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Health Management Associates, Inc. (NYSE:HMA)

Impending 60 Minutes Segment Conference Call

November 30, 2012, 08:00 a.m. ET

Executives

John Merriwether - VP, Financial Relations

Alan Levine - SVP and Florida Group President

Eric Waller - SVP and CMO

Operator

Good morning. My name is Rob, and I will be your conference operator today. At this time, I would like to welcome everyone to the Health Management comments on impending 60 Minutes segment conference call. All lines have been placed on mute to prevent any background noise. (Operator Instructions) Thank you.

Mr. John Merriwether, you may begin your conference.

John Merriwether

Thank you, Rob, good morning everyone. We apologize for the technical difficulties in getting the call started little late. I think we have everything ready to go. I’d like to welcome you to Health Management’s conference call. We anticipate this call to be brief.

As you may recall in July, we first called your attention to local newspaper reports on our Pennsylvania markets saying that 60 Minutes was interviewing emergency physicians who formally worked in some of our hospitals, then at the time we noted that a (inaudible) for 60 Minutes for soliciting contact from physicians through the American Academy of Emergency Medicines website.

Yesterday at approximately 5:30 p.m. Eastern Time, we received notification from the executive editor CBS’s 60 Minutes, they intended to broadcast a story related to Health Management on Sunday December the 2nd. Given that 60 Minutes has not released any indication on its website of the airing of the story, we continue to have no certainty about the exact contents of the story. Although we have been able to gather certain information about the themes of the story based on our interactions with 60 Minutes.

That said, we wanted to share some details with you about the operation of company by the company’s emergency departments. We appreciate everyone rearranging their schedules to be with us on such short notice.

Before we get started with the call I’d like to read our disclosure statement. Statements made in this presentation are based on current estimates of future events and the company has no obligation to update or correct these estimates. Listeners are cautioned that any such forward looking statements are not guarantees of future performance and involve risk and uncertainties that our actual results may differ materially result of these various factors. Additional disclosure statements accompany the data charts that have been provided for the call this morning at 8:50 a.m. Eastern Time.

Presenting with me on the call today are Alan Levine, Senior Vice President and Florida Group President; Eric Waller, Senior Vice President and the Chief Marketing Officer. Now let me introduce Alan Levine prior to assuming his role with Health Management Alan was Secretary of Health for both Florida and Louisiana and in those capacities led efforts to fight Medicaid fraud. For the past few months we have attempted to cooperate with 60 Minutes to provide information and answer their questions. Further Health Management provided an on-camera interview with Alan on October 8, 2012.

Alan Levine

Thank you, John, and good morning. First I’d like to reiterate what John said in that at this point we do not know for certain what specifically will be in the story other than what we can surmise from the questions I was asked during my interview with 60 Minutes. That having been said we do want to take some time this morning to share with you what we do know and to discuss our emergency room operations.

At Health Management it is our commitment to remain focused first and foremost by doing what is right for our patients; if we do this and we do we believe our hospitals and our company will thrive as we have. This strategy is proving results as evidence by the fact that the joint commission named 41 of our then 65 hospitals as top performers in the United States for 2011 which is a rate four times the national norm and it's a recognition earned by only 18% of hospitals nationally.

Fortune Magazine named Health Management one of the world’s most admired companies in healthcare including ranking us number one in social responsibility and number one in quality of product and service. And company-wide our hospitals compiled a score above 98 out of 100 for adherence to core measures process of care measures that are tracked by the centers for Medicare and Medicaid services. Our scores are among the leading scores in the industry. These results happened because we do measure what we do but focused on providing the best processes of care for our patients and the results do show.

We expect our physicians more than 10,000 affiliated and contracted physicians throughout the United States to consistently provide high quality care for our patients by adhering to evidence based practices in the exercising of their outstanding medical skills and patients are admitted from emergency departments only, only by primary care doctors, hospitalist or specialist exercising their independent medical judgment in working in consultation with our ER doctors. Simply put administrators cannot and do not admit patients.

