The March 2005 article in Counsel to Counsel discusses the complex but supposedly legal transaction involving Mariner and other entities including National Senior Care.  The article mentions the complexity of the billion dollar transaction.   After all, the deal took nearly seven
months to complete; involved roughly 80 attorneys from a half-dozen law firms; and hinged on the sale and lease-back of Mariner’s most valuable assets—its skilled nursing facilities.  Through its operating subsidiaries, Mariner owned, leased or managed nearly 260 skilled nursing facilities in more than 20 states and over a dozen long-term acute care hospitals in four states.

NSC (Harry Grunstein, Defendant Leonard’s brother from Israel) came calling in April 2004. NSC wanted to take the company private and made Mariner and its shareholders an offer that really was too good to refuse—$30 per share for a stock that was at that time trading in the low $20 range, plus the assumption of some $350 million in debt.  Specifically, the deal involved selling
170 of Mariner’s 260 skilled nursing facilities to a third party—SMV, a real estate investment company—to help NSC finance the merger. Under terms of the proposed agreement, SMV would lease the properties back to either Mariner (which by then would be an NSC subsidiary), or to another company, Sava SeniorCare. Further, after establishing a bridge loan to pay off Mariner’s shareholders, NSC would use the approximately $600 million realized by the sale of  the properties to finance the acquisition—including paying off both the bridge loan and Mariner’s
outstanding debt.

Executive compensation attorneys came in to review and restructure Mariner’s senior management agreements and benefit packages—including an employee retention plan
developed after NSC made it clear it wanted to keep the Mariner management  team in place.

Many readers may be wondering how this kickback scheme affects residents in a nursing home. Jim Edwards wrote on a blog recently that "The scariest wrinkle in the Omnicare kickback case is just how vulnerable old people in nursing homes are to schemes in which drug companies allegedly induce pharmacies to prescribe drugs they otherwise wouldn’t." Edwards cites one case where one patient cited by the government’s complaint received 67 — sixty-seven! – different drugs under Omnicare’s “care”. Those drugs included Cipro, Neurontin, Heparin, Pepcid, Oxycodone and Seroquel or their generics, according to the complaint.

Remember we as taxpayers pay for these medications and services to provide for the most vulnerable citizens in our country not to go into the pockets of corrupt and greedy corporate owners.

Today I want to write about the people and entities involved in this kickback scheme. 

Murray Forman is the principal owner and decision maker for hundreds of nursing homes throughout the country including the Mariner, SavaSeniorCare, GranCare, and THI/Fundamental chains. Leonard Grunstein is a real estate lawyer and partner at Troutman & Sanders.  Rubin Schron is an owner of the Woolworth Building.

The Atlanta Journal Constitution had an article about the trio above.  Leonard Grunstein is a prominent attorney at Atlanta-based Troutman Sanders named in a federal complaint charging he and several other parties, including two companies with Atlanta ties, were involved in a $50 million kickback scheme to steer nursing home patients to OmniCare.  Leonard Grunstein, a New York-based partner at Troutman Sanders and leader of the firm’s real estate capitalization and investments practice groups, was named in the complaint.  In an e-mail statement, Troutman Sanders spokesman Mark D. Braykovich said Grunstein is taking a leave of absence until the matter is resolved.

Also named is Grunstein’s business associates Rubin Schron and Murray Forman, both of New York; Atlanta-based Mariner Health Care Inc. and SavaSeniorCare Administrative Services, which also is headquartered in Atlanta.

According to the detailed 32-page Complaint, Omnicare paid Mariner and Sava $50 million in 2004 to get them to sign long-term pharmacy contracts and steer nursing home patients — including those covered by Medicare and Medicaid — back to it for pharmacy dispensing services.

The scheme allegedly worked this way, according to the complaint:

Mariner, one of the nation’s largest nursing home operators with more than 263 assisted living facilities, announced in June 2004 it was selling itself to National Senior Care Inc. for $1 billion. National Senior Care, which is headed by Grunstein’s brother, Harry, was created solely for that transaction. It is an affiliate of SavaSeniorCare.

