The Envision Healthcare (EVHC) case examines the operations of one of EVHC's divisions, EmCare, a national physician services outsourcing company. The case describes EmCare's controversial use of out-of-network billing for a significant share of its revenues. As the company faced increasingly negative scrutiny for these practices, the case highlights the different perspectives and vantage points- both good and bad- of this strategic decision, and delves into the question of ethical practices as it relates to out-of-network billing. Students will explore the legal, societal, and economic implications of EmCare's business model, grappling with questions of business ethics and responsibility to customers. As EVHC contemplates reducing the out-of-network billing practices of its divisions including EmCare, the company faces important questions around financial viability, which serve as an opportunity for students to develop recommendations and novel approaches to EVHC's strategic quandary.

Ethical challenges are common to healthcare organizations as they develop and implement strategy. Organizations must deal with questions of profitability and performance against the backdrop of making self-guided decisions around social responsibility and ethical practices. The case provides relevant context regarding emergency medicine, out-of-network billing, and payer-provider-hospital relationships. With this background, students are encouraged to consider the gamut of considerations, some of which are not so obvious, when weighing strategic decisions that bear in mind social and ethical implications.

Beginning in 2013, Humana Inc., headquartered in Louisville, Kentucky, pursued a major organizational transformation, from being an insurance company focused on paying claims to becoming a health and well-being company focused on improving the health of its beneficiaries. The company set a “Bold Goal” of improving the health of the communities it served by 20% by 2020. To achieve this new goal, Humana undertook a multiyear redesign and investment of people, processes, and products in order to gain the trust of consumers and providers, and to partner with communities to improve health. The case focuses on community initiatives, where Humana was developing its new role as “convener of conversations,” providing leadership infrastructure and partial funding to spark community planning with a wide range of stakeholders and to design and monitor interventions that were tailored to local health improvement. At the same time, Humana remained a publicly-held corporation accountable to its shareholders for revenue growth and financial return. The case protagonist, Andrew Renda, MD, MPH, Director, Bold Goal Measurement, must design and implement a business plan, including leading and lagging performance metrics, that would measure Humana’s progress toward its Bold Goal in ways that supported continued investment in community health improvement in Humana’s local markets, while satisfying its traditional business constituents.

This case can be used in courses on strategy, community health improvement, the corporate role in public health, and other courses exploring the intersection of business and society. It also offers a rich opportunity to explore the research design and measurement challenges associated with evaluating the impact of public health interventions on local communities.

“Alameda Health System” (AHS) describes a county-owned safety net health system adapting to the implementation of the Affordable Care Act and an increasingly competitive health delivery environment. It takes the perspective of senior management, specifically the Chief Medical Officer for the system, who has been in his job for just over one year. The case begins in late 2014, when the CEO of 9 years announced that he was leaving AHS to become CEO of a Detroit health system. He was leaving behind a senior management team that had been in place for 1–2 years, and had turned over several times throughout his tenure. At the same time, the system was experiencing a financial downturn, brought on in part by the loss of many low-income, formerly county indigent patients who selected subsidized private health insurance plans on the new state health exchange that contracted primarily with AHS’s two largest competitors. AHS also had yet to integrate clinically or administratively with two community hospitals, both of which were in poor financial health, recently acquired as part of a strategy to diversify the AHS payer mix.

The system faced operating challenges common to many publicly-owned safety net hospitals, including: a unionized workforce; an independent, mission-driven medical staff that had grown weary of administrative turnover; a poorly functioning revenue collection system; unprofitable contracts with managed care plans; relatively few commercially insured patients or contracts; long wait times for care; lack of telephone and transportation access to providers; and a low-income population with multiple poorly managed chronic diseases, including mental illness and substance abuse, as well as a high rate of violent crime.  

The case requires that students understand key aspects of the ACA and can synthesize other relevant environmental and organizational trends in order to recommend and evaluate the actions that senior management should take.

Southcoast Health System consists of three hospitals in southeastern Massachusetts: St. Luke’s in New Bedford, Charlton Memorial in Fall River, and Tobey in Wareham, as well as numerous affiliated entities. But how did the merger that created the Southcoast system came about?

“Basically, we merged because we wanted to, not because we needed to,” said John Day, President and CEO of Southcoast Health System (formerly the CEO of St. Luke’s Hospital). “We wanted to avoid a divide and conquer situation. As community hospitals, we needed to be able to serve the long-term interests of our communities.”

“We decided it was ridiculous to be competing with each other,” added Ron Goodspeed, MD, President of Southcoast Hospitals Group and Executive Vice President of Southcoast Health System (formerly the CEO of Charlton Memorial). A mix of events and environmental conditions set the stage for the three hospitals to consider merging. One of the most critical of these was a turnover in Charlton’s CEO position. Meanwhile, the health care environment was becoming increasingly volatile and competitive, and the focus in the business community was shifting away from city-specific planning and toward developing the larger southeastern area of the state. 

The predominant goal of the management and boards at all three hospitals was to find a way to best serve the interests of their communities. They decided on a full asset merger: building a single executive management team and board of trustees to oversee the organization. 

When Dr. Marwan started as director of Ramses Hospital in Cairo in 2008, charged by the Minister of Health with improving performance, he found the hospital had been neglected for decades. A Ministry of Health quality audit had recently given the hospital the worst score of the five hospitals designated as critical to the greater Cairo area. 

Dr. Marwan vowed that Ramses Hospital would come in first in the next round of quality audits. Without improving its quality scores, the hospital would be unable to pass the accreditation process required for hospital participation in a new universal social health insurance scheme. In addition—and just as critically—Dr. Marwan needed to develop a longer-term strategy for obtaining the considerable additional resources required to upgrade the long-neglected facility.

This case considers the challenges, benefits, and costs of hospital participation in a widely recognized surgical quality improvement benchmarking program. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) issues performance reports twice a year to participating hospitals, creating benchmarks based on data submitted by over 500 hospitals. NSQIP claims that participation reduces surgical complications.  

The protagonist, the Chief of General Surgery at a large academic medical center, faces skepticism about the value of the report on two fronts: from some surgeons on his staff and from a statistician he consults. Some of the hospital surgeons find the data difficult to interpret, and question their utility in focusing quality improvement interventions. The statistician has reservations about the validity of the statistical results as a basis for action. The chief must decide if and how the NSQIP report can be used to improve quality. In the coming era of value-based purchasing initiatives for hospitals, the chief also needs to be concerned about how payers might interpret this data as they develop payment systems that reflect available measures of surgical quality.