In Florida, a long-running healthcare industry legal battle could be coming to an end, thanks to the rare feat of passing bipartisan legislation affecting trauma centers.
The legislature this week passed a bill that will change how trauma centers are distributed throughout the state. It will also designate some HCA facilities as trauma centers, thus ending several legal challenges. And it will establish an advisory council that can help resolve future conflicts.

What exactly is a trauma center?

“Emergency rooms are not trauma centers,” according to the Florida Committee on Trauma. Whereas any emergency room has staff who can treat a broken bone or mild burn, a facility that is designated as a trauma center “has highly trained specialists in-house or immediately available 24 hours a day, 7 days a week.”
Trauma centers must meet certain state standards and are specially prepared to handle things like major car accidents, severe burns and gunshot wounds. A trauma center can be part of a hospital or in some cases, a stand-alone facility.
Like it or not, healthcare in America is a business, and hospitals must compete for patients, their paying customers. Because hospitals are expensive to run, the state wants enough of them to serve the population, but no so many that patients are spread thin and rates increase. Like about 30 other states, Florida regulates how many hospitals can open, and where. The state regulates trauma centers in similar fashion.
There are 303 hospitals in Florida, 209 of them with emergency departments, according to the Florida Hospital Association. Yet the state has only 27 trauma centers.
Under current regulations, which have been in place for 26 years, a hospital can receive a designation as a Level I, Level II, pediatric or provisional trauma center depending on its offerings. Florida’s 67 counties are divided into 19 “trauma service areas” and only a certain number of trauma centers are allowed in each.
In recent years, for-profit HCA Healthcare pushed to open trauma centers at more of its hospitals. Competitors balked, filing legal challenges that have wound through the courts for a decade.
Some have argued the market should be opened and hospitals should be allowed to open more trauma centers in crowded or lucrative areas. Others have argued that such a move would siphon patients from needier areas and disadvantage rural and community hospitals.
Legislators this year, after exhaustive meetings with hospital industry leaders, said they have finally worked out a compromise. New rules would dictate that no service area can have more than five trauma centers, nor more than one stand-alone pediatric trauma center. The service area borders would be adjusted and the number of areas would drop from 19 to 18. The Department of Health would establish an 11-member Florida Trauma System Advisory Council, which would begin meeting in 2019.
The new rules would also settle the litigation by approving three HCA trauma centers: at Kendall Regional Medical Center, Orange Park Medical Center and Aventura Hospital & Medical Center. One HCA facility, Northside Hospital in St. Petersburg, would not be allowed to proceed with trauma center designation.
The bill passed the state House and Senate unanimously and will go to Gov. Rick Scott for his signature.
Income from red-light camera violations has helped fund trauma centers in Florida to the tune of $12.6M in 2012. Following a mass shooting incident at Marjory Stoneman Douglas High School in Parkland Feb. 14, state lawmakers have been considering measures that would take money collected from applications for firearm licenses and direct those funds to trauma centers as well.

Source: Bisnow

While most of the rest of the real estate investors vie for industrial product and the other more recognizable asset classes, Virtus Real Estate Capital is opting out and doubling down on “cycle-resilient” real estate investments like medical office buildings.

“The easy money has been made in commercial real estate. The easy money has even been made in our property types, which are still more nascent and still have more opportunity than traditional property types,” Virtus Real Estate Capital founder and CEO Terrell Gates told National Real Estate Investor. “We’re no longer in the part of the cycle where you can just sort of put it to work, go long and hope everything works out. We believe you’ve got to dig a little deeper than that.”

According to Gates, high occupancy created by sluggish pipelines and strong, stable demand are what attract him and Virtus to MOBs. Despite strong demand for the product, inventory has crept up by only about 1%, meaning that fundamentals are on the way up.

“New supply is rarely an issue in medical office because there are a lot of natural barriers to entry that keep inventory growth very low. Over the last five years, despite overwhelming demand from tenants and healthcare systems for more healthcare space, inventory growth has averaged less than 1%. What little inventory has been delivered is mostly replacing older, functionally obsolete product. So, for that reason, you’ve seen increasing occupancies, increasing rental rates and overall positive trends for the underlying medical office assets,” Gates said.

Source: Bisnow

The number of people seeking hospice care is growing statewide as the population ages and health care evolves, resulting in an increasing need for compassionate end-of-life care.
Florida has the second most hospice patients in the nation. Only California has more, while Texas ranks third, national health care data show.
The number of people receiving hospice care in Florida has increased steadily for at least the past 14 years although there was a slight dip in patients one year about about a decade ago, said Paul Ledford, president and chief executive officer of the Florida Hospice and Palliative Care Association.