Forman and Leonard Grunstein subsequently proposed Omnicare purchase a Mariner subsidiary, Mariner Medical Supply, for $50 million. If Omnicare didn’t, it would lose the pharmacy services contract it had with Mariner after the sale to National Health Care.

Omnicare executives raised the concern about such a transaction being perceived as a kickback but agreed to the deal because it risked losing $155 million in revenue and $26 million in operating profit a year on the three years it had left in the contract with Mariner.

Crain’s New York Business had an article discussing the complaint and allegations.  The Complaint says the above men were part of a trio who received a $50 million payment from Omnicare Inc., the nation’s largest nursing home pharmacy, so it could continue to provide services to their nursing home companies, Mariner Health Care and Sava Senior Care. The government alleges the trio attempted to disguise the $50 million from Omnicare as a payment to acquire a business unit from Mariner that in fact only had two employees and was worth far less than $50 million.

The San Jose Mercury News had an article with a great quote from a DOJ official.  "Illegal conduct like this can undermine the medical judgments of health care professionals, lead to patients being prescribed medications they do not need, and drive up the costs of health care," said Tony West, Assistant Attorney General for the Civil Division of the Department of Justice. The agency added that Omnicare specializes in providing drugs to homes caring for dementia and Alzheimer’s patients, who have little control over their medications.

 

 

My next three entries will discuss the exploits and complaints against OmniCare, Mariner, SavaSeniorCare, and Murray Foreman, Rubin Schron, and Leonard Grunstein who own and operate hundreds of nursing homes through a complex maze of corporate shenanigans, and were finally caught gaming the system to make millions and deprive our loved ones of the necessary care they deserve.  Our taxes are going into the pocket of these greedy corrupt men.

There have been numerous articles on these cases and I will try to organize, summarize, and paraphrase most of them in the next three days.  It is interesting that none of the article discusses Murray Foreman and Leonard Grunstein’s ownership of Fundamental Long Term Care Company that owns and operates hundreds of other nursing homes using the THI name.

The Wall Street Journal wrote geriatric pharmacy company Omnicare Inc. will pay $98 million to settle charges that it engaged in several kickback schemes with drug makers and nursing homes.  The Justice Department alleged that Omnicare regularly paid kickbacks to nursing homes in order to induce the homes to refer their patients to Omnicare for pharmacy services.  Separately, the department said it was intervening in a lawsuit alleging that two nursing-home chains, Mariner Health Care Inc. and SavaSeniorCare Administrative Services, accepted kickbacks from Omnicare in return for pharmacy-service contracts.

Reuters had an article that added additional facts.   DOJ filed a complaint against two large nursing home chains, Mariner Health Care Inc. and SavaSeniorCare Administrative Services LLC, both of Atlanta, and their principals, Leonard Grunstein, Murray Forman, and Rubin Schron, for accepting a kickback from Omnicare in return for pharmacy services contracts.  The company allegedly solicited and received kickbacks in exchange for agreeing to recommend that physicians prescribe Risperdal, a  dangerous antipsychotic drug, to nursing home patients.

The government further alleged that Omnicare regularly paid kickbacks to nursing homes by providing consultant pharmacist services at rates below the company’s cost and below the fair market value of such services in order to induce the homes to refer their patients to Omnicare
for pharmacy services.

The United States alleges that Omnicare, Mariner Health Care, SavaSenior Care, Grunstein, Forman, and Schron conspired to arrange for Omnicare to pay the nursing home chains $50 million in exchange for the right to continue providing pharmacy services to the nursing homes, which together constituted one of Omnicare’s largest customers. Defendants attempted to disguise the $50 million kickback as a payment to acquire a small Mariner Health Care business unit that had only two employees and was worth far less than $50 million.

After they became aware of the government’s investigation, Grunstein, Forman, and Schron allegedly created false backdated documents in a further attempt to hide the kickback. These
allegations are detailed in a separate complaint that was unsealed recently.  Read the Complaint here.

