Memorial Hermann CHSSA 12.10.2023

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 3 F. Geographic area traveled to for clinical services G. Referral Relationships H. Workforce/ Workforce needs. I. Diagnostic Technology J. Medical Error rate K. Key quality indicator measures L. Patient Safety Measures M. Health Policy issues N. System growth Section 3 A. Population Health Efforts B. Participation in ACOs C. Market Consolidation (past five years) D. Impact of State Health Reform Initiatives E. Social Justice Issues F. Handling of ethical issues G. Impact of Cultural issues H. System values I. Meeting needs of population. Conclusion

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 6 area with a wide range of accessibility. The Memorial Herman health system has a long 112 years of operational history.

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 9 sports, and lots more for entertainment. With so much offered in the state of Texas it can easily be seen why the states population is growing at such a rapid rate. The top tier medical schools in Texas draws many of in state residents and out of state residents. The McGovern Medical School at UTHealth Houston is the largest medical school in Texas and the eigth largest medical school in the United States. Due to their affiliation with the medical center, there is a vast opportunity for research, extensive clinical training, and highly specialized and sought after clinical rotations in medical fields that are difficult to access in other schools. (Kim, 2023) Therefore, being they have such a rich history in being responsible for training the majority of today’s public health leaders, they are a very competitive school and is moderately difficult to get into. The average GPA is 3.82, average MCAT is 511, interview rate is 22% for in state and 5.7% for out of state with an acceptance rate of 9.5%. Tuition rates are $20,092 for in state students and $29,708 for out of state students. (Freeman, 2023) Comparing their out of state tuition to other medical schools, McGovern seems to be of the lowest which is understood why they are a much sought after medical school along with the quality of education received. D. SOCIAL AND ECONOMIC DETERMINANTS OF HEALTH The conditions that people are born, raised, or even make it out of are determined by the social determinants surrounding them. These conditions shape the lifestyle of an individual. The most important factor that determines these lifestyles is income. Income reflects the affluence of an area. This quite visible that areas where the household income is the highest typically holds the most educated residents while unemployment rates are the lowest. Home values are higher as well as have extra income to partake in the luxurious activities in life such as traveling. In the Fort Bend area that Memorial Hermann services, the median income is $94,331 which is on the which side for the entire United States.

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 12 E. HEALTH PROFILE It’s fair to say that the environment that an individual resides in shapes the health outcomes of the community. Texas being a very hot state, there is extra precaution around preventing heat strokes. As we know, Texas is known for the massive meals and known to be a state that indulges in a hefty helping of red meat. With that said, it can be assumed that the health profile of the community isn’t going to be the best. Chronic disease is the leading cause of mortality in Harris County, and heart disease, cancer and stroke are responsible for almost 60 percent of deaths. Breast and prostate cancer are among the most frequently diagnosed cancers in the county, but lung cancer remains the leading killer of both men and women. (UTA, 2023) Texas has been ranked in bottom tier when it comes to being able to have access and quality of care for individuals of ethnic backgrounds. Besides the obvious factors of receiving healthcare, minorities are prone to unhealthy eating, lack of exercise, smoking habits, and living an edgy lifestyle. The four figures below show four different statistics. The first figure shows that as of 2015 there was a high percentage of pregnant women smoking while pregnant. The numbers were highest in the North Texas area. The lifestyle of the community may have contributed to these figures. The second graph shows that although diabetes is the second biggest diagnosis for adults in the entire United States, diabetes was the leading health diagnosis for adults in the Texas area, obesity being the second. The third and fourth graph measures the rates of maternal hypertension and diabetes. Not by surprise, blacks come in first place for maternal hypertension. This isn’t a surprise due to the stressful lifestyles that surrounds everyday living for minorities. The fourth graph is a bit surprising with other races coming in first for diabetes. Hispanics come in second and Texans come in third. Typically, figures usually show blacks coming in first due to unhealthy lifestyles.

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 15 (TexasMed, 2017)

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 18 a household of four with an income of $59,400 before taxes. (Understanding Houston, 2023)

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 21 Hispanic - 30.1% Total - 10.2% Uninsured rates for the nonelderly by age Texas Uninsured Children 18 and under - 11.8% Adults 19-64 - 24.4% Total 20.5 U.S. Uninsured Children 18 and under -5.3% Adults 19-64 - 12.2% Total - 10.2% Distribution of the nonelderly with employer coverage by age Texas Children 18 and under - 25.6% Adults 19-64 - 74.4% U.S. Children 18 and under - 241% Adults 19-64 - 75.9% (Texas Medical Association, 2023) While Texas is known to have a great economy with semi wealthy individuals. The overall big picture is, if something isn’t done about the uninsured there are great risks to face the Texan economy. While the people of Texas aren’t receiving the much-needed care, the hospital can face many hardships including the loss of physicians who are of great use to the people of Texas as well as themselves. The Memorial Hermann Health System is a private teaching hospital for the McGovern Medical School at the University of Texas Health Science Center at Houston. The goal of this union is to provide top tier patient care using teaching and research through the advancement of medicine. This provides patients with access to over 700 physicians that currently represent over 80 different specialties. These physicians are known to be great leaders in their field and provide their patients with access to the latest treatments available. Memorial Hermann strives to build