“The increase in number has slowed a little bit. It used to be it was increasing 4, 5 or 6 percent. Now it’s down to a 1 percent and 2 percent increase annually,” Ledford said.

Florida residents receiving hospice care — either at in-patient facilities or at home — last year are on track to total at least 130,751 admissions statewide, according to health care data to be published in about two weeks, Ledford said. Total hospice admissions were 128,878 in 2016, and 126,156 in 2015, he said.
Ledford said only 3.4 percent of patient days in Florida occur at a hospice in-patient unit. The remaining 96.6 percent of patient days occur where the patient resides, he said.
Florida has 48 hospices. About three quarters of them are nonprofit, while the rest are for-profit, according to national health care data.

Source: Florida Times-Union

A bill that expands direct primary care services is on its way to the Governor’s desk for final approval. Supporters of the measure believe that in the end, separating primary care doctors from insurance standards will ultimately trickle down benefits to the healthcare industry.
Direct primary care is a model where patients pay monthly fees to their doctors for specific care without dealing with insurance companies.
Currently, these agreements are not subjected to insurance regulations, but there is no written law that guarantees that. A bill on the way to Governor Rick Scott protects these direct care agreements, keeping them out of the Florida Insurance Code.
Rep. Danny Burgess (R-Zephyrhills) believes the model could lead to more preventive healthcare.

“With more affordable primary care, we’re going to be focusing in on more preventative medicine. Hopefully mitigating the need, more so than not, to have to present themselves to an ER, to an Urgent Care, or to other forms of potentially catastrophic situations. So preventative care is key, and we need to encourage that, and I think this bill actually helps do that,” Burgess says.

Sen. Tom Lee (R-Brandon) says this measure will not only benefit patients, but doctors who can circumvent the time consuming insurance process.

“We’re obviously looking for ways to be more creative, to offer different service delivery models here in the state of Florida. And this is an approach that would allow direct primary care physicians who want to take advantage of this opportunity to enter into agreements and avoid the 30% to 35% of their staff time that ends up getting consumed in dealing with insurance companies,” Lee says.

Not all lawmakers are believers. Rep. Richard Stark (D-Weston) is fearful the bill could lead to more cases of patients being scammed.

“Eventually people looking to begin marketing it, eventually insurance agents in the field will probably sell it, and unfortunately people who are not licensed, have no idea what’s going on in the healthcare delivery system, they may be marketing this. And we’ve had plenty of scams in the past where people buy what they call ‘discounts to see doctors’, even though this not, it’s similar. And then people use this and they think they have insurance when they don’t,” Stark says.

Because the practice is relatively new, there is not enough available research showing its effects. But, the model has been endorsed by organizations like the Heritage Foundation and Heartland Institute. The bill is now awaiting Governor Rick Scott’s signature.
Source: Florida Trend

The Miami Medical Center, a 67-bed hospital that suspended patient services in October 2017, filed for Chapter 11 bankruptcy protection March 9.
Here are four things to know.
1. Leawood, Kan.-based Nueterra, along with its partners, acquired Miami Medical Center in 2014 and invested $70 million in the facility. Children’s Health Ventures, the for-profit arm of Miami-based Nicklaus Children’s Hospital, invested in Miami Medical Center with hopes of bringing a unique care model to South Florida. However, the Miami Medical Center struggled to stay afloat.
2. The hospital suspended patient services Oct. 30, 2017, and subsequently laid off its 180 employees.
3. In its bankruptcy petition, the hospital listed its assets as between $10 million and $50 million, and its liabilities as between $50 million and $100 million.
4. Miami Medical Center listed the creditors who have the largest unsecured claims against the hospital in its bankruptcy petition. According to the petition, the hospital owes about $1.2 million to Cardinal Health, $1.4 million to Aramark Healthcare Support Services and about $802,000 to Miami Anesthesia Services.
Source: Beckers Hospital Review

A huge wellness center with a rock-climbing wall, pools and high-tech equipment is planned for the new Lake Nona Town Center.
Tavistock Development Co. announced on March 2 the creation of an innovative wellness, performance and medically integrated fitness facility which has yet to be named in partnership with Signet LLC and its subsidiary Integrated Wellness Partners.
The new 110,000-square-foot center will be built across the street from Lake Nona Medical City in the second phase of development of the Lake Nona Town Center, Lake Nona’s premier entertainment, dining and shopping district that will have more than 4 million square feet at full build out.
The Lake Nona wellness center will offer a medically-based fitness center, sports performance training center, physician offices, community education spaces and community-based programming, which extends well beyond the walls of the brick-and-mortar facility.
The facility will offer:
  • Childcare facilities with outdoor play
  • Public concourse
  • Indoor/outdoor demonstration kitchen
  • Indoor climbing wall
  • Indoor and outdoor swimming pools
  • Outdoor classroom
  • Outdoor training turf
  • Sports performance area with 40-yard sprint track
  • Wellness plaza
  • Zen garden
The fitness center in the wellness center also will feature first-class equipment and on-demand fitness by Lake Nona partner Technogym.

