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Reports released this week by theCalifornia Department of Public Healthchronicle a series of nurse-related hospitalmishaps that led to the deaths of four

patients, including an infant. The head ofthe states largest union blamed the errorsin part on hospitalexecutivesmismanaging theirnursing staffs.

John F. KennedyMemorial MedicalCenter in Indioreceived fouradministrativepenalties totaling$100,000 the mostever levied by the CDPH at once.

According to CDPH documentation, all ofthe incidents were linked to issues with the145-bed facilitys nursing staff. All occurredin 2008.

The most serious incident involved a 2-day-old boy who died of sepsis, meningitisand acute hypoglycemia within hours ofbeing admitted. Although the child showedsigns of sepsis when brought to the ER, notesting was immediately performed, hisvital signs were not closely monitored, andit was more than two hours beforeantibiotics were administered. Anotherchild did not have its full vital signs taken

until eight hours after being admitted, atwhich time she had developed a 106-degree fever. That oversight was linked toa traveling nurse assigned to the

emergency department who had recentlygraduated from nursing school and was

not qualified forER work.In anotherincident at JFK, an87-year-old patienreceived a dose ofthe blood thinnerheparin 10 timeslarger thanprescribed. Aninvestigation

found that seven nurses assigned to JFKs

ER were not specifically trained for theassignment.

Deborah Burger, president of theCalifornia Nurses Association andNational Nurses United, among thenations most influential nurse unions,claims its fairly common for hospitals toplace nurses in positions where theydont have specific clinicalcompetencies.

There are some facilities that have ahigh number of traveling nurses. They

State Links Hospital Errors to NursesFour Citations at One Facility Alone; Union Reacts

California Edition

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March 9-10

February 10

Calendar

28 January 2010

February 10

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published in the Calendar section,space permitting.

Continued on Next Page

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January 27 Administrative Penalties

Number Levied: 16

Hospitals cited: 13

Patient Deaths involved: 4

Physician/staff-involved errors cited: 4

Nurse-involved errors cited: 12

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Payers & Providers

may have difficulty recruiting nurses towork at those facilities because ofworking conditions, Burger says. But iftheyre using travelers, they need to givethem a proper orientation, and make suretheyre competent to work in the unitwhere theyre assigned.

JFKs executives agreed to intensivelyretrain portions of its nursing staff,particularly in the ED, to address theviolations. Weve implemented thetraining, and have reduced the number oftraveling nurses we use, says hospitalspokeswoman Linda Evans. She adds thatno further incidents have occurred.

Aside from JFK, only one otherhospital has racked up four administrative

penalties Los Angeles County-HarborUCLA Medical Center, according toCDPH spokesman Ralph Montano.

In other incidents, Santa Clara ValleyMedical Center in San Jose was fined$25,000 for a patient death linked to animproper triage performed by its ERnurse. The nurse had claimed that thepatients hemoglobin count appeared to

Page 2

be crossed out, rather than underlined,prompting him to disregard it.

Another patient death case at St. JudeMedical Center in Fullerton occurred after nurse ignored a lack of vital signs on apatients cardiac monitor. The nurse hadnoted the patient had left his bed a coupleof times during the evening, and thoughtthe monitor leads were disconnected.

Nurses were also linked to surgicalerrors at San Francisco General Hospitaland Western Medical Center in Santa Anawhen they did not conduct a proper post-surgical count of sponges. In the SanFrancisco General case, the error was notdiscovered until the sponge was removedfrom the patient during an ER visit more

than three months later. San FranciscoGeneral was fined $25,000 for the incidentWestern Medical $50,000.

Burger claims the surgeons involved arealso normally involved in tracking spongesbefore a procedure is completed. All ofthem are responsible for the count, shesays.

The CDPH declined comment on anytrends involving nurses.

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A Boost to Medi-Cal In L.A. County

Health Net, L.A. Care Stretch on Dental Coverage

In Brief

City of Angels CivilCharges Settled For

$10M

Two former executives ofCity ofAngels Medical Center in Los

Angeles will pay $10 million aspart of a consent judgment tosatisfy state and federal civilcharges over their operation of aMedicare fraud scheme.