More to come tomorrow.

There are many caring and wonderful nurses and CNAs that work in nursing homes.  However, because of corporate decisions to cut staffing, decrease training, and pay minimum wage which causes burn-out, frustration, high turnover rates and stories such as the ones below.

Tulsa World had an article about Jason Lynn Pearl who was arrested in March on allegations that he abused patients in his role as certified nursing assistant at the Silver Lake Care Center, a 92-bed Bartlesville nursing home.  Washington County District Judge Curtis DeLapp gave him a slap on the wrist by splitting five-year term with two years in prison and three years suspended and a $1,150 fine after he admitted guilt in abusing patients at a nursing home  Thankfully, he will no longer be allowed to care for older people or children.

A police investigation began in February after family members of patients at the care center became concerned about allegations made by their loved ones. Investigators learned that situations involving three patients were recorded on Pearl’s cell phone and had been seen by several witnesses before they were erased. The recordings showed Pearl yelling at one patient and violently jerking the shirt of another, an affidavit states. One count alleged that Pearl inappropriately touched a third patient and spit in his face.

 

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I saw another story on Channel 7 about a CNA  accused of slapping a resident in Washington County.  Snell is accused of slapping a 90-year-old woman in the face, while caring for her at the Signature Health Care Center in Jackson County.   The nurse is facing elderly abuse charges filed by the State Attorney General’s office. Certified Nursing Assistant Cigi Serrevera Snell, surrendered herself at the Jackson County jail.  Snell is charged with one count of abuse of an elderly adult. If convicted, she faces up to five years in prison and a $5,000 fine.

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 Tulsa World had another article about Franklin D. Hughes, Jr. charged with caretaker abuse after he allegedly sexually abused dementia patients at a Bartlesville nursing home.  Two charges filed accused him of harming patients where he worked as a certified nurse’s assistant.  Hughes was arrested after police say he admitted to committing inappropriate sexual acts with patients.

One charge alleges that Hughes assaulted an 83-year-old man.  The victim told his pastor and a nursing staff member that Hughes asked to get in his bed and "tried to have sex" with him, a court affidavit states. Another charge alleges that Hughes assaulted a 76-year-old dementia patient who has since died.  The nursing center personnel told police that they no longer have records about the incident.  The victim told his family that he hated Hughes, accusing Hughes of "hunching" him and kissing him on the cheek and mouth in a bathroom at the nursing center between July 1 and Aug. 8, 2008, the affidavit states.

Prior complaints against Hughes were filed with the Oklahoma State Department of Health in 2003 and 2007 regarding his work with dementia patients at the Nowata Nursing Center, a court affidavit states. Another complainant alleged that Hughes asked to have oral sex with him.  The Nowata Nursing Center did not report either case to local law enforcement authorities, the court affidavit states.

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ABC 7 had a tragic article about Anthony Joseph Garcia, an employee at a Las Cruces nursing home,  sentenced for beating an elderly man in his care. Frank Vallejas, now 80, was a 76-year-old nursing home resident beaten by his own caretaker. The family later found out his caretaker had a lengthy criminal record. He was sentenced to 5 1/2 years in prison. Garcia had three previous felony convictions and rape charges, all of which under New Mexico state law would prohibit him from working as a caregiver. By law, a background check must be conducted before someone is hired as a caretaker.

ABC-7 contacted District Attorney Susana Martinez, who said it appears either the Las Cruces Nursing Center did a background check, saw Garcia’s record and let him work there anyway, or they failed to do a proper check altogether.  The human resources department and the Nursing Center said they do in fact follow standard procedures when it comes to background checks.

The administrators in human resources say they have not been on the job long and do not remember anyone by the name of Anthony Garcia. The victim has been moved to a different facility and is improving.