“The creation of this world-class facility in Lake Nona is yet another example of how we are building out one of the most unique and comprehensive wellness communities in the country,” said Gloria Caulfield, executive director of the Lake Nona Institute. “This best-in-class collaboration with Signet and IWP will create an incredible regional asset, offering world-class programs and services across the entire spectrum of health and wellbeing.”

Memberships will be available, though rates have not yet been released.

“The only solution to overcoming the national health care crisis is prevention that comes ultimately through lifestyle change,” said Jim Ellis, managing director of Integrated Wellness Partners. “The overwhelming evidence shows we need to deliver impactful solutions that create community environments where, increasingly, the default choices for individuals, families and employees are healthy choices. The Lake Nona wellness center delivers on the vision and promise made by Tavistock to the entire Lake Nona community to offer its membership a healthy, happy lifestyle. This then will have a ripple effect on not only the Lake Nona community, but many others for years to come as Lake Nona becomes a health and wellness flagship model for the country and around the world.”

CLICK HERE TO WATCH A PROJECT VIDEO

 

Source:  OBJ

Medical office buildings have long been considered a niche sector, but surging interest among investors and developers is rapidly bringing the asset category into the commercial real estate mainstream. The aging U.S. population—combined with the sector’s long-term, stable returns and resistance to e-commerce—is providing steady tailwinds for MOB demand.

“Medical office buildings are the hottest asset class outside of multifamily,” asserted Louis Rogers, founder & CEO of Capital Square 1031, a Glen Allen, Va.-based real estate investment and management company. “Investors intuitively understand that medical needs increase as we age.”

To Rogers’ point, the 65-and-older segment of the population is expected to increase by 1.7 million in 2018 and by 9.2 million over the next five years, according to CBRE’s 2018 U.S. Real Estate Market Outlook for Medical Office. That is driving short-term and long-term demand for medical services, particularly in markets with high concentrations of older residents (many of them in the Northeast and Midwest) or those with populations that are growing quickly overall as well as skewing older (characteristic of many southern and western metros). That demand should continue, notwithstanding changes to the Affordable Care Act that have created some uncertainty in the healthcare market, CBRE predicts.
In a sign that institutional investors are ramping up interest in the sector, an affiliate of Heitman LLC announced in February that it had acquired a 1.4 million-square-foot, 17-property MOB portfolio. Texas accounts for seven properties and five are in Indiana, with one apiece in New Jersey, Virginia, North Carolina, Illinois and Missouri.
In its deal announcement, Heitman cited the properties’ recent vintage—most date from after 2005—their affiliations with top health systems, and their locations in high-growth markets. Among the assets is the Medical Arts Pavilion in Plainsboro, N.J., which opened in 2012 as part of a new medical campus developed for the Princeton HealthCare System. In January 2018, the MOB became part of Penn Medicine Princeton Health, formed by the merger of the two university healthcare systems.

CURE FOR CONCERNS

As the real estate industry enters the ninth year of the current cycle, Rogers noted, the need-based, recession-resistant qualities of medical care offer a safe haven for investors, when prospects for other asset categories may be less certain.
In addition, a shift away from hospital campus-based services, adoption of new technology, health-care job growth and tight market conditions are all boosting demand, explained Andrea Cross, CBRE’s head of office research for the Americas. Since 2000, healthcare employment has jumped 47 percent, compared to 12 percent for employment overall. And it’s projected to grow further, adding nearly 1 million jobs over the next five years, CBRE reported.
Lease terms for MOBs are also typically attractive to investors, as tenants tend to be financially stable customers like physicians or healthcare systems with investment-grade credit. MOB tenants also tend to invest significant amounts of capital in equipment and fixtures, and as a result they are unlikely to relocate merely because a building down the street will save them a few dollars per square foot.

