Greenville-area lawmakers are pushing a General Assembly resolution that, if it passes, could profoundly impact how the state's largest health system manages care in the Upstate.
The competition-friendly resolution introduced by Greenville Sen. Dwight Loftis effectively compels Prisma Health to treat private practice doctors the same as doctors who draw a salary directly from Prisma.
It is the most direct move yet by a group of Greenville lawmakers to control changes to health care delivery in the Upstate. They say they are doing it to protect doctors and patients but face an uphill battle against national medical industry trends toward consolidation, accountability and increased cost.
Prisma, created by a merger of Palmetto Health in Columbia and the Greenville Health System in 2017, said it already puts patients at the center of all care decisions.
"The Greenville County Legislative Delegation and the General Assembly believe that a healthy, competitive, and patient-centered environment requires GHA’s assurance that physicians can practice independently and in a manner they deem to be in the best interests of their patients without direct or indirect fear of retribution in any form," the resolution said.
The suggestion, voiced in that clause and repeated in anecdotes shared by lawmakers with The Post and Courier, is that independent Greenville-area doctors have experienced retribution.
The "GHA" in the resolution is the Greenville Health Authority, a public entity from which Prisma Health leases most of its major facilities across Greenville, Oconee, Pickens and Laurens counties. It is these publicly owned assets — still controlled by a lawmaker-appointed board — that Greenville-area state Reps. Garry Smith and Mike Burns are trying to use as leverage with Prisma.
Getting the GHA board to agree to that strategy is another matter.
"So bottom line is this, just, this is really a wake-up call to GHA," said Burns, who helped get the concurrent resolution drafted.
The resolution largely reiterates the Greenville Health Authority's duty to meet the health care needs of the Upstate but it goes on to say GHA's tenant — Prisma — must give all qualifying doctors a chance to join the system's medical staff and must give all qualifying doctors, including non-Prisma doctors, equal access to all GHA-owned clinical resources.
In other words, private practice doctors should be on equal footing with Prisma-employed doctors when scheduling tests or procedures for their patients at GHA-owned facilities. Those facilities include Greenville Memorial Hospital and the 75-acre Patewood campus on Greenville's east side.
The Senate version of the resolution was referred to that body's medical affairs committee on March 31 and will likely be introduced in the House on April 6.
Checks and balances
The genesis of the resolution, Reps. Smith and Burns told The Post and Courier, was complaints from some doctors in the Greenville area who felt the balance of power within the Prisma organization had shifted away from doctors, with decisions reached more for financial reasons than patient care. The pair of lawmakers, who opposed the 2017 merger, authored the resolution with input from legislative attorneys at the Statehouse.
"What they're doing, it's all out war is what it is," Burns said of Prisma. "It's an all out war for control. It has nothing to do with what's best for the patient. It's for control. And, you know, what we're simply saying is we got to protect the patients, we've got to protect the doctors. And the only way to do that is for the GHA board to step up and start exercising its authority in this area."
Traditionally, hospitals were set up like hotels, said Jerry Youkey, a retired surgeon appointed unanimously to the GHA board in March by Greenville lawmakers. Doctors who owned their practices gained access to hospital facilities through a vetting process and those doctors together formed the hospital's medical staff. Over the years, he said, medical staffs have grown to include increasingly more doctors employed directly by hospitals.
Today, private practice doctors, once the norm, make up a significantly smaller share of doctors practicing at Prisma. Youkey said Prisma Upstate's predecessor, Greenville Health System, had a medical staff of around 1,500 when he arrived in Greenville in 1998, 110 of whom were employed by the hospital. Prisma spokeswoman Sandy Dees said the system's Upstate medical staff, now numbering 2,911 physicians, has 1,310 doctors employed directly by Prisma — a roughly 12-fold increase of employed physicians over 23 years.
This follows a national trend: A 2019 American Medical Association report found that "employed" practicing physicians outnumbered doctors who own their practices for the first time in 2018.