 

Read More →

Chicago Tribune had an article that is a good follow-up or counter balance to yesterday’s blog entry.  The article discusses the overmedication of nursing home residents including Delores Fleming.  She moved into Heritage Manor of Mount Zion and scored 23 out of 30 on a mental exam and was deemed to be "moderately impaired," state inspection records show.  Fleming had few problems her first week in the nursing home, according to her medical records, which her family provided to the Tribune.  But after she repeatedly had crying spells and tried to wander away, the nursing home doctor prescribed two anti psychotic drugs, even though she was not psychotic. Her family had given consent for the Seroquel, but the medical records show the permission sheet erroneously described the drug as an anti-anxiety medication. Seroquel is an anti psychotic drug intended for serious mental illnesses, such as schizophrenia.

Records show that Fleming briefly improved on the Seroquel, but over the next three months she had episodes of extreme anxiety.  The doctor doubled the dosage of one medication no fewer than four times, putting her above the recommended limit.  Once she thought she was possessed, nursing notes state. Another time she thought her brother had left her $50 million.

Her doctor ordered multiple injections of the anti psychotic drug Haldol and the anti-anxiety medication Ativan, state inspection records show. Fleming’s dose of Seroquel also was repeatedly doubled, putting her above the recommended limit for that drug.

After Fleming’s family complained that she had grown lethargic, the staff referred her to a neurologist. According to a state inspection report, the neurologist found her catatonic and believed she had developed tremorlike "Parkinson’s symptoms, due to the Haldol."  When he gave her the same mental exam she had previously taken, she scored zero out of 30. The neurologist recommended that her drugs be curtailed, and her condition dramatically improved. When she retook the test, she scored a 30 out of 30.

Both her family and the facility decided she should live elsewhere. The family wanted her in a home that specialized in Alzheimer’s care; Heritage Manor believed Fleming was endangering other residents, records show, and gave her 30 days to leave.

When the Tribune reviewed 40,000 state and federal inspection reports filed since 2001 on 742 Illinois nursing homes, numerous instances emerged in which regulators cited facilities for misusing psychotropics even though the patients’ doctors had created the problems.

When physicians or psychiatrists prescribe a drug for a patient, facilities must administer it as long as the order is consistent with state and federal nursing home regulations. If inspectors determine a violation occurred, they cite the nursing facility, not the doctor.

The Tribune found that inspectors documented many cases in which doctors prescribed powerful anti psychotic drugs without adequate justification or in doses that were too high.  The doctors also sometimes failed to provide adequate follow-up care, the inspection records show. They are required to see their nursing home patients only once every 60 days, though some do not visit even that often.  Several nursing home owners interviewed by the Tribune said they have struggled with doctors who rarely make time to visit patients.

Nursing homes are required to have pharmacists visit the facilities regularly and review prescriptions. If they discover irregularities, such as a patient placed on a drug without cause, they notify the nursing staff and doctor. But the Tribune found that when pharmacists recommended that a psychotropic be discontinued or the dosage reduced, physicians sometimes ignored the advice.

The difficult task of monitoring for side effects is left to nurses who are poorly trained in the use of psychotropic drugs. Experts say the situation can affect quality of care, and the Tribune’s review of inspection reports shows that is true — sometimes with tragic consequences.

The Chicago Tribune has done a great job researching, investigating, and writing about the use and abuse of anti-psychotics in nursing homes. See full article here.
 

The Washington Post had an ainteresting article about the effect of drug enforcement on nursing home residents receiving pain medications.  Efforts by the Drug Enforcement Administration to crack down on narcotics abuse are producing a troubling side effect by denying some hospice and elderly patients needed pain medication.

Tougher enforcement of the Controlled Substances Act, which tightly restricts the distribution of pain medicines such as morphine and Percocet, is causing pharmacies to balk and is leading to delays in pain relief for those patients and seniors in long-term-care facilities.  The DEA has sought to prevent drug theft and abuse by staff members in nursing homes, requiring signatures from doctors and an extra layer of approvals when certain pain drugs are ordered for sick patients.

Most nursing homes do not have pharmacies or doctors on site, adding to delays for patients who fall ill late at night or in transition from a hospital.  The pharmacies face tens of thousands of dollars in fines if they deviate from strict controls that require doctors to sign paper prescriptions and fax them to a pharmacy before a nurse can administer them in the nursing home setting.

