To the tune of "Dirty Laundry," by Don Henley, some more of health care's dirty laundry...
We have frequently discussed the seemingly unstoppable rise of compensation given to top hired managers of health care organizations.  Their compensation seems to rise regardless of the financial status of their organizations, much less how well their organizations are caring for patients or otherwise fulfilling the mission.  Top hired managers of other organizations, particularly big for-profit corporations, have seen similar enhancements of their personal wealth, leading to the charge that they are acting as "value extractors," rather than responsible leaders.
Justifications for this rise are superficial, often limited to talking points we have repeatedly discussed, (first  here, with additional examples of their use here, here here, here, here, here, here, and here.)  They are:
- We have to pay competitive rates
  We have to pay enough to retain at least competent executives, given how hard it is to be an executive
- Our executives are not merely competitive, but brilliant (and have to be to do such a difficult job).

The notion that top hired managers are entitled to rich compensation no matter what now seems to have metastasized to medium-sized and even small US non-profit hospitals and other health care provider organizations.  Three relevant examples have appeared so far in February, 2015, listed in alphabetical order by state.

Georgia - West Georgia Health

West Georgia Health is a health system that includes a single hospital, West Georgia Medical Center, in LaGrange, Georgia, a town with a population of approximately 30,000 located southwest of Atlanta.This story comes courtesy of the LaGrange (GA) News.  Here are the essentials regarding compensation given the CEO.

About a month ago, someone at WGMC went into the doctors’ and surgeons’ lounges and anonymously posted pages of the hospital’s publicly available 2012 IRS 990 form, according to a confidential source who is a local doctor.

On the surface, they appear condemning. The pages showed compensation for CEO Fulks and other top hospital management. By the numbers, Fulks was compensated $1,989,538 during fiscal year 2012. On top of that, the hospital also paid $90,867 in travel expenses for Fulks and his wife, Cindy. It didn’t stop there: they also paid his monthly dues at a country club, according to the 990s obtained by the Daily News.

In years prior, Fulks was compensated $469,785 with $88,637 in travel expenses and $470,814 with $86,210 in travel for 2011 and 2010, respectively.

In 2012, Fulks’ base salary was $375,812, but with the $1.6 million “payout” and other compensation, such as nontaxable benefits and deferred compensation, the hospital actually gave Fulks more than $2 million in compensation.

In contrast, the News reported that the health system has been running deficits, decreasing services, and laying off employees.

Between the years of 2010 and 2013, West Georgia Medical Center on Vernon Road listed revenue deficits each year — sometimes as high as nearly $6.2 million dollars as in 2013, according to publicly available IRS filings by WGMC.

A round of layoffs in August of 2014 and the sale of its dialysis center in 2012 wasn’t enough to turn the tide, and hospital officials have said publicly they’ve hired a firm to shop around for what they’re calling a 'strategic partner' for a potential merger.

Seeking an explanation of a million dollar plus payout to the CEO when the system was running deficits, reducing services and laying off employees, Reporter Tyler Jones was able to do what reporters in larger markets rarely can do, get a response from the CEO himself,

'It’s … 10 years worth of funding 457(f) retirement plan vested for me during that year and I took it and paid the taxes on it and continued with investments,' he said.

When asked if it was appropriate for him to take such a large lump sum of money when the hospital was doing so poorly financially, Fulks balked.

'I don’t determine what my income is,' he said. 'There is a process that involves bringing in an outside consultant who does surveys and can report what the compensation is for higher compensated executives compared to the region.'

'Part of the answer to your question is that money was accumulated over a 10-year period, which included up and down periods in terms of financial performance. It was already funded. It’s not like they took it out of operations, it had been written through the books already. So, it was part of my employment contact arrangement with the board.'

The CEO did not explain, however, why his retirement benefits were so high relative to his base salary (apparently averaging $160,000/ year, at least 40% of base salary), and how they compared to the benefits given other employees.  Note that he did invoke, however, one of the talking points commonly used to justify large payments to hired management even by financially stressed organizations.  This was the "we have to pay competitive rates" argument.