STRONG VITALS

The MOB sector’s healthy fundamentals have also expanded the pool of interested investors. The property type registered a lower peak vacancy rate than traditional office properties during the 2008 recession, according to CBRE. Net absorption has outpaced new supply in 24 of the past 29 quarters, and gross asking rents have been stable, reflecting consistent user demand and long-term leases that reduce tenant turnover.
Medical-office cap rates declined to 6.4 percent in 2017 from 8.3 percent in 2010, according to Stephen Newbold, national director of U.S. office research for Colliers International, while sales volume increased over the same stretch to $11.3 billion from $4.3 billion. The top five markets for sales volume last year were Atlanta, Los Angeles, Dallas, Houston and Chicago.
On the development front, Colliers reports that 16.2 million square feet of medical office space was completed in 2017 and forecasts a modest increase to 20.5 million square feet in 2018. States with the largest pipelines include California (5.4 million square feet), Texas (3.1 million), Florida (2.6 million), New York (4.8 million) and Pennsylvania (1.9 million)—all large states with a substantial older population.
The stable, resilient performance of MOBs is attracting lenders, as well. “The market for acquiring existing properties is very strong, and there is a tremendous amount of capital for stable assets,” said Charles Foschini, a senior managing director at Berkadia. One challenge is the three-year-old High Volatility Commercial Real Estate regulations, which stipulate minimum equity and a maximum loan-to-value ratio in order for lenders to meet a 150 percent risk weight requirement. “The HVCRE rules have made it difficult for all but the strongest developers to get financing,” Foschini observed, noting that pre-commitments from tenants may make it easier for developers to secure funding.
In March 2017, Berkadia lined up a $22.5 million bridge loan to reposition 625 Flagler, a 110,000-square-foot Class A property formerly occupied by Bank of America in West Palm Beach, Fla. FRI Investors, the new owner, plans to reposition the 34-year-old building primarily as medical offices; current tenants include Mount Sinai Hospital and Jupiter Medical Center.

DISSECTING THE DETAILS

As MOBs gain in popularity, discerning investors cite qualities of tenants and properties that make these assets attractive. “If you have a strong healthcare system, Class A MOBs, whether on or off campus, remain especially compelling,” said Mary Beth Kuzmanovich, national director of healthcare services for Colliers International.
Assets located on or near hospital campuses provide stability because they are convenient for both physicians and patients, and doctors are usually affiliated with the healthcare system, providing an incentive for them to sign long-term leases. As medical services move closer to patients, particularly in suburbs, patients no longer have to go to a hospital for procedures like outpatient surgery, radiation therapy or dialysis. Accordingly, assets in suburban MOBs are becoming more desirable.
Location isn’t the only factor, however. “The investor class has to be very careful to understand who’s in their building and their long-term financial viability to continue to be able to pay their rent and continue to renew and stay in the building,” Kuzmanovich said.
American Healthcare Investors and Griffin Capital Co., the co-sponsors of Griffin-American Healthcare REIT IV, focus more on the tenant than on the asset’s location, said Danny Prosky, a founding principal of American Healthcare Investors. “Healthcare is a growth industry in all 50 states,” he said. “There isn’t any one particular part of the country that we avoid.”
In October 2017, Griffin-American Healthcare REIT IV acquired Fairfield County Medical Office Building Portfolio, comprising two MOBs located in Connecticut. The 80,000-square-foot portfolio is 94.6 percent leased to 15 tenants with an average remaining lease term of more than seven years. The portfolio’s anchor tenants, affiliates of Advanced Radiology Consultants, occupy about 29 percent of the leasable space, and recently extended their leases to 2029.
Source: CPE

This fall, Mount Sinai Medical Center plans to open a medical office building and stand-alone emergency room in Hialeah — 15 miles from its hospital on Miami Beach and less than a mile from Palmetto General’s own ER.
Meanwhile, Baptist Health, the South Miami-Dade powerhouse, is finishing a large medical center on South Beach that will open later this year.
That’s going into Sinai’s heartland. “You bet!” says Ana Lopez-Blazquez, chief strategy and transformation officer for Baptist Health South Florida.
If this isn’t an all-out hospital war in South Florida, it certainly seems to be getting close to it as hospitals accelerate the trend of developing outpatient centers throughout the region — often providing urgent care to millennials and others who don’t have established relationships with doctors.
Cash-rich Baptist Health, with $2.9 billion in reserves, has 20 new outpatient facilities planned over the next five years. The health systems of Jackson, Nicklaus Children’s and Memorial have at least two each listed as “coming soon.”
Most consumers think of hospitals and health systems as components in critical care. But they are also businesses — although sometimes nonprofit — whose ability to deliver high-quality care and attract top medical professionals depend on their own financial well-being.
Today, that includes delivering services at multiple locations. “This is the future of the industry,” says Ben Riestra, chief administrator of UHealth’s Lennar Foundation Medical Center in Coral Gables — eight miles from its main medical campus.
The $155 million, five-story Lennar Center structure on the University of Miami’s Coral Gables campus, which opened in late 2016, provides everything from sports medicine to oncology, but most particularly many outpatient procedures.