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 22 lasting relationships with their consumers and patients. They have done the work to reduce the overall cost of care without sacrificing the delivery of patient care with a free- for- service or fee for volume payment model. Being that Hermann Memorial Health system is an organized non-profit Accountable Care Organization, under section 501©(4), they are not entitled to tax exemptions. Memorial Hermann provides care for both Medicare and commercially insured patients. Medical providers contract with Memorial Health Accountable Care Organization (MHACO) to coordinate and provide care for patients in exchange for a share of the payments that petitioner receives under its shared savings programs, which include both the Medicare Shared Savings Program (MSSP) and non- MSSP programs negotiated with commercial insurers. (ACO, 2023) SECTION 2 A. FISCAL YEAR 2022 REVENUE/ EXPENSES/ PROFITS Fiscal Year Ending June 2022 Extracted Financial Data Extracted Financial Data from Form 990 Revenue $7,314,063,690 Expenses $6,423,696,348 Net Income $890,367,342 Net Assets $7,204,356,797 Notable Sources of Revenue Percent of Total Revenue Contributions $140,727,497 1.9% Program Services $6,694,634,314 91.5% Investment Income $417,785,697 5.7% Bond Proceeds $0 Royalties $1,532,348 0.0% Rental Property Income $0

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 23 Notable Sources of Revenue Percent of Total Revenue Net Fundraising $0 Sales of Assets $0 Net Inventory Sales $0 Other Revenue $59,383,834 0.8% Notable Expenses Percent of Total Expenses Executive Compensation $6,366,133 0.1% Professional Fundraising Fees $0 Other Salaries and Wages $2,493,238,55 7 38.8% Assets/Debt Total Assets $11,387,026,05 1 Total Liabilities $4,182,669,254 Net Assets $7,204,356,797 Other Operated hospital facilities Reported conflict of interest transactions Compensation Key Employees and Officers Base Related Other David L Callender Md (CEO/President) $3,133,129 $0 $421,070 Erin S Asprec (Evp/Coo) $1,774,357 $0 $260,531 (Roberts, 2023) B. MARKET SHARE Memorial Hermann Hospital system is spread all throughout the “Greater” Houston area. That is coverage of 12 counties with 26.1 % of market shares. Memorial Hermann is striving to be a distinguished organization of its kind in the United States integrated health system. C. ORGNIZATIONAL STRUCTURE

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 24 Memorial Hermann health is led by President and CEO Dr. David Callender. Dr. Callender joined the organization in 2019 as the President and CEO. His vision is to create healthier communities in the greater Houston area by focusing on a new strategic direction. Dr. Callender is an Ear, Nose and Throat doctor as well as a tenured Professor of Otolaryngology at the University of Texas Medical Branch. The Board of Directors who assist Dr. David Callender consist of 23 members that shares the same vision of better health for the Houston area. ( France, A.-C., Garbade, D., Inurria, J., Monroe, D., & Shabot, M., 2013)

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 25 David Callender President and CEO Product & Engineering  Brian Conroy Director, Design and Construction Finance (367)

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 26 Alec King Chief Financial Officer HR  Amalia Maislos Stanton Senior Vice President, Chief Strategic Communications and Marketing Officer Legal  Bonnie Cphrm Director of Risk Management Marketing  Emily Nelson

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 27 Paul O'Sullivan Senior Vice President and Chief Executive Officer Operations  Dan Humphrey Vice President Supply Chain and Surgical Support Services Sales  Amy DePedro Director, Revenue Cycle Ma (RocketReach, 2023)

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 28 D. CLINICAL SERVICES There is a wide rage of clinical services offered within the Memorial Hermann health system. The attention to a better healthcare system for the Houston area is a true goal of the Memorial Hermann health care system. Therefore, clinical services range from a wide list of specialties from cancer, heart and vascular, children’s services, weight loss, women’s health, surgical services, neuroscience, joint centers, etc. Alongside online services of everyday well being and virtual care. E. CONTINUUM OF CARE Memorial Hermann Health is committed to providing a full continuum of care for their patients in every aspect. It is believed that when such care is delivered, the clinical outcomes will be much improved as well as control the costs associated with healthcare. The system believes that if health care providers are held accountable for the care provided to their patients, then services will be held at top quality. With advancing the care of the community, Memorial Hermann is seamlessly bridging the gap between physicians and health solutions. MHACO consists of a network of affiliated physicians that unite independent and employed physicians of every specialty throughout the Houston area in a common commitment to quality and accountability. These physicians practice evidence- based medicine proven to result in better clinical outcomes and shorter hospital stays. (Memorial Hermann, 2023) Continuum of care is impossible without a full care team and proactive approach. Memorial Hermann stays true to their values of making sure each physician is involved while making careful and informed healthcare decisions for their patients. Technology plays a big part in

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 29 providing this continuum of care. Staying abreast to the latest technical advancements and implementing these devices into the Memorial Health system with ample training to assist. This implementation increases safety, efficiency, and provides patient engagement to be more involved in their personal care. F. GEOGRAPHICAL AREA TRAVELED TO FOR CLINICAL SERVICES. Memorial Hermann is one of the largest not- for- profit organizations servicing the Southeast area of Texas. As an Accountable Care Organization with 17 hospitals and a number of specialty programs and services located in the Greater Houston area. Clinical Services are primarily located within the Memorial Hermann Memorial City Medical Center, Harris, and Fort Bend Counties. This is a number of 35 various zip codes. Therefore, with so many services provided along with the array of specialists available, there is no need for the population to travel to another geographic location for clinical services. Patients from other countries and states actually sought after the care provided in the Texas area and at the Memorial Hermann Health system. Below is a table showing the percent of the patient population served by County. COUNTY PRIMARY SERVICE AREA PRECENTAGE Harris 56.05% Fort Bend 18.62% Memorial City 74.67% (Memorial Hermann, 2022) G. REFERRAL RELATIONSHIPS Memorial Hermann do have contractual relationships with many other affiliated physicians outside of the Memorial Health System. H. WORKFORCE/WORKFORCE NEEDS

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 30 Being one of the largest healthcare employers that covers a large area of the Greater Southeast of Texas, Memorial Hermann currently employs 3,000 physicians but are affiliated with 6,000 physicians and employs a total of 30,000 non physician employees. Memorial Hermann is centered in a very diverse region. Therefore, the goal of the organization is to reflect that diversity, equity and inclusion within their workforce. Currently, the workforce population consists of 79% of female employees and 21% of male employees, but there is a significant effort in recruitment and efforts in retention strategies that will contribute to a workforce that is reflective of the region served. (Memorial Hermann, 2022) I. Diagnostic Technology