In summary, despite financial stress causing recurring deficits, and leading to layoffs, service reductions and merger discussions, the CEO of a single hospital health system in a small town in Georgia recently had a base salary exceeding $300,000, got retirement benefits at least worth about 40% of his salary, and extra perks such as country club dues.   

Idaho -  St Luke's Health System, Saint Alphonsus Health System

Boise, Idaho is a city with a population over 200,000.  The Idaho Statesman recent published a story about executive compensation at Idaho hospital systems.   Key points about compensation were:

The latest tax filings by St. Luke's Health System, Saint Alphonsus Health System and their hospitals show that pay boosts at the top exceeded overall raises the systems reported for employees, and for Idaho workers.

Total compensation - including salary, bonuses, retirement and other pay - rose an average of 14 percent for the six CEOs. St. Luke's Health System CEO David Pate again led the pack. His total compensation rose 19 percent to $1.2 million, mainly because of other compensation, including retirement pay.

The second-highest paid CEO was Sally Jeffcoat, of St Alphonsus Health System, who received $849,880.  The highest paid executive who was not a CEO was Gary Fletcher, Chief Operating Officer of St Lukes, who received $1.08 million.

However, neither St Lukes nor St Alphonsus has been doing particularly well financially as of late.

St. Luke’s Regional Medical Center lost almost $6 million in fiscal 2013 — a drastic change from recent years. St. Luke’s local operations had reported net income of $39 million to $58 million since fiscal year 2010.

The St. Luke’s cancer center, Mountain States Tumor Institute, also lost money in fiscal 2013 for the first time in at least five years. Expenses overran revenues by $10 million.


Net revenues at Saint Alphonsus Medical Center-Nampa also declined in fiscal year 2013, though the hospital did not lose money. The decline was due to fewer emergency visits and inpatient admissions at the Nampa hospital, said Saint Alphonsus Health System CFO Blaine Petersen.

Furthermore, note that the St Luke's mentioned above is the same St Luke's that recently was found by a court to have violated antitrust laws in the course of its takeover of physicians' practices, and that ruling was just affirmed by an appeals court (see this post, and this Associated Press story via Also note that St. Luke's strenuously tried to keep details of the litigation out of the public eye, including details suggesting that the main goal of St Luke's actions was increased revenue, not better patient care. 

The Idaho Statesman article included only this brief justification of rising executive compensation in the face of declining revenues,

Hospital officials say the raises were deserved.

'There are people here working really hard, and I think we have a lot to be proud of,' said Jeff Taylor, St. Luke's chief financial officer. 'Our board is actively involved in setting (executive) compensation, and we are transparent about it.'

Note that this is a brief version of the "brilliance" talking point, and the person making it presumably reports directly to the CEO who received so much.  Given the results of the antitrust case noted above, I wonder specifically what he was proud of?

Vermont -  Health Care and Rehabilitation Services of Southeastern Vermont

This story came by way of the Barre Montpelier (VT) Times-Argus.  It described Health Care and Rehabilitation Services thus,

HCRS is one of five 'designated agencies' in the state that provides mental health services to people in crisis, school-based mental health services, and programs such as the Kindle Farm, a private school for troubled boys in Newfane and Townshend, and the Hilltop Recovery Residence in Westminster.

The issue was again a lump-sum retirement payment given a former CEO

A $650,000 compensation package for the retired CEO of Health Care and Rehabilitation Services of Southeastern Vermont has raised eyebrows from Montpelier to Springfield.

Judith Hayward left HCRS after 17 years as CEO on July 1, 2014, with a $650,000 cash golden parachute that HCRS officials said compensated her for the organization’s lack of a pension plan.

Hayward oversaw an agency with a $41 million budget with 600 employees, with offices in Springfield, Brattleboro and White River Junction. She was paid $162,000 annually.