"The system is broken. It isn’t working, and patients are suffering," said Claudia Schlosberg, director of policy and advocacy for the American Society of Consultant Pharmacists. "While we need to ensure there are proper controls on the medications, the overall law enforcement concern has to be compatible with meeting patients’ needs, and right now it’s not."

Doctors in nursing homes say the restrictions do not take into account that many more patients, with higher levels of illness and pain, are moving into long-term-care sites and out of hospitals.

 

 

The Contra Costa Times had a good article from the Oakland Tribune’s review of records from California’s Department of Public Health which is the watchdog that oversees the quality of care in California nursing homes.  They have allowed facilities to continue operating despite serious problems that persisted over years, a review by the Tribune revealed.  Consistent problems include urine-soaked mattresses, festering bedsores, patients lying in feces or restrained in wheelchairs without supervision.

In some cases, operators were able to hide a pattern of problems by changing the names of their companies or their facilities after they were cited by the state or sued. In other cases, records show that regulators were aware of the care centers’ history of noncompliance but licensed them anyway.  The department has been accused numerous times of not enforcing the state’s own laws.   It has been sued for taking years to respond to complaints about abuse and neglect, as well as for not requiring state-mandated staffing levels at facilities. One lawsuit claimed that the department’s lack of oversight was contributing to poor care residents received at facilities.

Unchecked neglect and abuse was at least one factor that drove Diana Harden to walk into an Oakland nursing home last month and shoot her disabled daughter and then kill herself, according to a letter Harden wrote to KGO-TV ABC7 News before the Sept. 13 murder-suicide. Harden asserted that her brain-damaged daughter, Yvette Harden, was mistreated and neglected at the Oakland Springs Health Care Center on 10th Avenue, where she had been a patient for six years.

Between 2004 and the September murder-suicide, Oakland Springs received more than 152 complaints and 212 deficiencies, many of them serious. But the state took no enforcement actions. Instead, the facility was required to submit a plan of correction and largely expected to enforce its own compliance with the plan, according to Department of Public Health records.

Annual inspections are the principal tool the Department of Public Health uses to monitor the quality of care in nursing homes. If significant problems are found during surveys or when inspectors investigate complaints, the facility can lose its contract with Medi-Cal and Medicare. That poses a considerable threat to many homes because the two federal programs pay for the majority of all long-term resident care. But in 2006 the department was so behind in investigating complaints that a judge required it to improve its oversight of nursing homes and submit quarterly reports showing that investigators were addressing complaints on time — within 10 days, or 48 hours when the complaint involves imminent danger to the resident.

In one case, an 87-year-old man’s wound became so infected that his leg had to be amputated in 2005 despite numerous complaints from his family to the department from the time the wound began to fester. Shortly after the amputation, he died of multiple causes including widespread infection.

In another case, a woman suspected her mother’s October 2004 death had to do with her treatment at a nursing home and complained to the department. Inspectors took seven weeks to arrive at the Los Gatos facility, Terenno Gardens Extended Care. They also took more than a year to investigate the death of a patient at a nursing home whose bedsores had become infected. In the meantime, another resident of the same home developed severe bed sores. An on-site investigation was not conducted until a year after the complaint was filed.

With each day that passes, the chance of properly investigating and redressing violations diminishes. Instead, the delay means the complaint is more likely to be unsubstantiated because the residents, witnesses and evidence may no longer be available.  Then in 2007, the California state auditor criticized the department for not correctly prioritizing complaints, too often understating their severity and not completing investigations. The auditor criticized the agency’s policy of waiting for a nursing home to submit a plan of correction before informing caregivers of the investigation results. The auditor also found that the system used to track complaints is subject to error, the disbursement of funds is suspect, and the timing of nursing home inspections is predictable, allowing some facilities to hide violations.

