. I don't see any way this can't but ripple out negatively into adversely affecting our HIE initiative. Lots of Renown Suits are gonna be skulking around in low profile in the coming year. No one's gonna want to stick their necks out into any areas that might prove contentious.


Renown's treatment of all constituents needs review

...The former Washoe Medical Center has undergone enormous change since Washoe County sold it to the nonprofit that now operates the hospital and all of its offshoots.

In recent years, new buildings have been built or purchased. Medical groups, specialty practices and urgent care centers have been opened in every corner of Washoe County and as far away as Fernley, Fallon and Silver Springs.

Renown is not alone. Similar consolidations of health-care services are going on all across the nation, with growing hospitals at the center of the changes.

The growth that Renown has experienced has not been without turbulence, however. A few years ago, the organization’s leaders were locked in a bitter battle with unionized nurses, who complained of part-time nurses brought in from out of state and claimed that patients were endangered by the hospital’s personnel policies, claims denied by Miller and others in the hospital’s administration.

Patients also have complaints about their treatment and their bills.

The complaints came to a head, however, when doctors from Sierra Nevada Cardiology, which was purchased by Renown in 2010, filed suit against Renown, accusing the medical system of using “bait and switch” tactics in the negotiations with SNCA. In December, the Federal Trade Commission ordered Renown to release the doctors from the noncompete clause in the sale agreement.

Then, in February, Renown settled the lawsuit with Sierra Nevada Cardiology, agreeing to pay the doctors $4 million, along with $872,000 in attorneys’ fees.

To its credit, Renown’s board of directors ordered an independent review of the events that led up to the settlement. Miller’s resignation — along with those of general counsel Kelly Testolin, vice president of system development Andy Pearl and business development administrator Phil Schweber — followed the review.

What’s needed now is a much broader review of how the system operates and how it deals with all of its constituents — doctors, nurses, staff and the patients who depend on it, often for their very lives.
apropos, from Forbes

Who's To Blame For Our Rising Healthcare Costs?

...Many independent practicing physicians are seeking employment at larger hospital systems to avoid administrative burdens.  Forty percent of primary care physicians today who see patients at hospitals are employed by the hospital, which has doubled since 2000.

But hospitals may not be the solution for lowering healthcare costs in the United States.

Hospital costs during 2010 in the U.S. constituted $814 billion or 31.4 percent of all healthcare expenditures. Furthermore, the cost of care will only continue to rise as we shift into a consolidated healthcare system and programs like Medicare allow higher payments for services performed in hospitals as opposed to independent private practices. One widely reported example found a Nevada patient whose echocardiogram bill came to $373 before the physicians’ practice had been purchased by a hospital system and then increased to $1,605 after the merger...
Finally, an observation from The Wall Street Journal
According to the Medicare Payment Advisory Commission, a 15-minute doctor visit cost the program about $70 last year at a free-standing physician practice, but the same visit ran about $124 if it was billed as a hospital-outpatient service. WellPoint Inc. recently cited an example in which the cost for a spine MRI done at a free-standing physician center in Nevada ranged from $319 to $742, while the same test done by a hospital would generate charges from $1,591 to $2,226. No wonder hospitals are so eagerly recruiting physicians from private practice to join their systems.

These large health entities are destroying any hope for real competition in the medical marketplace, driving out or buying out independent doctors and extracting as much money as possible from taxpayer-funded entitlements and the privately insured.

 On April 12, 1955, Jonas Salk, who had recently invented the polio vaccine, appeared on the television news show “See It Now” to discuss its impact on American society. Before the vaccine became available, dread of polio was almost as widespread as the disease itself. Hundreds of thousands fell ill, most of them children, many of whom died or were permanently disabled.