“Total shoulder repair, interventional radiology — a lot of services that used to be inpatient are now outpatient,” Riestra says.

“There is a clear trend … toward outpatient care,” says Sal Barbera, a former hospital exec who’s a professor at Florida International University. And the increase in outpatient facilities is coming for many reasons that signal a major shift in America’s healthcare system.

The American Hospital Association reports inpatient admissions have been falling steadily since 2008. Outpatient surgeries now outnumber inpatient operations, and total outpatient revenue for hospitals has risen from 28 percent in 1994 to about 45 percent in 2014.
As the inpatient facilities become less important, hospitals seek out new locations to attract patients, not only to get their outpatient business but set them up to be inpatients if the need arises, says Steven Ullmann, professor of health-sector management and policy at the University of Miami.
This outpatient trend is bolstered “as the health field moves from volume-based to value-based,” says Ashley Thompson, an AHA executive.
Ullmann explains that this industry jargon refers to the long-held belief that the American healthcare system — the most expensive in the world despite the fact that life expectancies in the U.S. are short, relative to those in many other industrial countries — must undergo profound changes.
Currently, every service delivered in a hospital tends to be billed separately. For instance, a hip replacement involves separate fees for use of the facility, the anesthesiologist, the surgeon and other goods and services, right down to the notorious $7 aspirin.
What that means: American healthcare is now like buying a car by paying Sam for a bumper, George for an engine, Judy for the steering wheel and so on. It makes more sense to make one payment for the whole vehicle at an auto dealer. And eventually, Ullmann, Barbera and many others believe, the country will move toward a bundled payment for that hip surgery.
Now add in the Obamacare push to increase accountability, meaning hospitals are responsible for post-operative care for that hip surgery and face penalties if a patient must be readmitted.
Together, these concepts encourage hospitals to control networks of physical therapists, doctors and others to provide the bundled care run by a single entity. When the patient leaves the hospital, a network social worker makes sure she gets her prescription filled. A therapist works on mobility issues. The system works more effectively, and efficiently, when the hospital is linked with outpatient sites that provide such services.
Another factor: Healthcare providers are trying to improve patient satisfaction.

“People don’t like to be in hospitals,” Ullman says. “The technology is great, but the quality of the experience is low. And it’s much more expensive to be in the hospital.” Patients are generally happier in outpatient settings.

For some hospitals, such as Mount Sinai, going outpatient is a matter of survival.
Fifteen years ago, experts forecast that stand-alone hospitals such as Sinai were doomed when competing against large chains. Steven Sonenreich, Sinai’s chief executive, says his hospital couldn’t grow in Miami Beach, where the population has remained stable at about 90,000, so he has expanded with 11 locations from Sunny Isles to Key West. Now, 70 percent of Sinai patients come from outside Miami Beach.
Another driver: a long-standing shortage of primary care doctors — exacerbated by the trend that many new doctors don’t want the hassle of running their own practices. In 2016, the American Medical Association reported that for the first time, less than half the nation’s physicians had an ownership stake in their practices.
One impact: More people are using emergency rooms for basic care. More than 20 years ago, Brian Keeley, chief executive of Baptist Health, realized that the Baptist Hospital ER was crammed with “people who really weren’t that sick,” Lopez-Blazquez says.
That started the creation of urgent-care centers — and hospitals directly employing doctors. Since 2012, Baptist’s physician employees has gone from about 100 to 255. The number at Mount Sinai’s has doubled in the past five or so years, Sonenreich says. Most of these Baptist and Sinai doctors work in outpatient settings.
Insurers, too, are driving the trend, UM’s Ullmann says. Many lately are trying to control costs by putting consumers in “very narrow networks” that the insurers have negotiated deep discounts with, so that a single entity could provide hospital, doctor and other services.
What’s more, many employers are moving toward high-deductible plans — an incentive for patients to seek outpatient services, which are generally cheaper than inpatient care.
A final explanation: traffic. Laura Hunter, a Jackson Health System executive, notes that “it’s very difficult to travel around Miami-Dade County.” Many consumers prefer to be treated closer to home or work.