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 31 Being that the Memorial Hermann Health system is known for being one of the leading teaching hospitals, it can be imagined that being on top of the latest technology is top priority for the organization. Expanding their technological capabilities allows Memorial Hermann to be innovative leaders and differentiate them from the rest. In an effort to hold their promise of delivering coordinated patient- centered care all across their organization, Memorial Hermann decided to change their electronic health records system to Epic beginning in 2023. Epic is the most used electronic health records system in large hospitals across America. The implementation will take several years for the whole organization but this will allow physicians to focus deeply on their patients long term care as well as their overall health. In addition to the implementation of Epic, Memorial Herman has an outpatient imaging and diagnostic facility with an open and closed magnetic resonance imaging, CT, radiology, mammography, and ultrasound technology. The MRI technology implemented by Memorial Hermann health systems is a newer portable machine allowing physicians to perform scans on patients while bedside using a wireless tablet. This has been allowed for quick scans in the event of a traumatic event such as a stroke providing quick diagnosis and treatment for a better patient outcome. In some instances, this has given patients and their family members a sense of calm because they are able to stay close by during the scan and even hold their loved ones hand. There has been the implementation of three dimensional Tomosynthesis technology that has allowed radiologists to see through layers of breast tissue to detect even the smallest tumors that has saved the lives of thousands of women. As of recent, Memorial Herman has implemented Viz.ai which is an artificial intelligence software platform that expedites the care for stroke patients. This software has been implemented throughout the entire Memorial Hermann health

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 32 system, making them the largest users of artificial intelligence technology for stroke care in the Houston area. (Memorial Herman, 2022) J. MEDICAL ERROR RATE Medical error is a very serious issue and a leading cause of death in the United States. At times it can become difficult to come across an error or it may take some time to find that error at all. To minimize the chances of error they must first be recognized then a process of learning and trying to prevent them over must occur. The factors that play a role in medical errors are the wrong diagnosis, prescribing the wrong medications and wrong dosages, lack of communication between staff, poor patient education, and administering drugs incorrectly. When it comes to the area of the practices and measures taken to prevent medical errors, Memorial Hermann has a score of 100 according to the Hospital Safety Grade website. Despite the overall grade of a “C”, this organization shows there is a true effort in reducing the chances for error. On the scale of wore than average to better than average, safe medication administration, handwashing, and staff working together is scored at better than average. Communication about discharge is scored at average, while not the worst, this is an area of concern because while the most terrifying part of receiving care in a hospital is over. The most detrimental part of care outside of the home begins. Patients need to be aware of the proper techniques to provide care for themselves at home, without following protocol this can lead to life or death. Communication about medicines was score the worst at worse than average which is alarming because lack of communication about medication is one of the leading causes to medical errors. It is not specified if the communication is between staff or to patients. Being that the score is so low, it can only be imagined that this is on both spectrums, where no clear communication is gives from doctors to staff or patients. Which is a recipe for disaster.

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 33 K. KEY QUALITY INDICATOR & MEASURES The Memorial Hermann organization has been recognized as a national leader in quality and patient safety. While exceeding the current standards, Memorial Hermann have been setting the benchmark in creating new standards in the industry where teamwork and accountability are at the forefront of all the components of providing effective care in the safest forms of practice. Currently, there are five teams of resident at TIRR Memorial Hermann and the Baylor/ UT Health Alliance for Physical Medicine and Rehabilitation who are working on a quality improvement project in hopes to provide redesigning an efficient flow of improved quality of care. As mentioned above, lack of communication and patient handoff or home care is an issue for Memorial Hermann facilities. There are current works in developing a system that meets the Joint Commissions requirements for communicating patient information from physician to physician, which is a practice that has dwindled over time due to long working hours. Since communication seems to be a problem area, the residents have created a secure online tool that will make patient hand off smoother in hopes of improving patient care, especially when working with multiple facilities. The major focus in the quality improvement project is removing the limitations of accessibility, compliance issues, HIPAA compliance, efficiency, lack of complete information, and physician satisfaction. These red flags came up during a survey that was provided to the residents and physician attendings who were eager to address the anticipated goals they felt were important to address. The survey shed light on the two groups of residents and physicians. The resident surveys resulted that after the changes were implemented, there was an increased sense of security,

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 34 improved efficiency, as well as improved physician satisfaction. The physician’s surveys resulted in a assorted results. While physician satisfaction was improved, the concerns at the top of the list were security, efficiency, and patient safety. This is an ongoing project that is not only being worked on by the facilities but also part of the training of the residents. L. PATIENT SAFETY MEASURES As it is obvious, the Memorial Hermann Healthcare System is very extensive. In lieu of extension of this assignment, out of the 17+ facilities under the Memorial Hermann umbrella, we will focus on Memorial Hermann- Texas Medical Center. On the Leapfrog Hospital Grade website, the hospital’s overall grade is a “C”. Under the patient Safety Problems, the hospital has many below average or just average issues to address. This includes: Harmful events: Worse than Average Dangerous bed Sores: Average Patient Falls and injuries: Average Falls causing broken Hips: Average Collapsed Lung: Worse than Average Dangerous Blood Clot: Worse than Average Air or gas bubble in the blood: Better than Average While it can be assumed that there is a standard for all Memorial Hermann facilities, these are issues that can be improved on. The goal of the system is to put patient needs and safety first. In the overall scheme of things, the facility scored well when it comes to preventing patient harm. Measures that take place includes ensuring there is sufficient nursing staff of all levels to provide the needed direct patient care, ensuring the hired staff have the proper credentialing, raising awareness about proper patient safety, implementing patient safety programs, holding