In providing the highest quality care possible for our patients we also strive everyday to operate with the highest ethical standards and in compliance with the heavy regulatory requirements of our business. We have a comprehensive compliance program that seeks to assure that the laws are clearly understood and followed. When any employee, doctor, patient, member of the community or anyone raises complaints or concerns about our company or about our hospitals, we endeavored to fully investigate the concern and rectify any issues that are uncovered.

As I said, 60 Minutes questions to me focused on admissions to our emergency rooms and the general time period of late 2008 through 2011. An analysis of our admissions data by a third-party expert shows that during that time periods the admissions rates through Health Management’s emergency rooms remain consistent and completely in line with industry norms. We have seen no evidence of upward trends, spikes our jumps that could be attributed to anything going on in the emergency department. Given the hard data we remain uncertain about what to expect from the 60 minute story.

Just to repeat emergency room admissions data across our hospitals reflects no significant change and are in line with industry norms. We will discuss the admission data points with you in a moment and provide background on the analytics firm that conducted this review for us.

Based on the questions asked to me during my interview with 60 Minutes, let me discuss some of the areas I expect that they may cover in their report. While I hope the story is an accurate reflection of the challenges faced by our industry covering topics like, number one, overutilization of observation status classification for patients. It should be classified as inpatient. And two, the pressures created on hospitals by the recovery audit contractor process.

I understand that such topics do not make for sensational news. In fact we could spend days discussing the policy nuances of hospital operation and how these policies are impacting hospitals throughout the United States. Given that I’d relate that I did my best to educate 60 Minutes about the topics they raised. The realty is as the American Hospital Association has clearly articulated in their law suit against CMS, and in the public comments issued by the American Hospital Association and as a Center for Medicare Advocacy stated in their class action suit against CMS on behalf of senior citizens, Medicare beneficiaries are being severely impacted and hospital struggle with how to manage these patients between observation and inpatient status under threat of serious financial consequences or even inappropriate allegations related to admission.

Again I refer you to the AHA law suit for specific example. I’d also refer you to the study recently conducted by Brown University which is perhaps one of the best examples of how the shift is occurring. One of the hospitals cited incidentally in the American Hospital Association law suit is a neighboring hospital to Carlisle Regional and is not affiliated with Health Management. All told, I was asked extensive questions about whether Health Management has excessive admissions from our emergency departments, we do not. Further we provided 60 Minutes with hard data from the government to support it. I was also asked about hospital testing protocols. We follow recommendations made by the American College of Emergency Physicians related to triage-based testing, our hospital medical staff determined what testing is done and we measure our process of care results everyday to make sure we see patients timely, provide an accurate diagnosis and get care provided appropriately.

Since we take these matters so seriously we have been conducting an extensive review and internal investigation since we first became aware of certain allegations including those raised we think being raised by 60 Minutes.

We have retained some of the top experts in the United States to examine our practices, guide our internal investigation and evaluate our data. We looked at the data on our admission from both the ER and the number of test ordered for emergency patients both at the hospital and company levels.

Health Management’s review shows there is no basis for an allegation that admission through our emergency departments increased or not in line with the industry standards. This morning we have posted the results of the relevant data analysis on our website and we would encourage you to review it. You can access this data by visiting the company website at hma.com where you will see a button entitled ER admissions data. This button also resides on the Investor Relations page.

While we do not know for sure 60 Minutes did enquire about several former Health Management employees including some with pending litigation against our company. As always we will not comment about pending litigation and those matters will be handled appropriately not in the media but in the courts. Also we sincerely hope that 60 Minutes has the journalistic integrity to thoroughly investigate any claims or statements to assure that inaccurate allegations are not aired inappropriately by CBS.

Once again what our experts have determined was that the admissions data simply does not support any allegation that Health Management’s emergency rooms were operated inappropriately. Our performance on these metrics is in line with national averages, in our individual hospitals are in line with local competitors. Eric Waller will have more to say about data and other research in just a few Minutes.