Prosecutors alleged thatbetween 2004 and 2007, RobertBourseau and Rudra Sabaratnam,M.D., recruited homeless personsfor $500 apiece to undergounnecessary treatments andprocedures. The pair in turnedbilled Medicare and Medi-Cal atleast $4 million. They pled guilty tofederal criminal charges last year.

Performing unnecessarymedical procedures just to take

money from taxpayers' pockets isbad enough, but to prey onhomeless people struggling tosurvive day to day is particularlyreprehensible, says Tony West,Assistant Attorney General for theCivil Division of the Department of

Justice. We won't tolerate illegalconduct and we will continue tohold companies, institutions andindividuals accountable forhealthcarefraud.

Bourseau will be sentenced onFebruary 22, and Sabaratnam onApril 5.

Molina Offers Full 2010Guidance

Medi-Cal managed care insurerMolina Healthcare has issuedearnings guidance for the full 2010calendar year that are moderatelyabove its 2009 earnings.

The Long Beach-based Molinaissued a forecast $39 million in net

Nurses (Continued from Page One)

As part of a cost saving measure last yearto close a huge budget decit, Californiaeliminated the Denti-Cal program for adults,limiting coverage only to tooth extractions.

In response, the two major health plansthat cover Medi-Cal enrollees in Los AngelesCounty have tried to provide dental care ontheir own. This week, Woodland Hills-basedHealth Net announced it would extend basicdental coverage to its adult Medi-Cal enrolleesin Los Angeles County through the

commercial dental plan it operates. Thecoverage includes routine checkups, x-raysand cleanings. Other procedures, such asllings, are discounted by as much as two-thirds.

The move follows on the heels ofL.A.Care Health Plans provision for dentalbenets last year.

Health Net ofcials say the need toprovide dental care had become obvious,particularly in light of studies linking oralhealth to overall health. Its not one of the

higher cost services overall, and we weregetting a negative response from many of ourenrollees, says Sean OBrien, Health Netsdirector of dental operations. The decisionaffects about 70,000 Medi-Cal beneciaries iL.A. County who are over the age of 21, headds. It covers about 450,000 Medi-Calbeneciaries in L.A. County.

Last September, Health Net began offerindental benets to the approximately 10,000adult Medi-Cal beneciaries it covers in

Sacramento County. In response, it signed onabout 2,000 new enrollees this month, aboutdouble the average, according to OBrien.

Whereas Health Net is using its existinginfrastructure, L.A. Care, which covers about785,000 Medi-Cal enrollees countywide, ismostly paying providers to offer dentalcoverage. Its small health plan for dual-eligibles with 700 Medicare and Medi-Calenrollees began offering dental benets inearly 2009. But the plan granted more than

Continued on Page 3

NEWS

Continued on Next Page

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Claiming price-gouging by Merck & Co. Inc.for its antiretroviral drug, the AIDS HealthcareFoundation has banned sales representativesfrom the pharmaceutical giant at its clinics.

The move came after ofcials with the LosAngeles based AHF claimed Merck did notlower the price of its drug Isentress after it wasrepositioned as a rst-line defense for patientsghting HIV. Isentress was initially introducedas a salvage drug to treat patients who werenot responding to other forms of antiretroviral

therapy. Typically, salvage drugs are pricedconsiderably higher than rst-line drugsbecause the lower demand cannot coverresearch costs.

According to AHF data, Merck recentlyraised the wholesale price of Isentress from$12,150 per year to $12,868, rather thancutting the price. AHF ofcials say manyantiretrovirals cost less than $9,000 per yearwholesale.

The fact that Merck recently obtainedFDA-approval for wider use of Isentress as arst line treatment, but kept it priced as if itwere a salvage drug is reprehensible, says

AHF President Michael Weinstein.

AHF operates 15 clinics throughoutCalifornia and in Florida and providesantiretroviral drugs to about 8,000.Weinsteinsays AHF spends about $180 million a yearon drugs, but could not estimate how much ispends on Isentress.

The prohibition on Mercks sales forcedoes not include a ban on Isentress,according to Weinstein. However, AHFofcials note that its representatives havemade regular calls to the clinics, and often

provide its staff with lunches.AHF enacted a similar ban a decade ago

on Glaxo representatives over objectionsabout how it prices its antiretroviral drugs forthe African market. The ban was in effect forabout four years before Glaxo relented onpricing, according to Weinstein.