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 35 leadership accountable for unsafe practices, assessing staff education and the culture of safety, and overall, being sure that proper hygiene such as handwashing is in effect for everyone on all levels especially those who interact with patients. The table below shows the measures that are taking place in the Memorial Hermann- Texas Medical Center facility to protect patients in all aspects. The scores are very relevant as they are from recent years of 2022 as well as 2023. Measure The Hospit al's Score Worst Perfor ming Hospita l Avg. Perfor ming Hospita l Best Perfor ming Hospita l Data Sourc e Time Period Covered Doctors order medications through a computer What 's This? 100 15 90.58 100 2023 Leapfr og Hospit al Surve y 2023 Safe medication administration What's This? 100 25 92.67 100 2023 Leapfr og Hospit al Surve y 2023

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 36 Specially trained doctors care for ICU patients What's This? 100 5 62.31 100 2023 Leapfr og Hospit al Surve y 2023 Effective leadership to prevent errors What's This? 120.00 64.62 117.49 120.00 2023 Leapfr og Hospit al Surve y 2023 Staff work together to prevent errors What's This? 120.00 0.00 116.99 120.00 2023 Leapfr og Hospit al Surve y 2023 Nursing and Bedside Care for Patients What's This? 100 15.00 71.00 100.00 2023 Leapfr og Hospit al Surve y 2023 Handwashing What's This? 100 15 77.32 100 2023 Leapfr og Hospit al Surve y 2023 Communicatio n with nurses What's This? 89 75 89.55 97 CMS 10/01/2021 - 09/30/2022 Communicatio n with 89 76 89.45 98 CMS 10/01/2021 - 09/30/2022

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 37 doctors What's This? Responsivenes s of hospital staff What's This? 79 60 80.97 95 CMS 10/01/2021 - 09/30/2022 Communicatio n about medicines Wha t's This? 70 57 73.85 88 CMS 10/01/2021 - 09/30/2022 Communicatio n about discharge What 's This? 85 62 84.80 95 CMS 10/01/2021 - 09/30/2022 (Hospital Safety Grade, 2023) M. HEALTH POLICY ISSUES Healthcare policies are vital to all healthcare organizations. Policy management and implementation sets the tone by providing a guideline of what is expected for the agency. Setting a general plan of action helps the organization to make decisions as well as help the staff of the organization to understand their roles and their responsibilities, promoting health and preventing diseases. Memorial Hermann Healthcare system fully holds policy implementation. It seems difficult to find any policy related issues against the organizations. The most recent issue was an investigation being held by the attorney general for access within children’s medical records. Texas Attorney General Ken Paxton allegedly accused Memorial Hermann of a policy that

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 38 parents are prevented of having the ability to access their children’s medical records for children between 13 and 17 years of age. According to a spokesperson for Memorial Hermann, the organization was not aware of such policy, or any complaints made by parents of not having access to their children’s medical records. Memorial Hermann became aware of the issue during a press release by the attorney general on October 27, 2022. Memorial Hermann released a statement via their spokesperson saying “we believe all our health system’s policies are in compliance with both federal and Texas State laws. We take all patient-related concerns very seriously and will investigate any complaints brought to our attention. We will also work with the attorney general’s office to determine the facts and appropriately address this matter”. (Diaz, 2022) The findings in the concluded in November of 2023. What was revealed was the hospital’s policy that prevented parental access to medical records after the age of 13 was a technological glitch. In a press release from Attorney General Kex Paxton it was stated “The Office of the Attorney General determined that, instead it was Memorial Hermann Health System’s own technological limitations that accounted for the restriction”. To rectify the issue Memorial Hermann is in the process of working to introduce a new program that provides parents full access to their children’s medical records. Memorial Hermann will provide clear instructions for parents through their website on how they can access their children’s medical records. N. SYSTEM GROWTH Memorial Hermann Health system is a progressive organization always looking for growth. As seen in recent years and current times, the population of Houston continues to grow, with that said, the Fort Bend County expects to see their population to grow to one million residents by the

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 39 year 2027. Memorial Herman is preparing to welcome this growth by announcing that they will be expanding their Sugar Land location. The announcement made in 2022 was said to be a $231 million investment has been made to expand the facility with a new tower on the campus with the addition of new surgical and medical beds, rand new universal beds, and a new neonatal intensive care unit. The project also includes the expansion of a catheterization lab capacity, outpatient areas, emergency department rooms, operating rooms endoscopy suites, CT and X-ray capabilities, and a new parking facility. (Diaz, 2023) Along with this expansion, there were a couple of other projects in the works with previous approval. This was the addition of a $10 million operating room which was completed in spring 2023. There has been the addition of a brand new five story medical building sitting on 135,000 square feet. The buildout of this project started in early 2023 with hopes of housing multiple tenants. With the goal of servicing the community, Memorial Hermann realizes that it takes more than providing healthcare. With the growth the city of Houston and the entire state of Texas is facing, it is going to impact the economy of the state. Memorial Hermann is helping that impact to go in a positive light with the continuous expansion of their facilities. Expansion is a great sight because this means the organization is investing into their communities with job creation. This not only benefits the economy but also helps Memorial Hermann to fulfill their vision of creating healthier communities and minimizing the poverty levels for the present and the future. (Memorial Hermann, 2023) SECTION 3 A. POPULATION HEALTH EFFORTS