ER CENTERS SPRING UP

One large part of the outpatient trend puzzles some healthcare experts: free-standing ERs.
Baptist has four “coming soon,” including one scheduled to open later this year near Country Walk. The Memorial system will build one in West Broward. Kendall Regional, an HCA-owned facility, has proposals for two in West Dade. Even the slow-moving Jackson Health System has plans for a stand-alone ER in Doral, which may open in two years.
Ullmann and Barbera point out that the Trump administration’s attempts to dismantle Obamacare could increase the number of uninsured, who often have to resort to ERs, where federal law requires all be treated, regardless of ability to pay — making these new ERs potential magnets for uncompensated care.
Offsetting this threat are potential benefits. Barbera suggests hospitals may be focused more on “trying to position themselves for access points” to get new patients as Baby Boomers age. Ullmann notes the new stand-alone ERs are “generally not in low-income areas,” meaning hospitals are most intent on seeking paying patients.

“In reality, we don’t have an option,” says Lopez-Blazquez at Baptist. The system needs to “decompress” its always-full ERs at its South Dade hospitals. Its first stand-alone will open “right across the street from Tamiami Airport” in the fall. But it’s also planning free-standing facilities in Doral and Miami Lakes, considerable distance from its hospitals.

Barbera and Ullmann wonder whether ambulances will take patients to an emergency room where they could not be immediately transferred to an operating room if need be. Miami-Dade Fire Rescue did not respond to four requests for comment.
The answers to many of these questions may come from Mount Sinai, which a decade ago opened the first stand-alone ER in Miami-Dade — a mile from Aventura Hospital in affluent Northeast Dade.

Sonenreich says it has worked out well: “We do about 20,000 visits there a year, and that generates 1,500 admissions” to the Beach hospital, 12 miles away. Fire Rescue brings patients there “from time to time” but mostly it’s “people who are driving themselves or walking in.”

For Hialeah, Sinai is constructing a three-story medical center on four acres near the Palmetto Expressway that will include 24 emergency treatment bays on the first floor, with physician and clinical offices on the second and third.
Palmetto General, a Tenet Healthcare facility, fought the expansion by urging local doctors to ask Hialeah officials to stop the project. That failed.

Still, Shelly Weiss Friedberg, Palmetto General spokesperson, says there’s no need for Sinai’s intrusion: “Our community is well-served from an emergency-care perspective as there are already three hospitals,” and Palmetto General recently expanded its ER with with a “new 31-bed clinical decision unit to help reduce wait times.”

Sonenreich maintains the area is poorly served: “We notice that 85,000 people every year leave [the Hialeah area] to go to other hospital emergency departments.”
Barbera, the former hospital exec, remains skeptical about a stand-alone ER: “I wouldn’t go to one. I’d go where there was a hospital connected, if you needed backup.”

EXPRESS CLINICS

In the spectrum of outpatient services, the most basic is the express clinic, a place to go for a flu bug or vaccine, often open from 8 a.m. to 8 p.m.
In South Florida, UHealth, the medical enterprise of the University of Miami, took over operation last year of the clinics at 17 Walgreens (seven in Dade, seven in Broward and three in Palm Beach counties), using nurse practitioners who can write basic prescriptions and are overseen by UM physicians. It’s possible to make appointments on line.
CVS has Minute Clinics in some of its stores, and Baptist is getting into this space too, with Express Care clinics in Country Walk and Key Biscayne and others “coming soon” in Doral and Parkland.
The next step up is urgent care, with doctors on site, ready for walk-ins and sometimes offering same-day appointments. Some have imaging equipment on site.
Of the hospital groups, Baptist has been the most aggressive, with 18 urgent-care centers already open, stretching all the way north to Wellington in Palm Beach County, with another three “opening soon.” Memorial opened one in December, and another is planned for later this year.
HCA, the national for-profit hospital chain, appears to have five urgent-care centers in eastern Florida, all in the Treasure Coast area. Tenet Healthcare, another national chain, has one in North Dade (Miami Gardens), four in northern Broward and two in Palm Beach County. HCA and Tenet did not respond to requests for interviews about their outpatient activities.
Dozens of more urgent-care centers not connected to hospitals are scattered around South Florida. “For sure, it’s a heavily competitive market,” says Chris Wing, who oversees Jackson’s belated urgent-care initiative.

“Jackson has been pretty hospital-centric,” Wing says. Over the past year and a half, it has branched out a bit by opening three UHealth/Jackson urgent-care sites — Cutler Ridge, Country Walk and North Miami — with two more scheduled to open this year. The partnership uses UHealth doctors in Jackson facilities. They’re open 8 a.m. to 8 p.m., seven days a week, 365 days a year.