The Department of Public Health claimed that a lack of qualified evaluator nurses was behind the backlog of complaint investigations, which stretched into the previous decade. That demand is expected to grow more severe as the number of baby boomers move into retirement age — 78 million by 2030, according to the Institute of Medicine. Already there are 1.5 million Americans in nursing homes. Without tough oversight, operators can continue to rack up deficiencies while residents suffer.

In 2005, federal surveys found that California surveyors missed at least 25 percent of serious deficiencies. They are overlooked, a 2005 Government Accountability Office report said, because surveyors often are confused about what poses an imminent danger, such as worsening, avoidable pressure sores and untreated weight loss — frequently signs of understaffed facilities with poor quality of care.

In addition, surveyors across the country reported being asked by superiors to overlook or downgrade survey findings, the GAO said.  These problems distort the system of accountability for negligence and put residents at risk, said Carole Herman, founder of Foundation Aiding the Elderly. She sued the state Department of Public Health in 2006 because the agency still had not issued regulations that required nursing homes to provide each resident an absolute minimum 3.2 hours of skilled nursing care on a daily basis three years after the agency developed the staffing law.

Meanwhile, medical errors at Oakland Care Center mounted, employees complained they had to use their own money to buy supplies, and there were 72 deficiencies and 34 complaints between 2004 and 2009, Public Health Department records showed.

 

The following is a press release from the AAJ.  New Paper Debunks Malpractice Myths 

As enemies of health care reform spread lies and mistruths about medical negligence, a new white paper tackles the issue head-on, debunking the most common myths with sound science and research while refuting the hyperbole and empty rhetoric.

 Five Myths About Medical Negligence, one in a series of reports from the American Association for Justice on this issue, examines the errors and faults behind the most commonly used talking points of health care reform opponents. 

Myth #1: There are too many “frivolous” malpractice lawsuits.
Fact: There’s an epidemic of medical negligence, not lawsuits. Only one in eight people injured by medical negligence ever file suit. Civil filings have declined eight percent over the last decade, and are less than one percent of the whole civil docket.  A 2006 Harvard study found that 97 percent of claims were meritorious, stating, “portraits of a malpractice system that is stricken with frivolous litigation are overblown.”

Myth #2: Malpractice claims drive up health care costs.
Fact:  According to the National Association of Insurance Commissioners, the total spent defending claims and compensating victims of medical negligence was just 0.3% of health care costs, and the Congressional Budget Office and Government Accountability Office have made similar findings.

Myth #3: Doctors are fleeing.
Fact:  Then where are they going? According to the American Medical Association’s own data, the number of practicing physicians in the United States has been growing steadily for decades. Not only are there more doctors, but the number of doctors is increasing faster than population growth. Despite the cries of physicians fleeing multiple states, the number of physicians increased in every state, and only four states saw growth slower than population growth; these four states all have medical malpractice caps.

Myth #4: Malpractice claims drive up doctors’ premiums.
Fact: Empirical research has found that there is little correlation between malpractice payouts and malpractice premiums paid by doctors. A study of the leading medical malpractice insurance companies’ financial statements by former Missouri Insurance Commissioner Jay Angoff found that these insurers artificially raised doctors’ premiums and misled the public about the nature of medical negligence claims. A previous AAJ report on malpractice insurers found they had earnings higher than 99% of Fortune 500 companies.

Myth #5: Tort reform will lower insurance rates.
Fact: Tort reforms are passed under the guise that they will lower physicians’ liability premiums. This does not happen. While insurers do pay out less money when damages awards are capped, they do not pass the savings along to doctors by lowering premiums. Even the most ardent tort reformers have been caught stating that tort reform will have no effect on insurance rates. 

“All the facts and evidence show that tort law changes will do practically nothing to lower costs or cover the uninsured,” said AAJ President Anthony Tarricone. “It’s no wonder the tort reformers, insurance lobby, and other corporate front groups have to gin up lies and phony stats, since no legitimate data or research supports their claims. Our focus should be on reducing the 98,000 deaths by medical error that occurs every year, not limiting patients’ legal rights.” 