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 40 Memorial Hermann understands the impact of their organization in the community they serve. While being not-for- profit there was a reported contribution of $520,986,854 distributed to the community in various ways. These contributions included $306,258,400 in financial assistance and government programs. $122,194,336 to community health improvement services and community benefit operations that improves access to care. $51,689,308 towards the education and training of health professionals. $27,950,703 towards clinical services to the community regardless of loss of income. $6,118,183 towards research that serves the community. $6,775,925 towards awareness initiatives in the community and sponsoring various other organizations. In addition to the listed community contributions, Memorial Hermann has also given $2,634,373 to programs in the community that in direct correlation of providing health education, disease prevention, support groups, fitness classes, screenings, nutrition classes community events, and a variety of other programs that help to improve the individuals lives within the community. (Memorial Hermann Health System, 2020) Memorial Hermann is a big believer that education is one of the trails out of the pits of poverty. In 1996 Hermann Memorial started the Health Centers for Schools which is a school- based program that supports the primary healthcare needs of children and teenagers. These services range from sports physicals, dental clinics, mental heal, nutritional advice, general care, immunizations, etc. The children receiving these services is on a 6-month rotation as the clinics operate all year round as well as the summers, holidays, or whether school is open or closed. The beauty of this service is care will be provided regardless of the ability to pay of the status of insurance. This service removes barriers that families face such as transportation or having to take time off from work.

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 41 ER and Inpatient Navigation is another program offered to the community from Memorial Hermann. Through this program community healthcare workers help discharging patients to access to medication, food, and medical homes as well as help them to have an understanding to their health conditions before they are discharged. The reason for this service it to help reduce the number of returns in the emergency rooms and inpatient units. Health women, healthy families is another program offered by Memorial Hermann. Under this program community healthcare workers assist expecting mothers with tools to that assist with their healthcare needs before, during, and after the birth of their child so there is a smooth transition with their new addition in their life. These services include WIC, baby formula, pediatrician selections, breast pumps, and appointments. One of the main goals of Memorial Hermann is to improve the access to the quality of foods in the community. The program Food as Health addresses the issues of food insecurity in the low-income areas. The goal is to help the community understand the connection between a balanced diet and good health. The program provides a food insecurity screening that is completed with two questions. Once the application and approval process is met, the food is distributed once a month at a nearby park where the connection between physical activity and food is made, a walk in the park is followed after pick up. The Houston Food Bank’s Food for Change Food Rx program provides 30 pounds of free fruits and vegetables twice a month. A community garden increases the access for food while connecting the community. Overall, there are many programs created by Memorial Hermann for the community that backs their overall mission of building a better and healthier community not just for today but for the future as well. The hospital is sure to not only service those who are capable of affording services, but also those who are not in the position to afford services anywhere else.

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 42 B. PARTICIPATION IN ACOs Memorial Herman is an Accountable Care Organization also known as MHACO, which is wonderful considering the population that they serve. The network consists of not only the 17 hospitals under Memorial Hermann but also a various number of specialties institutes, advanced outpatient facilities and several affiliated physicians who are employed through the system and those who work independently providing a full continuum of care. The doctors are a part of a better coordinated team, patients will not have to complete as many forms, and each doctor visited will have a better vision of the patients’ healthcare record as it will be under one system. The physicians under the MHACO practice with medicine that has been proven to show results of a better clinical outcome that has resulted in shorter hospital stays, which their goal is to keep patients out of the hospital through preventative medicine and practices. Memorial Hermann has partnered with Aetna Whole Health to provide their patients care at a lower cost. Most organization pay their physicians according to how sick their patients are. The sicker they are, the longer the hospital stay and the more they get paid. Physicians in the MHACO and Aetna Whole Health network are rewarded when they work together to improve the quality of care and keeping costs down.

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 43 CO Governing Body Member Member's Voting Power - Expressed as a Percentage or Number Membership Type ACO Participant Legal Business Name / DBA, if Applicable Last Name First Name Title / Position Aronson, DO Laura MHACO Primary Care Physician 1 Participant Representative Memorial Hermann Health System Callender, MD David Serves on Board of Directors; MHHS CEO 1 Participant Representative Memorial Hermann Health System Cannon Deborah Serves on Board of Directors 1 At-Large member Memorial Hermann Health System Chang, MD Phillip MHHS Chief Medical and Quality Officer 1 Participant Representative Memorial Hermann Health System Esquivel John Serves on Board of Directors 1 Participant Representative Memorial Hermann Health System Flax, MD Ira L. Serves on Board of Directors 1 Participant Representative Memorial Hermann Health System Heaps, MD Brian MHMD Board Chair 1 Participant Representative Memorial Hermann Health System Jackson Grover Serves on Board of Directors 1 Medical Beneficiary Memorial Hermann Health System King Alec Serves on Board of Directors; 1 Participant Representative Memorial Hermann Health System

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 44 Treasurer McCarthy, MD James J. Serves on Board of Directors; President 1 Participant Representative Memorial Hermann Health System Key ACO Clinical and Administrative Leadership James McCarthy, MD ACO Executive Phillip Chang, MD Quality Assurance/Improvement Officer Tiffany Albritton, MD Medical Director Robert McStay Chief Compliance Officer Types of ACO Participants, or Combinations of Participants, That Formed the ACO  Hospital employing ACO professionals  Partnership or joint venture arrangement between hospitals and ACO professionals  Networks of individual practices of ACO professionals Shared Savings and Losses Amount of Shared Savings/Losses  Second Agreement Period o Performance Year 2022, $6,957,179 o Performance Year 2021, $0 o Performance Year 2020, $11,491,733 o Performance Year 2019, $10,117,659 o Performance Year 2018, $7,965,918 o Performance Year 2017, $14,499,448 o Performance Year 2016, $14,025,212  First Agreement Period o Performance Year 2015, $41,912,527 o Performance Year 2014, $22,723,305 o Performance Year 2013, $28,338,705