Our industry faces serious concerns related to our regulatory environment. We have discussed many of these topics in detail with 60 Minutes and we hope they will address subjects like the proper classification of patients including the law suits filed against CMS by the American Hospital Association and the class action filed against CMS by the Center for Medicare Advocacy. These very law suits evidenced that hospitals throughout the nation and Medicare beneficiaries are faced with serious challenges related to the issue of observation and inpatient. Frankly, we don't understand how any story that discuses admission processes in the ER can be a fair story unless also appropriately tells the story that the industry is facing with the proper management of patients in the ER related to inpatient and observation status.

These are the last three points I want to emphasize. Number one, our focus has been and is now always on our patients. As long as we continue to do the right thing for our patients which means providing the highest quality healthcare that we can, successfully follow. Number two, we are proud of the work, our almost 45,000 employees and 10,000 affiliated staff physicians do every day to ensure the safety and wellbeing of our patients. And third, it is our goal to not only meet but exceed regulatory requirements by doing the right thing and providing the best care possible for patients. The joint commission is the agency that credits hospitals on behalf of the Federal government and the Federal government on credit agency has highlighted our hospitals as among the top performing in the United States.

The bottom-line is if we do missed out, we are fully committed to remitting any errors and improving our process to make sure it doesn’t happen again. That’s what you would expect from any responsible company. True to our mission to enable Americas best local healthcare. Our work often is what ensures our communities have a local hospital at all. So, patients can get the care they need close to home, fulfilling that mission is the basis of all of our success, clinically, operationally and financially.

Now I will turn it back to John.

John Merriwether

Thanks Alan. I’d now like to introduce Eric. As you may recall Eric gave a presentation at our 2011 Investor Day on the analytic capabilities that we are developing. Our leading edge use of the massive amounts of data we collect at our 70 hospitals helps us recognize pattern and our company’s patient data to predict the clinical needs of our communities potential for readmission rates, demand for services and staffing needs. Eric has led this and many other important initiatives for the company since he joined us in 2009. He will now take us through the research that company conducted including the data that undercuts the assertions that we believe 60 Minutes plans to report on.

Eric Waller

First of all thank you for coming. As Alan communicated we took this very, very seriously. What we get is we undertook an analytic unemotional unbiased effort to try to get at is (inaudible) data that would indicate what maybe the allegations made it through. The conclusion here is we find no validity in any of these potential allegations in the data that anything outside of industry norms.

We hired a firm called Opera Solutions. Opera is actually headquartered here in New York. Opera was recently selected by CMS to provide advanced analytical services to their exchanges, actually looked for fraud in the exchanges once they are developed. It's a very reputable firm. We provided Opera our data and said, look at it, we looked at it on a national level, we looked at (inaudible) level, we looked at it by DRGs and some of the stated approaches. We looked at it even down to the physician level doing some very advanced analytic technique.

And the conclusion is that our ER rate and I will just walk you through four very brief slides or five slides that sort of just very summarize what I’m saying. Our ER rates tracked the national norms. If you look at it over the period in question, we did (inaudible) we find no significant difference between the national averages and us. If you look at our hospitals and you normalize for service lines in a different age, different parts of the country of what older population in Florida, we find there are not statistically different than the average. It's not there.

And if you look at statistics from sample hospitals, we find it at local level that we are in line with local averages, local state averages. John will walk you through slide 2, it's hard to read. The first slide is probably the most (inaudible) is our ER admission rate was 13.3% in start of the period in ’08 and we actually in July of ’11 coincidentally are the exact same. The ups and downs in the chart are winter flu, it's up in the winter, it's down in the summer. You guys are the industry experts, so this is very, very familiar. So, the bottom-line it's been flat over the period.

If you look at the Medicare rates, the Medicare rates actually decreased, view their internal data from 36.4% to 34.4%, very flat decline and again these are in line with the national norms those statistical significance.

We looked at it sort of by hospital system and calculate our one day stay rates we used, we availed ourselves for the (inaudible) as well as our internal data about most of the data sources we would have accessed to. I know many of you have run these analyses to yourselves; we have seen them in reports. If you look at it by system it's about 10% and the red bar on the chart up there, and it's difficult to read, we are in the middle toward the back of the pack. And matter of fact we are the lowest as the first couple of months through 2011.