Youkey said he believes the best care outcomes occur within a well-integrated system in which doctors and hospital administrators work together for the benefit of the institution and the patient. With too much doctor control, the frequency of procedures might spike. With too much administrator control, doctors might be told what they can and cannot do, and what resources they are allowed to access.
Neither scenario is good for patients, he said.
"It all gets down to whether the patient's best interests are driving the system," Youkey said, "and whether there's an appropriate balance of power between hospital administrators and physicians."
This balance can be especially tricky in systems like Prisma that are open to qualified private practice physicians to treat their patients. Theoretically — and this is addressed in the concurrent resolution — Prisma's salaried physicians might get preferential scheduling for tests and operating rooms. This would contribute to the doctor-administrator relationship falling out of balance.
Sandy Dees, spokeswoman for Prisma, said that is not happening.
"Regardless of whether a physician is employed or affiliated with Prisma Health, we work to ensure that, together, we provide excellent and convenient care, always putting the needs of each patient at the center of everything we do," she wrote in an email to The Post and Courier.
Lawmakers speak, physicians reticent
Still, lawmakers pointed to multiple accounts to suggest Prisma is playing hardball with doctors.
Smith said one local ear, nose and throat practice was escorted from the Patewood campus in March after physicians there changed their status from Prisma-employed to private practice. Burns said another independent practice, Gastroenterology Associates of Greenville, had its lease renewal at the Patewood campus blocked when Prisma claimed the space and then, when the gastroenterology practice applied to relocate its Greenville Endoscopy Center, Prisma filed an objection with state regulators.
Dees confirmed that 13 doctors in the system's Greenville-based ENT practice notified Prisma in December that they intended to change their status to independent. She said Prisma worked with the doctors to extend their hospital privileges to carry on with surgeries at Prisma hospitals and remain in the system's network for insurance contracts. She did not address the nature of their move from the Patewood campus.
The endoscopy center, she said, "leased space in a building owned by another party." That party is GHA. With the endoscopy center's lease expiring, she said, Prisma had first right of refusal, "and we are exercising our option to lease that space for the needs of our patients."
Documents related to the endoscopy center from the S.C. Department of Health and Environmental Control reveal a legal feud.
On Oct. 30, attorneys for Gastroenterology Associates wrote to DHEC saying the 43-year-old practice had to move its Patewood endoscopy center by September 2022 because its lease at the campus was coming to an end. The letter, penned by the Womble Bond Dickinson law firm, was part of a 510-page "certificate of need" application to DHEC, which regulates health care facilities. The doctors wanted to relocate the four-bed endoscopy center to Halton Road in Greenville.
That CON application was "deemed accepted," according to a DHEC report, on Nov. 27.
But on March 4, Prisma attorneys filed a formal objection to the endoscopy center's CON, arguing the terms of the gastroenterology practice's 2006 lease at Patewood gave the hospital's operator, now Prisma, the right to take over the endoscopy center. This objection, submitted by the Parker Poe law firm, was filed despite an August 2019 letter updating the 2006 lease and signed by Prisma Upstate's chief administrative officer saying Prisma would not oppose or hamper the gastroenterology doctors from pursuing a CON for a new endoscopy center.
The gastroenterology practice's lawyers argued in a follow-up letter March 9 that Prisma could have the old endoscopy center at Patewood, and that a new facility on Halton Road would have plenty of demand and would be convenient for existing patients. At stake is a $4.3 million outpatient surgery center where 20 doctors expect to perform 10,000 procedures a year. Construction would need to start by June, according to the CON application, and the timeline is "urgent" in order to have the facility ready by the end of the Patewood lease in September 2022, the application said.
The Greenville County delegation, led by Rep. Smith. signed a letter on March 17 in support of the Greenville Endoscopy Center's relocation to a space on Halton Road in Greenville.
Doctors themselves have been reluctant to comment.
Dr. Rob Brown, who heads up the ENT practice, said he was busy moving this week and was not immediately available for comment.