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 45 2022 Quality Performance Results Quality performance results are based on CMS Web Interface Measure Number Measure Name Rate ACO Mean 001 Diabetes: Hemoglobin A1c (HbA1c) Poor Control 1 6.61 10.71 134 Preventative Care and Screening: Screening for Depression and Follow-up Plan 78.06 76.97 236 Controlling High Blood Pressure 71.78 76.16 318 Falls: Screening for Future Fall Risk 95.78 87.83 110 Preventative Care and Screening: Influenza Immunization 79.35 77.34 226 Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention 84.21 79.27 113 Colorectal Cancer Screening 81.73 75.32 112 Breast Cancer Screening 76.94 78.07 479 Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Groups 2 0.15030.1510 MCC1 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC) 2 32.86 33.99 Payment Rule Waivers  Skilled Nursing Facility (SNF) 3-Day Rule Waiver: o Our ACO uses the SNF 3-Day Rule Waiver, pursuant to 42 CFR § 425.612.  Waiver for Payment for Telehealth Services: o Our ACO clinicians provide telehealth services using the flexibilities under 42 CFR § 425.612(f) and 42 CFR § 425.613. (Memorial Hermann, 2021) C. MARKET CONSOLIDATION (PAST FIVE YEARS) In 2018, Memorial Hermann and Baylor Scott & white, who are the largest not-for-profit healthcare system based in Dallas, Texas, were in talks of a merge. The merger was expected to bring in a revenue of over $13 billion and over $360 in operating income. There would be a combined 68 hospitals, two health plans and more than 14, 000 affiliated physicians.

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 46 Unfortunately, the two giants announced in early of 2019 that they were no longer pursuing the merger in a statement: After months of thoughtful exploration, we have decided to discontinue talks of a merger between our two systems. Ultimately, we have concluded that as strong, successful organizations, we are capable of achieving our visions for the future without merging at this time. We have a tremendous amount of respect for each other and remain committed to strengthening our communities, advancing the health of Texans and transforming the delivery of care. We will continue to seek opportunities for collaboration as two forward-thinking, mission-driven organizations. (Baylor Scott &White, Memorial Hermann, 2019) Since this anticipated merger, Memorial Herman has had other prospects, but as of December 2023, no mergers have gone into effect. As a matter of fact, Memorial Hermann has stated they are not looking for mergers and acquisitions to scale up. (Kacik, 2023) D. IMPACT OF STATE HEALTH REFORM INITIATIVES The healthcare reform of Texas’s initiative was to provide affordable health coverage for individuals who either did not have coverage through employment or simply cannot afford health coverage at all. The health care reform of Texas provides a wide variety of HMO, PPO, and custom health plans outside of employment and to those who do not qualify for Medicaid or Medicare. Memorial Hermann accepts a wide variety of insurance plans and does not turn away anyone regardless of their financial situation. There are standard hospital charges for the organization. The Centers for Medicare and Medicaid Services have encouraged hospitals to provide a list of standard hospital charges. This list is known as the Charge Description Master (CDM). Charges remain the same for all patients

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 47 no matter if they have insurance coverage of have/ lack the ability to pay for services. Due to wanting to remain an organization of transparency, Memorial Hermann has provided their patients with a good faith pricing estimate tool. This tool gives patients the opportunity to contact their insurance company to determine what their out-of-pocket cost will be based on their deductible and health benefits. The online Financial Resource Center offers estimates as well as payment options for patients with insurance and financial assistance for patients without health coverage. (Memorial Herman, 2023) Memorial Hermann Healthcare system supports the initiatives of Texas healthcare reform by promoting increased patient access to care. They provide system wide programs like the Nurse Health Line, which is a 24/7 resource for patients in the community weather they are insured or not to discuss any health-related concerns. Through this direct line patients can receive recommendations and be directed or referred to other appropriate resources. While there are many other resources available like free Oncology Nutrition Therapy, Med Data, and the One Bridge Health Network. There is also a transportation service for those who lack access to transportation to medical services. This reduces the limitation of access to care. E. SOCIAL JUSTICE ISSUES In July of 2021, Joseph B. Hill was ready to uproot his life from Georgia to Texas to start in his new role as Vice President, Chief equity, Diversity and inclusion officer at Memorial Hermann Health System. Four days before his start date, Joseph received an email from the Human Resources Vice President stating that the offer of employment has been rescinded. The reasons stated for rescinding the offer of employment was because of Joseph asking about hiring staff to build his team, asking for a larger relocation budget, renting a luxury vehicle under Memorial Herman, and believes Joseph is too sensitive about race issues. All listed issues are claimed to be

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 48 false by Mr. Hill. Memorial Herman issued a statement: We continue to make great strides in enhancing equity, diversity and inclusion within our system, but we know there is always more that can be done — which is why we are recruiting for a Chief EDI Officer.” (Bunn, 2021) There are many layers to Mr. Hills experience and while Memorial Herman stands on many great values, it’s quite clear there are still some issues to work on and admittedly so. Currently, the SVP and Chief Equity, Diversity and Inclusion Officer is Toi B. Harris, MD. Dr. Harris works on building on the Memorial Hermann Health Systems initiatives of identifying the equity, diversity, and inclusion efforts of the organization within the organization and outside the organization. In Mr. Hill’s situation, he believes his employment offer was rescinded due to being a black male. It has not been confirmed yet if that is the case, but Dr. Harris who is a black female was hired after Mr. Hills situation. This may have been a move played out by the organization to remove any bad press or assumptions. The reality is the organization prides themselves on being for the community. Being that the community they serve is so diverse, it would be difficult to believe there is discrimination being experienced within their own walls with their employees. F. HANDLING OF ETHICAL ISSUES As it can be imagined, it would be a magical world where ethical issues wouldn’t arise, but in a organization of this magnitude there are bound to be some issues to come to surface. There are bound to be some ethical issues to be faced. For instances as such, there is a policy to follow. Memorial Hermann strives to maintain the highest level of ethical standards which is key to providing care for the community with the utmost integrity. The Corporate compliance Program assists Memorial Hermann as a guideline in how ethical issues are to be handled. All employees are expected to familiarize themselves with the Standards of Conduct. Anyone facing