Let me shift gears for just a second that give you kind of a macro level view. Since Carlisle came up in a recent double based for our last earnings call there was a report in the Carlisle, it specifically mentioned Carlisle and I know one of you, Boyd Witt, mentioned Carlisle this morning in your reports. We mentioned in our July call as well. So, I want to give you a little bit of insight into Carlisle for that reason. If you look at Carlisle’s inpatient admission rate by year, it is actually below the national average least the other urban averages. The urban and rural. We fall (inaudible) 7% of our hospital, 85% of our hospitals overall are in the other urban category. And all of the hospitals in Pennsylvania are in the other urban category. And we are below the national average and we are at or below the Pennsylvania average. So, there is nothing there.

And if you looked at the one day stay rates in Carlisle Pennsylvania compared to that national average and the Pennsylvania other urban average as well. We are below those averages. We didn’t see anything in Carlisle Pennsylvania that would indicate anything out of the norm.

With that we have done exhaustive analysis even with to physician level, I don't have a slide to speak to it. We looked at the number of combinations emergency rooms, physicians do not admit patients they must consult whether your primary care physician, you must call a specialist, a cardiologist or one of the attending to admit so they have to partner as they should with other folks in the care and making the final admission determination. So, we looked at a representative hospital and 5,000 combinations of the multiple ER docs and ER with the multiple physicians that the primary care docs and other, 5,000 different combinations, so potentially 350,000 just do the simple math combinations it would be very, very difficult. We have a lot of people involved here. But we went down to the physician and it only brings that up to illustrate the level of effort we have gone to through Opera to look for anomalies in the data.

With that I will turn it back over to John.

John Merriwether

Thanks Eric. I think Alan wanted to add little something here before we conclude.

Alan Levine

Eric did a great job laying out the slides and I just want to add one thing, he mentioned HCUP (inaudible) which is the Healthcare Cost Utilization Project data. We often use the HCUPs data and the national emergency dataset for looking at our data primarily because that is the most nationally credible data that’s available. It's claims data, it's tens of millions of claims. It's the real data. There are multiple sources of data you can go to. Most of those other sources are voluntary surveys and other sources of the data. We went to the actual data source that researchers use, that CMS uses and that the HCUP data is ARC data. So, we went to the government for the government source of the data which is what is used throughout the industry and by analyst and by experts in analyzing trends in the industry. So, that’s why we chose the dataset and that’s why we chose Opera. Opera is very well regarded nationally as Eric mentioned they were selected by CMS to do CMSs own (inaudible) detection. So, we went to the best sources in the industry analysis.

John Merriwether

Thanks Alan. To follow that up we believe the data are very clear, it provide no basis to support allegations without emergency room [initiatives]. Our confidence that these allegations would not be supported by the data even before the analysis by the independent third-parties stems in part from our confidence and are very robust in comprehensive compliance program in Health Management.

Every Health Management associate receives compliance training upon being hired and at least annually thereafter. Including the annual review and signing of Health Management’s code of business conduct and ethics. It's commitment to our compliance program also extends to our vendors and physicians. They actively encourage our associates, report any questionable activities which might not be in compliance with our code of business conduct and ethics they we may investigate and resolve the concern.

I encourage you to review our code of business conduct and ethics which can also be found on our website at www.hma.com. In a moment we are going to be happy to take some question from those here in attendance and answer them as best we can given that we have not seen a story from 60 Minutes. After the story airs we will assess whether additional comment or information is necessary that will include our formal remarks. Just a couple of seconds here and then we will open it up to some questions here.

Question-and-Answer Session

Unidentified Analyst

[Question Inaudible]

Alan Levine

Two part question, the first part is, our physicians are in the emergency apartment employed by us or they outsourced. And the second part of the question is what’s the process for an admission. The answer the first question, we do not employ emergency room physicians, they are independent providers, normally under contract. I should also mention any contract physician is required to comply with our compliance policies as well, but the decision to hire or fire a physician in the emergency room is actually made by the independent group not by us. We have no direct authority to employ or deal with independent physicians. That’s handled through a, their private group or b, through the medical staff procedures that are deployed in the hospitals through the medical staff processes.