The details of the special retirement package were,

The HCRS board approved a $450,000 compensation package, in addition to Hayward’s $162,000 annual salary in June 2010, he said. But when the agency’s auditors said the finance package had been poorly designed, forcing Hayward to pay a higher rate of taxes on the deferred compensation, the board added another $200,000 to the package for a total of $650,000

He said the most recent filing showed Hayward was paid a total of $497,000 in 2012.

The contrast between the payment and the current financial status of the organization was:

The package comes as its hundreds of employees didn’t receive a wage increase in 2014, and the state faces an anticipated $100 million funding shortfall.

According to HCRS tax forms, in 2012, the first year of the extra payments to Hayward, the agency had a revenue shortfall of $102,000, while in 2013, it had a surplus of $99,000 on a budget of $41 million.

An article from the Brattleboro (VT) Reformer, via the Valley News, contains the justification for the payout,

'Everyone on the board thought she did a tremendous job. She brought the organization out of bankruptcy, developed new programs and everyone who had contact with her, including people from the state, thought she did a magnificent job,' said J. Allen Dougherty, former HCRS Chairman of the Board of Trustees who signed off on the package. 'She never had a retirement package and the board thought this was a way we could make it up to her.'

Again, this was a version of the "brilliance" talking point. 

A blog post in the Nonprofit Quarterly downplayed the amount of the payout as excusable, given the CEO's long tenure.  However, it also acknowledged that the amount may have seemed excessive to other employees,

[Current CEO]  Karabakakis said staff have been 'disappointed, angry and outraged.'

'Some people may see it as excessive,” he said. “If we’re going to provide a deferred compensation package, it’s important that we look at the industry standard, and make sure that we do have a culture of openness and transparency.'

But the staff were unlikely to have been solely concerned about transparency. The other thing a board needs to ensure is that fair retirement benefits extend to all workers. The notion of caring only about the old age comfort of top employees is, naturally, abhorrent and insulting to many others. It’s no surprise, and in times where income inequality begs for our attention, our organizations should try not to mimic the bad policies of the larger economy.


Here were more instances of generous compensation given to CEOs and other top executives of small to medium sized non-profit hospitals and health care provider organizations.  In all cases, the pay seemed disproportionate given the financial situations of the organization, the pay and benefits given to other employees, or the services provided to patients.  In all cases, justifications provided were perfunctory, and were at best based on talking points used before to justify executive pay, but without supporting evidence or logic.

In a 2014 interview, corporate governance experts Robert Monks and Nell Minow, Monks said,

Chief executive officers' pay is both the symptom and the disease.


CEO pay is the thermometer. If you have a situation in which, essentially, people pay themselves without reference to history or the value added or to any objective criteria, you have corroboration of... We haven't fundamentally made progress about management being accountable.

The symptom and the disease have metastasized to health care, from huge for-profit corporations now also to even small non-profit hospitals.   Thus, like hired managers in the larger economy, even managers of small non-profit hospitals have become "value extractors."  The opportunity to extract value has become a major driver of managerial decision making.  And this decision making is probably the major reason our health care system is so expensive and inaccessible, and why it provides such mediocre care for so much money. 

One wonders how long the people who actually do the work in health care will suffer the value extraction to continue?

So to repeat, true health care reform would put in place leadership that understands the health care context, upholds health care professionals' values, and puts patients' and the public's health ahead of extraneous, particularly short-term financial concerns. We need health care governance that holds health care leaders accountable, and ensures their transparency, integrity and honesty.

But this sort of reform would challenge the interests of managers who are getting very rich off the current system.

As Robert Monks also said in the 2014 interview,

People with power are very reluctant to give it up. While all of us recognize the problem, those with the power to change it like things the way they are.

So I am afraid the US may end up going far down this final common pathway before enough people manifest enough strength to make real changes. 

For our musical interlude,...

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