As part of its ongoing series on the topic, AAJ earlier released Medical Negligence: A Primer for the Nation’s Health Care Debate, The Truth About “Defensive Medicine,” and The Insurance Hoax: How Doctors and Patients Pay for the Huge Earnings of Medical Malpractice Insurers. These can be located at here.  Five Myths About Medical Negligence can be found here.   

 

Five Star Quality Care 3rd Qtr Results here and press release here.   Total revenues increased 5.9% to $297.2 million; net income $4.1 million.  Five Star Quality Care, Inc. is a senior living and healthcare services company.  Five Star owns or leases and operates 206 senior living communities with 21,953 living units located in 30 states. These communities include independent living, assisted living and skilled nursing communities. Five Star also operates five institutional pharmacies and two rehabilitation hospitals.  Five Star is headquartered in Newton, Massachusetts.

Kindred Posts Higher-Than-Expected Profits in 3rd Qtr.  See report here and press release here.  Net income was $5.5 million.  Revenue for the July-to-September period rose 6 percent to $1.06 billion.   The Louisville long-term care company recorded revenue growth in each of its three divisions — hospitals, nursing homes and rehabilitation. But the key was a 21 percent gain in hospital operating income.  Privately insured patients are generally more profitable than those covered by the government’s Medicare and Medicaid programs.   The company plans to keep growing.   Kindred expects to spend $45 million to $50 million to develop hospitals next year and $25 million to $30 million to grow its nursing-home business.

Ensign 3rd Qtr. Revenue Up Record 14.3%.  See report here and press release here.   The Ensign Group, Inc. (Nasdaq: ENSG), the parent company of the Ensign(TM) group of skilled nursing,
rehabilitative care services, hospice care and assisted living companies, today reported record results for the third quarter of fiscal year 2009.  Total revenue was a record $132.9 million, up 14.3% compared to $116.3 million for the third quarter of 2008.

Extendicare REIT 3rd Qtr. Results–Increased Profitability.  See report here.  Revenue of $532.1 million in Q3 2009, an increase of 8.5% compared to $490.2 million in Q3 2008, due largely to achieving higher per diem rates in Medicare and Managed Care. EBITDA of $71.1 million in Q3 2009, an increase of 39.2% compared to $51.1 million in Q3 2008, mainly due to cost controls.  EBITDA margins improved to 13.4% in Q3 2009 from 10.4% in Q3 2008 and 13.1% during Q2 2009.  Cash on hand of $130.9 million with no significant debt maturities until 2011 and beyond.

 

I have seen two lists that discuss the highest paid jobs.  One list is based on the Bureau of Labor Statistics and the other is from Forbes Magazine.  Both are dominated by health care professionals and show that there is clearly no need for tort reform.

1. Anesthesiologists: $197,340. (And anesthesiologists make more money in the state of Washington than in any other U.S. state)

2. Surgeons: $206,150. (Highest-paying state: Wyoming.)

3. Obstetricians and gynecologists: $192,040. (Highest-paying state: New Hampshire.)

4. Orthodontists: $194,900. (Highest-paying state: Wisconsin).

5. Oral Surgeons: $190,760. (Again, the highest-paying state is Wisconsin.)

6. Internists: $176,860. (Highest-paying state: Louisiana.)

7. Prosthodontists: $169,940. (Highest-paying state: Virginia)

8. Psychiatrists: $154,990. (Highest-paying state: Idaho.)

9. General Practitioners: $161,850. (Highest-paying state: Kansas.)

10. Chief Executive Officers: $144,600. (Highest-paying state: New Jersey.)

11. Dentists: $154,950. (Highest-paying state: Maine)

12. Physicians/Surgeons: $169,220. (Highest-paying state: Utah.)

13. General Pediatricians: $153,440. (Highest-paying state: Louisiana.)

14. Pilots/Co-pilots/Flight Engineers: $140,380. (Highest-paying state: Illinois.)

15. Podiatrists: $125,500. (Highest-paying state: Oregon.)