Second part of the question, the decision to admit a patient is a very complex medical decision that’s made by and using the independent medical judgment of a physician. That’s of a Medicare guidelines and we follow those guidelines. It's become more complicated because of the interference in that decision by for-profit, RAC auditors who are paid a contingency fee to come in and substitute their judgment for the judgment of the medical physician who actually examine that patients and made the decision about what was best for that patients that’s the essence of the law suit that’s going on right now between AHA and the Federal government.

What happens an ER patients comes into the hospital they are evaluated by triage nurse takes all their symptoms, our systems are deployed to do the proper testing that when the physician sees the patients they have all of the information they need to do a proper assessment of the patient. Remember in the ER timing is everything, if somebody comes in with a chest pain, if somebody comes in with a neurological issue, you want to make sure that you diagnose it quickly as possible so you can get treatment as quickly as possible. The ER physician if in their judgment they need additional testing, they order additional testing, we encourage the ER physician if presume most patients have a physician of their own. Many don't. We encourage the ER physician to contact the patients private physician because these ER physician in most cases never seen that patients before. We want them to have as much medical history on that patient as they can. That private physician consults with the emergency room physician and the private physician makes the decision whether or not to admit that patient. Sometimes that private physician could be a specialist, it could be cardiologist, it could be whatever doctors on call for that patient’s particular type of symptoms.

Once the decision is made to admit then all of the private doctors and all of the systems are deployed to get the patients quickly as possible up to a patient room. Now here is what also happens. When a patient is admitted to observation status, remember observation if you read Medicare’s own guidelines, observation is intended to be a 24 hour period or less, where the doctor can make you do additional testing and make their own decision about whether or not to admit the patient. Observation has never been intended to be a substitute for inpatient admission. And what you have seen in the Brown University study from 2007 to 2009 is that not only have observations exploded, but the number of observations that stayed two days or longer has also doubled. And so what happens is you have patients that could be put in observation status, those patients are sent to a floor just like an inpatient is. So, they are treated the exact same as an inpatient. They get testing, they get the same nursing care, they get the same everything.

At the end of the day, the patient often doesn’t even know whether they are in observation or inpatient until they get discharge. And if they are in observation status they get a bill because it's paid for by Medicare Part Billion, they have to pay a huge co-payment where they wouldn’t have to pay that co-pay has it been admitted and more importantly clinically. If a patient is put in an observation status that needed to be an inpatient that patient needs any post-acute rehab or nursing care. Medicare will not cover it, and the patient will often be asked to pay up to $10,000 or more out of their pocket in order to access those services. This is what happens if they can’t afford it. Patient ends up coming back to the ER, because they couldn’t get the post-acute services they needed.

So, this is the continuum of care issue that are raised earlier and it's the essence of the AHA law suit that’s been filed. But the process for admitting a physician and ER consulting a private physician and a private physician ultimately making the decision whether to admit that patient or not.

Unidentified Analyst

[Question Inaudible]

Alan Levine

I’m going to repeat the question, the question is in the Eric’s remarks earlier related to the differences in each of the markets and how the data maybe different in each market and adjustment. Let me be clear, the only adjustments to the data are actually labeled in the bottom of the slide and what they are adjusted for, is we wanted to make sure, I don't have the slide in front of me, but at the bottom of the slide that references the patients that left without being seen, patients that were transferred to other hospitals, those patients were removed. There was no adjustment made related to different hospitals. The data is absolutely clean. What Eric was referencing was that each hospitals going to have different admission percentages based on the dynamics in that market. For instance a rural hospital is going to have a lower admission percentage, we have hospitals that rule that have 5 to 6% admissions percentage. Whereas a high volume high intensity sophisticated hospitals, specialties is probably going to be upwards of I don't want to guess, but 20 or 30% depending on the type of markets. So, what Eric is referencing is variations by market and not in terms of adjustments to the data. Any data adjustments is at the bottom of the slide.

