In Miami-Dade, system crafts care model for indigent population

Carlos Migoya, who left Cuba at age 11, is an American success story. After Migoya retired from a successful career at Wachovia bank, Miami's new mayor in 2010 asked him to serve as city manager. Less than a year later, the city named him president and CEO of its financially ailing Jackson Health System. Migoya—named one of Modern Healthcare's Top 25 Minority Executives in Healthcare for 2016—led the public system's turnaround, including a tough downsizing, and it's now in the black. Modern Healthcare reporter Steven Ross Johnson recently asked Migoya about the turnaround and other issues. This is an edited transcript.

Modern Healthcare: What were the key factors behind the turnaround?

Carlos Migoya: The financial turnaround focused around being efficient, making sure that we had the proper resources in the right places. We've done that in a form in which we've started to improve our quality.

We've started some improvements on the brand by working on the facilities and the patient-centric environment. We're starting to see more paying patients coming in the door, not just working on our mission of (serving) the uninsured. Being a public hospital, it's important to continue our mission, but we need to make sure that we continue to find funded patients to help us pay for that mission.

MH: Why are you calling 2016 a transformational year for Jackson Health?

Migoya: Up until now, it has been a financial turnaround. Right now, our focus is more around the patient experience and the quality and safety side. In order for us to have a complete transformation, we have to be in the top 10 percentile in the country on both patient experience as well as in quality and safety.

We have a capital plan of $1.4 billion to work on facilities. But the hospital, although it's nice to have the right facilities and equipment and information technology, is made up of people. So, the idea is to have great doctors and great nurses (and) do it in an environment that is appealing to patients and their families.

MH: Did it call for any kind of cultural change within the staff?

Migoya: That is exactly what we're working on today. Besides being a top public hospital, we're also a top academic center. We have 1,100 residents. So making sure that the residents and doctors and nurses are not just providing great clinical care, but they're also giving the right hospitality to patients and their family members is important. That's where the cultural change is coming.

MH: How will Jackson Health adapt to the reduction in federal funding that's coming?

Migoya: Our capital campaign is not just about modernizing the entire plant, but getting our care closer to the community. So we're building urgent-care centers. We just got approved for a certificate of need for a hundred-bed hospital on the western side of the county. This gets the University of Miami and Jackson Health Medicine closer to the community. It's the 'Dr. Robin Hood' mentality: How do we get the paying patients to pay for the ones who can't afford to pay?

MH: What are some of your other challenges?

Migoya: It's going to take us about five years to be able to build everything we're talking about doing, which is a pretty aggressive transformation from a physical standpoint. We need to make sure that the reductions in federal reimbursements and the changes on how we pay Medicare and Medicaid stay with us for that period of time to be able to put the two things together.

MH: The Florida Department of Health turned down Jackson Health's application to open a trauma unit in south Miami-Dade County, yet it gave provisional approval for hospitals that are run by HCA.

Migoya: We are aggressively fighting that at this point. We're in the courts and, obviously, we can't talk about a lot of the stuff that's in litigation around the trauma site. But we believe—we know—that our trauma center is one of the tops in the world. For that reason, we believe that we should have the ability to open one in our Jackson South facility, and that's what we're fighting for.

There are other hospitals that are using trauma care from a competitive standpoint, and they're using much higher activation fees than we are. They're looking at trauma as a profitable unit, whereas we're looking at trauma in terms of how we can best take care of the community when they're in greatest need.

MH: HCA is looking to expand trauma care across all of Florida.

Migoya: Our activation fee is $1,500. Some of those other hospitals are $20,000 to $30,000 per patient. And I remember 23 years ago, in Miami-Dade County, we went from six trauma centers down to one because they were not profitable. But Jackson was here and that's when we built the Ryder Trauma Center. The community worked with us. The business community funded most of the monies necessary to build that facility. We will be here when it's profitable. And when it's not profitable again, we will continue to be here.

Some of the challenges you face when you're dealing with very serious spinal or brain injuries, the question becomes, 'Where is the right trauma center, and who are the appropriate doctors to take care of these patients?' That's one of the challenges today. They go to the nearest trauma center and not necessarily to the best neurosurgery center available.

MH: As a public hospital, one of your main missions is community health. What is an economically viable model for implementing population-health strategies?

Migoya: We're working on that today. There is one population that we totally own today, and have full risk for, and that's the indigent population, the ones who can't afford to pay. Those are the ones we're currently working with in population health to keep them from having to come back. We want to be able to reduce their readmissions and so forth.

We're using that experience, not only to make that population healthier and have them spend less time in the hospital, but also as a learning experience. We want to be able to turn around and use that expertise as we work with managed-care companies and HMOs around the area. We want to be able to sell to them in a member-per-month type environment, where we can share risk together with the HMOs and the managed-care companies.