The vaccine changed all that, and Edward R. Murrow, the show’s host, asked Salk what seemed to be a reasonable question about such a valuable commodity: “Who owns the patent on this vaccine?” Salk was taken aback. “Well, the people,” he said. “There is no patent. Could you patent the sun?”...
In 2009, the American Civil Liberties Union and the Public Patent Foundation brought a lawsuit, on behalf of more than twenty plaintiffs, against Myriad and the U.S. Patent and Trademark Office, challenging claims on Myriad’s patents and on the right of any company to patent gene sequences. (The company’s responding brief is here, and a collection of documents pertaining to the suit, assembled by the Genomics Law Report, can be found here.) On April 15th, after several years of appeals and reversals, the Supreme Court will hear arguments on the essential issue: Should human genes be patented?...
 “If these patents are enforced, our genomic liberty is lost,” Christopher E. Mason, of Weill Cornell Medical College, said. He and Jeffrey Rosenfeld, an assistant professor of medicine at the University of Medicine & Dentistry of New Jersey, published a study last week in the journal Genome Medicine demonstrating that, when one looks not just at entire genes but at DNA sequences contained within them, nearly the entire human genome is covered by patents. “Just as we enter the era of personalized medicine, we are ironically living in the most restrictive age of genomics. You have to ask, how is it possible that my doctor cannot look at my DNA without being concerned about patent infringement?” The biotechnology industry contends that if the patents aren’t upheld, entrepreneurs and many businesses, particularly pharmaceutical and agricultural companies that rely heavily on genetically-modified products, will have less incentive to innovate.
In arguments before the appeals court, lawyers for Myriad compared the use of the genes that the company has patented with efforts to extract minerals from the ground. Without the man-made process of extraction, the minerals are useless. When Judge William Bryson of the United States Court of Appeals for the Federal Circuit asked Myriad’s attorney Greg Castanias if that meant that simply getting an element out of the ground ought to be considered an invention—he used lithium as an example, but he could have chosen anything from the periodic table of elements—Myriad’s lawyer said yes. 
Jonas Salk would not be amused, but if the Supreme Court buys Myriad’s argument, the sun, along with the carbon, hydrogen, and oxygen contained within it, will indeed be up for grabs. And so will every gene in our bodies, as well as all the DNA that scientists have mined, with increasing success, in their efforts to overcome the diseases that plague us all.


It may appear that the clinical research enterprise is functioning well, even thriving. Nearly 30 000 trials globally are recruiting patients,1 and results from 75 trials are published daily in biomedical journals. However, there is a crisis, with an attendant opportunity, that requires change. A wall surrounds much of these clinical research data, sequestering knowledge, impeding the free flow of information, and obscuring a clear view of the totality of evidence relevant to many research questions and clinical decisions...
Link here (full article firewalled -- ahh.h... the Irony Free Zone. The Wall Must Come Down, except for the JAMA firewall, of course).


My hotel lobby (Hyatt Place, Reno airport), quick iPhone shot.

Pretty nice place.

Below, our 3rd HAWC clinic site visit in 2 days.

Downtown HAWC homeless clinic in the morning (Thursday). Very interested to see that. Back to Vegas tomorrow night.


$12.658 bllion paid through February 2013, two thirds of that to EHs.


I may go to this ASA presentation, Chebyshev-ista that I am.
Laplace Probability Distributions and Generalizations: An Excursion Beyond Normality

Abstract: Skew Laplace distributions, which naturally arise in connection with random summation and quantile regression settings, offer an attractive and flexible alternative to the normal (Gaussian) distribution in a variety of settings where the assumptions of symmetry and short tail are too restrictive. The growing popularity of the Laplace-based models in recent years is due to their fundamental properties, which include a sharp peak at the mode, heavier than Gaussian tails, existence of all moments, infinite divisibility, and, most importantly, random stability and approximation of geometric sums. Since the latter arise quite naturally, these distributions provide useful models in diverse areas, such as biology, economics, engineering, finance, geosciences, and physics. We review fundamental properties of these models, which give insight into their applicability in these areas, and discuss some extensions, including time series and stochastic processes.
 I loves me jargon when it comes to stats. And, "excursions beyond normality" are the "norm" rather than the exception -- a reality lost on a lot of statistical dilettantes.


Playing politics with patients' lives. Full story on The Washington Post.

More to come...

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