Unidentified Analyst

[Question Inaudible]

Alan Levine

Two parts of the question, the first part was Carlisle related to staffing and have we made changes to staffing at Carlisle and I will come to that in a minute. And the second part is and correct me if I misstate your question that the trends in the industry related to observation in inpatient and what r we seeing is that correct?

Unidentified Analyst

[Question Inaudible]

Alan Levine

Let me answer the second one first. In terms of the trends in the industry and HMAs Health Management’s metrics, I can’t comment on anything going on currently in the quarter, obviously that will occur to our proper reporting mechanisms. What I can say is what you have seen is similar to the rest of the industry, in fact we are seeing in terms of observations we are seeing the same trends, we are seeing growth in observations that are over two days. We are seeing which is troublesome to us because of the impact on seniors. Set aside all of the business metrics here, this is having a disgraceful impact on senior citizens when you have a senior citizen with a broken spine that it's an observation for five days and can’t get into post-acute rehabilitation that’s a story that ran in an ARP magazine. It didn’t happen in one of our hospitals but this is what’s going on out there and it is very harmful to seniors and that really fundamentally ethically why we think this needs to be addressed. But after the trends we are seeing the same trends as the rest of the industry.

Admissions pressure is the same as what we are seeing in the industry and Gary Newsome on one of our previous calls alluded to one of the challenges you see in our numbers is truly if you see the economic variations that are going on with joblessness. In the larger markets where people go for jobs, number one that you see migration towards markets where people go for jobs and those larger markets are typically not our markets, we are in the secondary and smaller markets primarily. And then those markets are also typically the first to come back. And so we think our metrics will follow just it's what you have been seeing in our quarterly reports.

As to the first question about Carlisle, I’m glad you raised it. I want to take a little liberty here. I’m glad Carlisle is coming up. Number one, to be clear last year Carlisle was one of the hospitals that was ranked by the joint commission as one of the top performing hospitals in the United States of America. Based on the process of care measures which are not subjective they are objective measures. We are very proud of what our staff and our doctors in Carlisle are doing.

From 2009 to 2011 Carlisle staff recruited more than 40 new doctors into the community. They added several new programs there including a major cancer program. And so we have seen very good success at Carlisle and let me tell you what happened to us about a year ago. We because of some of the success we’ve had with recruitment of physician and attracting people to that hospital we saw a sudden growth in our emergency room visits. And our staffing wasn’t prepared for that. And (inaudible) with the State of Pennsylvania citing us and all of that. And those issues were addressed in fact they were addressed even before the State cited us. One of the reasons I should mention 60 Minutes kept asking me about why we track admission percentages? Any hospital CEO will tell you one of the biggest challenges you have at staffing. You have to be reactive to your volumes, if you don't have good predictability in your admissions numbers you are going to have a staffing catastrophe. You are going to either be understaffed which is very bad for patients or you will be overstaffed which is very bad financially. So, we track our admission percentages on a daily basis so that we can project our staffing. That’s primarily why we do it in addition to making sure we are making the right clinical decisions for our patients.

At Carlisle we got surprised about a year ago with our staffing shortage in the ER. It was addressed and we are since in fact I got to tell you, today in the newspaper and the Carlisle one of the two Carlisle newspapers, it's a letter to the editor from a patient who was discharged about a week or so ago and said I’ve been reading all of the stuff about Carlisle. I don't know how you people are talking about, it was a best care I’ve ever had in a hospital. This was a letter that was in a paper today. We are pretty not proud of what’s going on in Carlisle we are proud of our employees there.

Unidentified Analyst

[Question Inaudible]

Alan Levine

Great question. The question is, what interaction have we had with regulators and other policy makers. We have a personally I have spoken with acting Administrator Tavenner to give her a heads-up about the story. We gave her heads-up about a month or so ago. When after I was interviewed we have met extensively with staff on Capitol Hill to brief them on it. One of the things that continue to come up as we talk to staff on Capitol Hill, as soon as I talk about this issues as soon as I mention observation in inpatient everyone understands the issue. They understand this is a major challenge and that’s a subject of major litigation now. And so we are like all of our colleagues in the industry, I talk to them all of the time, our competitors and other colleagues alike. We are all facing the same challenge. What are we supposed to do? Here is the bottom-line example, I mean if you don't admit a patients and you place them in observation and they stay in observation for three days, and they receive all of these services and then they get a bill or they can’t get post-acute services, we hear about it from the patient their family or maybe even their lawyers. We hear from the patient. And we are [going for it]. The hospital is [going for it]. If we admit the patient or if we advocate for admitting the patient then we are accused of improperly admitting patients.