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 49 any ethical issues are encouraged to speak to their supervisor or a member of senior management. The Compliance Helpline or the Chief Compliance Officer are available to assist as well. (Memorial Hermann, 2023) In 2017 Memorial Hermann was ordered to pay the United States Department of Health $2.4 million to settle a suit where they were found guilty of violation HIPAA rules. The suit came after an immigrant from Mexico was arrested at a gynecologist office after presenting a fake ID in 2015. Memorial Hermann is charged with releasing the patient’s name to the press, advocacy groups, state representatives, a state senator, along with the hospital’s website. Although the patient’s name was released through the police, the hospital reserved the rights to protect the patient’s information. (Morse, 2017) Since this incident, Memorial Herman Healthcare Systems have updated their policies and procedures to safeguard private patient information form unwarranted use and train their workforce. G. IMPACT OF CULTURAL ISSUES Memorial Herman serves a diverse community, therefore it can be imagined that their workforce is just as diversely rich in culture. This kind of diversity within can greatly support the works of Memorial Hermann in a positive light with their efforts. In order to keep with tradition there is a true dedication to empowering their employees with various skills and support to advance their careers. The support provided creates an inclusive environment for the employees and demands respect from all affiliated with the organization. These support groups are:  Allies for the Improvement of Disability Experience (AIDE)  Asian- American Alliance for Learning Inclusion, Growth and Networking (ALIGN)  Black Organizational Leadership and Development (BOLD)  Emerging Professionals of Memorial Herman (EMERGE)

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 50  Hispanic/ Latin American Organization Leadership and Advancement (HOLA)  Pride Alliance  Veterans and Employees Together in Service (VETS)  Women United for Equity Network (WUEN) (Memorial Hermann, 2023) These groups provide support and development for every background that is supported under the Memorial Hermann umbrella to provide a safe working environment as well as providing support to all affiliated providers, partners, and patients in order to address the inequities faced in the communities served. H. SYSTEM VALUES A health system that is on the magnitude of Memorial Hermann is tasked with providing the best possible service to a truly heavily populated and diverse community within the United States. Everything that Memorial Hermann contributes their time and services to not only is to benefit today but the future as well. As being one of the largest not- for- profit organizations, there are a large number of services as well as stellar education provided to the community which is at the center of their efforts. The mission, vision, and values of Memorial Herman states: Mission of Memorial Hermann: Memorial Hermann Health System is a non-profit, values driven, community- owned health system dedicated to improving health. Vision of Memorial Hermann: To create healthier communities, now and for generations to come. Values of Memorial Hermann: Community: We value diversity and inclusion and commit to being the best healthcare provider, employer, and partner.

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 51 Compassion: We understand our privileged role in people’s lives and care for everyone with kindness and respect. Credibility: We conduct ourselves and our business responsibly and prioritize safety, quality and service when making decisions. Courage: We act bravely to innovate and achieve world- class experience and outcomes for patients, consumers, partners, and the community. (Memorial Hermann Health System, 2020) I. MEETING THE NEEDS OF THE POPULATION Memorial Hermann health care system has a vast understanding of the community they serve. Which includes the vision of creating a healthier community in present day and for many generations to come. The effort of Memorial Hermann is centered around equity, diversity, and inclusion which forces the organization to expand their work to the population and the community to refocus and reduce the system’s impact on the environment. These efforts of incorporating equity, diversity, and inclusion can be seen as a very serious thought in every action taken and decision made from the workforce to the community outreach programs and events in the community involving relationships built with the patients, vendors, and suppliers. There is a strong focus around the social and economic factors that are barriers to the community such as access to care, sensible foods, exercise, and emotional well-being. As it can be imagined, this kind of action cannot be done alone. This takes employing a group of other healthcare providers, government agencies and business leaders/ stakeholders in the community to assist in these efforts. These collective sets develop a strategy that improves the overall health of the community, especially those who are uninsured or underinsured.

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 52 There is a strong recognition that Memorial Hermann can do more outside of clinical efforts to make an impact on the community. Memorial is a part of the Healthcare Anchor Network, through this network, they can align their resources with other businesses in the community to create a change for the better in the city of Houston, Texas closing the economic, social, and racial gaps. Awareness of the global change in the environment is also a concern of Memorial Herman. There is a strong focus on transitioning to a more sustainable model to sustain the environment. These efforts include redesigning the healthcare process, reducing their carbon footprint, and more recycling efforts. Newer facilities being built under the Memorial Hermann brand are being designed with sustainability in mind. This includes a partnership with Energy Star for cooling and lighting systems to reduce energy. Overall, the Hermann Memorial health system isn’t perfect, but being one of the largest health care systems to service the Greater Houston area, there is great strides being made to improve the health of the community no matter the age, race, or social and economic disparity, which is proven in their Leapfrog grade. CONCLUSION Memorial Hermann is a not-for-profit organization dedicated to serving a richly diverse community in Houston Texas. Their focus is to provide stellar patient care today and for many years to come. While it’s known that patient care is mostly provided within the walls of the hospital and satellite buildings, Memorial Hermann understands their efforts of achieving a healthy community cannot solely be dependent upon remaining indoors. Through various programs developed through the organization they have been able to make tremendous change by offering their community with resources for a betterment of their of health. Though there is an