Jackson has found the core customers for urgent care are 22 to 55 years old, and roughly a third of those have no regular relationship with a doctor, Wing says. About 20 percent are children.
A step beyond urgent care are doctors practices in traditional medical office buildings. Sonenreich says that Sinai opened its first medical office in 1985 in what’s now Aventura. In the past several years, Sinai has been expanding broadly. It now employs doctors in 11 locations, generally with standard office hours Monday through Friday.
Meanwhile, UHealth long has had offices of its doctors-faculty spread around South Florida, from Naples and Kendall up to Plantation and Boca Raton. It’s now using a $50 million donation to greatly expand its cancer services in Deerfield Beach.
In Doral, Jackson plans medical offices on a new 27-acre campus at the Palmetto Expressway and 25th Street, which will include primary- and specialty-care doctors, imaging and centers for treating women and children.
The county approved the development in 2015, but construction is not expected to start until March or April, with an opening in early 2020, says Hunter, the Jackson exec. Eventually, Jackson hopes to add a 100-bed hospital in that area — Jackson West — but state approval has been delayed as several other hospitals object to the new facility.
In South Florida, picking the right location can make all the difference. Most hospitals tend to stay away from low-income areas. In North Dade, Baptist, the largest player, has no locations east of Northwest 77th Avenue.
That has left an opening along U.S. 1 in affluent Northeast Dade. In a 1.5-mile stretch between Northeast 109 and 131 streets, there are three hospital-connected practices, each with slightly different services.
About 5 p.m. on a recent weekday, two persons were waiting on plastic chairs at a Walgreens for a UHealth nurse practitioner, who was seeing a patient behind a closed door. One said she had been waiting 20 minutes.
Just up the road, no one was in the waiting room at a Health/Jackson Urgent Care Center, where a doctor was available. A receptionist said in an hour or two, after people got home from work, the wait was likely to be a half-hour.
Down the road, at Mount Sinai Miami Shores, the door was locked. A sign indicated office hours were 8:30 to 5 p.m. for three specialists in internal medicine, a urologist, a cardiologist and a general surgeon.

TURMOIL AMONG INSURERS

Such satellite sites continue to ramp up despite the roiling uncertainty about the future of American healthcare, with the Trump administration assaults on Obamacare and the huge pending merger of insurer Aetna with CVS Health, with its pharmacies and in-store clinics. Most recently came the stunning announcement that Amazon is teaming up with Warren Buffett and JP Morgan Chase to revolutionize healthcare costs.

“With Aetna and CVS,” says Sonenreich at Mount Sinai, “that’s something we’re all going to wait and see what that means. I think the more exciting news is Amazon and JP Morgan. I have incredible respect for Warren Buffett, and Amazon is the great disruptor. And JP Morgan has the money.”

Still, despite all the turmoil, Sonenreich says he’s sticking with Sinai’s hub-and-spoke strategy that “will deliver healthcare in the most efficient manner, regardless of what happens in Washington, D.C.”
Many are watching the CVS-Aetna merger. “All kinds of interesting ventures could come out of this,” Ullmann says.
One possibility: Large healthcare providers may consider the need to offer their own insurance In the past, both Baptist Health and Jackson have marketed their own plans. For both, the experience was disastrous.

“We’ve been there, done that,” says Lopez-Blazquez at Baptist. “And it’s not something we want to do again. … We ask ourselves every once in a while” whether the time is right to get back into insurance “but we land up back in the same place.”

The entrance of Amazon and partners “is going to give everybody pause,” Lopez-Blazquez says. As “the king of disruptors,” it may attempt to get rid of middle men, such as the pharmaceutical managers.
The idea of bundled-care has receded somewhat during the Trump administration, but in the long run, Lopez-Blazquez says, it makes sense for insurers to pay for the value of results, “rather than paying individually for each widget. It’s a logical approach.”

One key to the future, she believes, will be service: “One of the things we’re trying to do is be much more consumer-attentive. We’ve stopped using the word patient.”

One example of trying to stay ahead tech-wise: Baptist has started offering an app — Care on Demand, which allows you to see a doctor for $59 by phone or computer. Lopez-Blazquez says it worked well for her son. He used the app to link up with a doctor, who determined he had pink eye and zipped a prescription off to a pharmacy.
Meanwhile, many hospitals are trying to be a go-to place for certain specialties. “Everybody wants to have a cancer center,” Ullmann says.
Baptist has launched the Miami Cancer Institute in South Dade, bringing in top names and forming an alliance with Memorial Sloan Kettering, the highly regarded New York cancer center. In South Broward, Memorial Cancer Institute has forged a clinical partnership with Moffitt Cancer Center, the well-regarded Tampa-based research organization. Meanwhile, UHealth’s Sylvester Comprehensive Cancer Center continues to receive high ratings. And Sinai markets innovative therapies.