Our bottom-line is this irrespective of all of these other issues that are out there. The guidance that I personally give our doctors and our hospitals is do the best for your patients. Do what you think is medically appropriate for your patients. We will deal with all of the other issues later. Don't ever put us in a position of not providing what’s best for your patient strictly for administrative or financial reasons, that’s the last thing that you should do.

Unidentified Analyst

[Question Inaudible]

Alan Levine

Let me repeat the question. Looking at the slide from 2007 to 2009 or 2010, the admit was overall just a percentage of increase. You have to look at this slide side by side with one day stay, with the one day admission. Let me tell you why? As I mentioned in beginning of 2008 we began doing aggressive physician recruitment into the community as the community was growing. We recruited more than 40 new doctors into the community from 2008 to 2011. We got in several new programs in the hospital including a cancer program. It's a high acuity programs, among the doctors recruited were neurosurgeons, [dental] surgeons, oncologists. These are high acuity doctors. Previously those patients would be set somewhere else. We care for. Because they could be cared for now Carlisle what you will see is your higher acuity admissions will go up. You have to look at the one day admission. The one day admission is what CMS looks at, that’s where you have potential liability for patients that could have been in observation or couldn’t (inaudible). And if you look at the one day admission, not only are we below the average each of those years but we were declining in each of those years. If we were doing something, if we were inappropriately admitting low acuity patients that didn’t belong in the hospital, you would have seen one day admission percentages go up. You wouldn’t see them go down. The data is absolutely conclusive.

Unidentified Analyst

[Question Inaudible]

Alan Levine

The question is about ProMED, how we use it in the ER and question is about why we stopped using it. First, let me tell you little bit about what ProMED is. If you Google emergency department IT systems, you will find probably 10 or 11 different companies that do what ProMED does. A pulse check, which incidentally is a system that’s used by our competing hospital from Carlisle. It's used down the street at one of the other hospitals. Pulse check does all the same things ProMED does. T-systems, there is multiple IT system that do this.

The American College of Emergency Physicians in 2004 put out a white paper where they talked about the need effectively for, let me back up a minute. There is two big group that represent the ER physicians. The American College of Emergency Physicians which represents more than 30,000 emergency room physician throughout the country and the American Academy of Emergency Physicians which represents about 2,000 ER doctors. The American College of Emergency Physician is the recognized authority on ER care. We followed their white papers and their guidance very closely. We read what they put out and we tried to follow what they put out.

The ACEP recommended in 2004 a couple of things. Number one, they recommended triage based order sets. Basically permitting triage nurses to order test that are predetermined based on patient’s symptom, so that the test can be rapidly so that you can improve throughput through the ER. ProMED does that. What happens is patients comes into the ER and they just their symptoms, they give triage nurse their symptoms. The triage nurse put the symptoms into the computer, the computer has predetermined test maps and the process for those test maps to be predetermined is very important. Those test maps are determined by ER board certified ER doctors, they are approved by the medical director of the ER in each hospital and the elected medial executive committee of each hospital which acts independently of the hospital has to approve all standing orders. So, these are all covered and joint commission reviews these as well as part of the accreditation process. And so all of our hospitals obviously are compliant with joint commission and 65% of them are top performers.