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 53 influx of immigrants and migrants a like, those who are insured, underinsured, or uninsured at all, Memorial Hermann is dedicated to providing necessary care no matter the financial status of an individual. There is a real focus on growth to continue to serve the growing city. No challenge faced by the organization is brushed under the rug and is consciously addressed in the best way possibly. Just as the hospital is a teaching hospital, they are also a learning organization working to correct their faults, and is a highlight that should draw anyone to their organization. References A Black chief diversity officer lost a job offer after flagging racial bias . (2021, November 2). NBC News. https://www.nbcnews.com/news/nbcblk/black-chief-diversity-officer-lost- job-offer-flagging-racial-bias-rcna4038 ACO not entitled to exemption under section 501(c)(4) . (n.d.). https://rsmus.com/insights/tax- alerts/2023/ACO-not-entitled-exemption-under-section-501-c-4.html#:~:text=The%20U.S. %20Tax%20Court%20issued,501(c)(4) . Bryant, M. (2019, February 6). Baylor Scott & White, Memorial Hermann end merger talks . Healthcare Dive. https://www.healthcaredive.com/news/baylor-scott-white-memorial- hermann-end-merger-talks/547764/ Diaz, N. (2022, October 28). Texas attorney general investigates Memorial Hermann for children’s medical record accessibility . https://www.beckershospitalreview.com/legal- regulatory-issues/texas-attorney-general-investigates-memorial-hermann-for-children-s- medical-record-accessibility.html Diaz, N. (2023, November 17). Tech issue limited medical record access at Memorial Hermann, Texas AG says . https://www.beckershospitalreview.com/healthcare-information-

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 54 technology/tech-issue-limited-medical-record-access-at-memorial-hermann-texas-ag- says.html Facts & Figures . (2022, September 11). Memorial Hermann. https://www.memorialhermann.org/about-us/equity-diversity-inclusion/facts-figures France, A.-C., Garbade, D., Inurria, J., Monroe, D., & Shabot, M. (2013, June). Memorial Hermann: High Reliability from Board to Bedside . The Joint Commission Journal on Quality and Patient Safety. https://cookcountyhealth.org/wp-content/uploads/8.-Articles- Shabot-et-al.-Reliability-Board-to-Bedside.-JCJQPS-2012.pdf Freeman, J. (2023, October 31). Medical schools in Texas: Rankings, information | MedEdits. MedEdits. https://mededits.com/medical-school-admissions/schools-by-state/texas/ High, M. (2018, June 14). Two-thirds of those surveyed feel Texas isn’t doing enough to ensure access to care . State of Reform. https://stateofreform.com/featured/2018/06/two-thirds- of-those-surveyed-feel-texas-isnt-doing-enough-to-ensure-access-to-care Hospital Details table . (2023). https://www.hospitalsafetygrade.org/table-details/memorial- hermann-texas-medical-center?findBy=hospital&hospital=Memorial%20Hermann%20- %20Texas%20Medical%20Center&rPos=0&rSort=grade Houston, TX | Data USA . (n.d.). Data USA. https://datausa.io/profile/geo/houston- tx#:~:text=Houston%2C%20TX%20is%20home%20to,any%20other%20race%20or %20ethnicity . Houston, Texas Population 2023 . (n.d.). https://worldpopulationreview.com/us-cities/houston-tx- population Improving and Expediting Care for Stroke Patients with Artificial Intelligence . (2022, October 18). Memorial Hermann.

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 55 https://www.memorialhermann.org/healthcare-professionals/advance/all-specialties/ neurosciences/improving-care-stroke-patients Kacik, A. (2023, December 8). How one Texas health system bucks the healthcare M&A trend . Modern Healthcare. https://www.modernhealthcare.com/providers/memorial-hermann- david-callender-houston-expansion-medicaid Kim, N. (2023). Best medical schools in Texas. Bold.org. https://bold.org/blog/best-medical- schools-in-texas/#:~:text=The%20University%20of%20Texas%20McGovern,course %20menu%20of%20clinical%20training . Memorial Hermann Health System 2020 Annual Report of Community Benefits Plan . (2020). Memorial Herman. https://www.memorialhermann.org/-/media/memorial-hermann/org/files/giving-back/cb- annual-report-community-benefit-plan-2020.ashx?la=en Memorial Hermann, (2022) https://memorialhermann.org/-/media/memorial-hermann/org/files/giving-back/chna/ memorial-city/mc-chna-2022.ashx#:~:text=The%20geographical%20boundaries%20of %20the,Harris%20and%20Fort%20Bend%20Counties. Memorial Hermann Standards of Conduct . (2023, July 1). Memorial Hermann. https://www.memorialhermann.org/-/media/memorial-hermann/org/files/healthcare- professionals/mhhs-standards-of-conduct.ashx Morse, S. (2017, May 10). Memorial Hermann ordered to pay $2.4 million over immigrant incident . Healthcare Finance News.

COMPREHENSIVE HEALTH SERVICES & SYSTEM ANALYSIS 56 https://www.healthcarefinancenews.com/news/memorial-hermann-ordered-pay-24- million-over-immigrant-incident Quick statistics on the uninsured in Texas and the U.S. (n.d.) https://www.texmed.org/Template.aspx?id=5519 Roberts, A. S. a. G. a. N. B. (2013b, May 9). Memorial Hermann Health System - Nonprofit Explorer . ProPublica. https://projects.propublica.org/nonprofits/organizations/741152597 Rocket Reach, (2023) https://rocketreach.co/memorial-hermann-health-system- management_b5c49d90f42e0dc5 The Aetna & Memorial Hermann Accountable Care Network . (2021, November 18). Memorialhermann. https://memorialhermann.org/about-us/our-organization/aco/aetna- accountable-care-network UTA. (2023, April 25). Public health issues in Houston . https://academicpartnerships.uta.edu/healthcare-nursing-online-programs/bachelor-of- science-public-health/public-health-issues-in-houston/#:~:text=Chronic%20disease%20is %20the%20leading,of%20both%20men%20and%20women . The Editors of Encyclopedia Britannica. (2023, November 1). Houston | Geography, history, & points of interest . Encyclopedia Britannica. https://www.britannica.com/place/Houston The state of health in Texas . (n.d.). https://app.texmed.org/tma.archive.search/46540.html Understanding Houston . (n.d.). https://www.understandinghouston.org/topic/health/access-to- healthcare/#uninsured_rate

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