“These are market opportunities — but very costly technologies,” Ullmann says.

Last year, Baptist installed a proton therapy unit — at a cost of $90 million, including housing, Lopez-Blazquez says. UHealth announced recently it plans to start building a proton unit this spring. It has not revealed the cost.

AT WHAT PRICE?

One big final question: How expensive are outpatient services?
Experts agree that procedures are generally cheaper done in an outpatient setting. A study by a Louisville University economist in 2014 reported that outpatient surgery is usually hundreds of dollars cheaper than inpatient. But there are exceptions. In 2016, Medicare reported that stents inserted into arteries in outpatient settings cost an average of $645 more than if done inpatient.
What’s more, outpatient pricing can vary dramatically between systems, and each insurer may have negotiated a different deal.

“The whole pricing issue is extremely perplexing and difficult, if not impossible, to understand,” says Barbera, the former hospital exec. “There is no rationale.”

Bottom line: Buyer beware.
Source: The Miami Herald

As state lawmakers prepare to determine the specifics of an $87 billion budget, hospitals are ready for the annual fight over state funds.
But this year’s negotiations, already off to a slower start, are likely to also be tangled by lower revenue, higher Medicaid costs and the political fallout from the state’s worst school shooting, which continues to rattle the Florida Legislature.
A top Senate leader said Tuesday both chambers had agreed on allocation numbers for the overall components of the state’s budget, including $543.6 million more in health and human services, which includes five state agencies. But the big-picture numbers only start the messy process of negotiating how those dollars are spent.
Both the House and Senate had rolled out plans earlier this month that diverged on healthcare spending, primarily how to compensate hospitals for Medicaid care. The House plan would preserve additional Medicaid payments, known as automatic rate enhancements, to 28 hospitals that currently serve a larger percentage of Medicaid patients. But the Senate plan would redistribute the $265 million in additional inpatient funds to all of the state’s hospitals instead, decreasing the amount of money those 28 hospitals receive.
The Senate’s proposed shift would disproportionately affect some of South Florida’s largest institutions — including Miami’s Jackson Memorial and Broward Health, which would lose $59 million and $17 million, respectively, according to an analysis by the Safety Net Hospital Alliance of Florida. Tampa General would lose $14 million, and Nicklaus Children’s Hospital in Miami and Johns Hopkins All Children’s in St. Petersburg, which each see about 70 percent of patients covered by Medicaid, would lose $10.5 million and $5 million, respectively.
But major for-profit hospital chains would see their reimbursements rise under the redistributions: the Hospital Corporation of America, which operates nearly 50 hospitals in the state, could see its reimbursements rise more than $40 million. Baptist Health South Florida, a nonprofit group of hospitals, would also come out ahead, according to the Safety Net Hospital Alliance.
The budget proposals have remained stalled since they were both passed Feb. 8, waiting for legislators to name budget conferences to begin the negotiating process between both chambers. But the process of agreeing on the funds could prove to be messier this year than most.
The Legislature has committed to hundreds of millions in additional expenses to address the shooting at Marjory Stoneman Douglas High School in Parkland, where 17 people were gunned down two weeks ago. Legislators are still trying to determine how to balance spending in the overall budget with the Parkland package, which will funnel at least $400 million in initiatives for gun control, school safety and mental health. The state is also expecting about $167 million less in corporate taxes than previously estimated after revenue estimates were revised, and in health care, legislators have to also tangle with about $100 million more than expected in Medicaid costs from the previous year.
Those numbers could affect overall budget discussions and the pace at which legislators come to an agreement on spending as a whole.

“When you take $400 million and put it towards necessary efforts, that creates challenges in other areas of the budget,” said budget chair Sen. Rob Bradley, R-Fleming Island, when he announced the allocations agreement Tuesday. “We’re up to that challenge.”

But those discussions are unlikely to directly influence discussions about hospital funding, which largely deals with redistributing the same amount of money in one pool, said Lindy Kennedy, vice president of the Safety Net Alliance. “I don’t see it impacting it directly, as the two chambers line up their priorities.”
For the session to end on time, lawmakers must come to an agreement on the budget by March 6, providing for a three-day waiting period before it can officially be passed. The session is scheduled to end March 9.
Source: Tampa Bay Times