So, we follow all of those guidelines to make sure that the primary issue with ProMED is to number one make sure that when a patient comes into the ER we capture the symptoms appropriately and we get the proper testing done. Another important feature of ProMED is that ER doctor can cancel test that they don't want. And so there is what we call true test and false test. Meaning a true test is a much smaller sample of test where the triage nurse basically send in those test are ordered. There is false test where the ER doctor has to approve the test before they are ordered. So, we believe that ProMED complies with all of the standards in the industry when you Google the other systems, the other pulse check T-systems, and you read the highlights of what those systems do and you read their case studies, they talk about improving throughput through automated order sets and evidence based order sets, it's exactly what ProMED does. Number two, ProMED also uses what’s called intercall criteria what’s called [Call Check]. If the patient needs inpatient criteria based on the intercall criteria, we let that physician the system lets the physician know that. And the physician then makes the decision whether they want to admit the patients or not. They don't have to admit the patient. They can send the patients home.

Now let me tell you what happens. If the patients meets inpatient criteria, we have what’s called flash meetings every morning in our ERs. The American College of Emergency Physicians in one of their white papers recommended that there would be routine communication between administration, nursing and ER physicians. We have those meetings every single morning, we talk about patients that left without being seen, patients that were transferred out of hospitals. We talk about patients that met criteria for admissions but weren’t admitted. And we also talk about patients that were admitted to inpatient that may not have needed to be admitted. We do these real time audits to make sure that the patient is in the right setting.

The reason we do this is if a patient meets criteria for admission but is sent home, that patient maybe exposed to unnecessary risk. We talk about it to make sure that we haven’t exposed a patient to risk. Similarly, a doctor might have a patient in the hospital, in does not meet intercall criteria. If that occurs and we usually find that in our audit process, if that occurs we go to the doc and we say patient does not meet intercall criteria, what you want to do? The doctor has the option of saying notwithstanding the fact it doesn’t meet criteria I want to keep that patient in the hospital, we asked the doctor the document the reason for keeping the patient in the hospital.

If the patient or the doctor can then convert the patient to observation status and that’s one of the (inaudible) right now, because that patient could be converted to observation and the patient not even know. They think they were admitted but then they were converted. The bottom-line is that what ProMED does is it basically if you read the checklist manifesto that Atul Gawande wrote, that ProMED and all of this IT systems are nothing more than a checklist for doctors, so that they make sure that they don't miss anything so that they don't expose a patients to unnecessary risk, no matter what we do in the ER, no matter what happens after the ER, there are multiple audit systems in place either through our own company or through the RAC audit process. So, it's really important for us to get it right and that’s why we use this metrics.

Eric Waller

We made available on our website the ProMED timeline, the issues with Tenet and the CHS and the ProMED, we make available at timeline when we made a decision to go from ProMED to MEDHOST. There are links to internal documents where we setup committee to look at the software and these pre-date any sort of public problem or issue with ProMED. And sort of give you the business outline after we got three or four different internal memos and a timeline, ultimately we like to just sort of put the decision to switch from ProMED to MEDHOST to rest. And it's purely a business decision, I have nothing to do with any problems with ProMED and that’s available on the website as well.

Unidentified Analyst

[Question Inaudible]

Alan Levine

The question is whether there is any other hospital other than Carlisle ? At this point we don't know.

Unidentified Analyst

[Question Inaudible]

Alan Levine

The question is whether we gave this data 60 Minutes and the answer is yes.

Unidentified Analyst

[Question Inaudible]

Alan Levine

The question is test per patient in ER and I will tell you we are very comfortable based on the data that we have seen, that our test per patient hasn’t changed.

Eric Waller

The same sort of time period, we look at the average test by Medicare patient and average test order by all patients. And we found no changes.

Unidentified Analyst

[Question Inaudible]

Alan Levine

The question is what percentage of the docs override ProMED? We don't really know that and I should also add, each hospital test maps can be different based on the local medical staff’s preferences. So, we wouldn’t have any way of centrally measuring that but what we would expect is that if an ER doctor was routinely overwriting for saying I don't want a certain test, we would presume that the ER doctor will talk to the ER medical director and they would eventually change that order set to better reflect what the local physician want. But at the end of the day the physicians ultimately have to do the orders.

John Merriwether

Thanks everybody. That’s going to wrap up the call. We appreciate your attention and have a great day.

Operator

Ladies and gentlemen this concludes today’s conference call you may now disconnect.

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