An administrator at the Gastroenterology Associates said she would need to go through her practice's attorney to respond. After a few hours, she shared a prepared statement, referencing the practice's pursuit of a certificate of need from state regulators to build a new ambulatory surgery center at a site off the Patewood campus.
"Greenville Endoscopy Center, Inc.’s CON is currently under review and we believe it is critical that we are able to build a new ASC in anticipation of Prisma taking over our current ASC and space," Becky Swoyer wrote on behalf of Gastroenterology Associates. "Currently, Prisma has filed an objection to our ASC and we are working to resolve this issue soon so that we can avoid interruption to patient care. With a practice of 20 gastroenterologists performing on average more than 10,000 ASC procedures each year, we believe there is a significant need for this CON to be granted."
Lawmakers turn to GHA
The Patewood campus was purchased and developed by Prisma Upstate's predecessor, Greenville Health System, in the early 1990s. That property's ownership shifted to GHA after GHS, a publicly governed nonprofit, merged with Palmetto. Prisma Health, a private nonprofit, is the name the newly merged organization took on.
It was unable to secure ownership of GHS's Upstate assets. Those assets, lawmakers agreed at the time, still belonged to the public.
GHA's publicly appointed board now owns the former GHS assets and leases them to Prisma annually.
But Smith and Burns have pressed the current GHA board to embrace a role that goes beyond simply acting as Prisma's landlord. The 1947 legislation, Act 432, that created Greenville County's public hospital system was amended more than a dozen times over the years to add responsibilities for delivering quality care in the Upstate — responsibilities GHA inherited after Prisma took over medical operations at the old GHS facilities, Smith said.
"What we need this board to understand is that none of those duties and responsibilities have gone away," Smith said.
One example Smith raised, because it came up when the ENT doctors were escorted off the Patewood campus, was Prisma's operation of an Upstate police force with arresting powers. That authority, Smith said, was granted to the Greenville Health System in 2010 when it was still a public entity. He said it should not have transferred to Prisma, a private entity. GHA is engaging in "illegal delegation of authority," he said.
At the same time, the lawmakers have supported efforts to boost competition in the Upstate market, most notably by inviting Charleston-based Medical University of South Carolina earlier this year to work with Bon Secours St. Francis to set up an emergency care center in northern Greenville County.
They think the GHA should support that, too.
Smith and Burns said the MUSC partnership was in direct response to Prisma's decision to close the little used and unprofitable emergency room at North Greenville Hospital in Travelers Rest.
Youkey, the newest member of the 14-member GHA board, said nothing precludes the GHA from working with other partners like MUSC to deliver care in the Upstate.
"My belief is that Prisma Health didn't have any obligation to continue to provide emergency services to North Greenville, under the terms of the lease, and so they elected to stop it," Youkey said. "And I presume that that still met the terms of the lease, so that's fine, but then I don't think that GHA, as I interpret their responsibility, is off the hook in regards to making sure that those systems are served. So they may need to find other partners or relationships to do it."
Smith and Burns have consistently pointed to the Prisma merger as the root of these conflicts. The Greenville Health System was the stronger of the two entities in the merger, they said, and the Palmetto Health side of the merger has drawn resources from the Upstate.
The trend toward mergers is powerful, studies have shown, and the benefits unclear.
The Kaiser Family Foundation reported in September that 778 hospital systems merged between 2010 and 2017, with two-thirds of hospitals part of a larger system by 2017. There is no clear evidence, the Kaiser report said, that mergers improve quality of care, and the preponderance of evidence indicates mergers increase cost. These pressures coupled with changes in care delivery brought by the Obamacare reforms of 2010 — including accountable care outcomes and bundled pricing — could also be at the root of some of the reported discontent among Prisma and Prisma-affiliated doctors.
Editor's note: An earlier version of this story indicated the staff of an ear, nose and throat practice was escorted from Prisma's Patewood campus by Prisma police officers. That was incorrect information provided to us by a source.