In a prepared statement, Merck defendedits pricing policies.

The price of Isentress was determinedafter consultation with respected leaders inthe HIV community, and is in line withMerck's long-standing commitment to ensureaccess, says Merck senior vice president

Patrick Bergstedt.

Page 3

AIDS Provider Challenges Merck

Bars Sales Force Over Claim of Price Gouging

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NEWS

In Brief

income, or $1.50 per share forcalendar 2010, about 20% aboveits projected 2009 earnings of$1.12 to $1.26 per share it issuedearlier this month.

Molina officials had said 2009earnings were put under pressuredue to additional expenses treatingenrollees who had contracted theH1N1 swine flu virus.

The 2010 earnings forecastdoes not take into account anydilutive effect for its recentlyannounced acquisition of thehealth information managementunit from Unisys, Inc., thecompany announced.

Loubet Joins Payers &Providers Board

Henry Loubet, chief strategy officerfor Keenan & Associates, has

joined the Payers & Providers

Editorial Board.Loubet, who is based in

Oakland, is the first NorthernCalifornian representative on thePayers & Providers board. He willregularly contribute to its Opinionpage. Keenan is the largestindependent insurance brokerageand consultant in California.

Prior to joining Keenan,Loubet held senior executivepositions at some of Californiaslargest health plans. He served aschief executive officer ofUnitedHealthCares westernregion, was president of the formerFoundation Health Plan, and was a

senior vice president with HealthNet .

Loubet holds masters degreesfrom the University of Pittsburghand University of San Francisco,and a bachelors degree from RiderUniversity, New Jersey.

Henrys deep knowledge ofthe payer side of healthcare is anenormous benefit to thepublication, says Payers &Providers publisher Ron Shinkman.

$700,000 to 10 community clinicscountywide to provide dental care to itsapproximately 200,000 adult Medi-Calenrollees. L.A. Care spokesperon Andrea VanHook also conrmed that it is consideringoffering dental coverage to its adult Medi-Calenrollees, but that it would require approvalfrom the California Department of HealthCare Services, which oversees the Medi-Calprogram. Those plans have not yetsolidied, she says.

That two health plans have stretched on

providing dental care benets has pleasedsome state healthcare advocates.

It would be amazing if we could getmore plans to expand their dental coverage,says Maria Robles, President of Sacramento-based Californians for Patient Care. The grousays its requests to nd both medical anddental care for individuals has increasedtwenty-fold over the past year. In one examplethe organization spent four months trying toget dental care for someone with an abscessetooth, without success.

Medi-Cal (Continued from Page Two)

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Landmark federal healthcare reformlegislation which was nearly a done deal isnow a deal undone.!Due to the recent endof a Democratic supermajority in theSenate, the future of healthcare reform willnow be significantly altered.

Whatever strategy Congress chooses toreform healthcare, it is essential that itaddress the major areas in need of change,including eliminating various unfairinsurance practices and fixingour current healthcare deliverymodel. Without reform the riskis real that our economy will

continue on a downward spiralas sky-rocking healthcare costscrowd out other criticalexpenditures.!

Part of the problem has beenour reluctance to transform anantiquated fee-for-servicepayment model one that hasbeen entrenched for decades into a higher quality, moreaccountable system of care.!Theexisting fragmented structure makes itvery difficult for patients to receiveoptimal care because the fee-for-

service model pays physicians fortreatment regardless of whether the careprovided is appropriate, beneficial, oreven warranted.! Additionally, within thefee-for-service model, patients are obligedto self navigate through a maze ofspecialists who frequently have noconnection to each other.!! !

Previous healthcare reform measuresoffered us the opportunity to transitionfrom this disorganized approach to onethat is more affordable, comprehensive,and coordinated through the establishmentof Accountable Care Organizations (ACO).!In fact, ACOs were one part of healthcarereform nearly everyone agreed with. It isvitally important that, in their quest totransform Americas healthcare system,Congress doesnt throw the baby out withthe bathwater. Therefore, any futurehealthcare reform proposal must includethe ACO model.

.! Think of Accountable CareOrganizations as Healthcare 3.0 providing a system that is moreaccountable, affordable, efficient,

innovative, and user-friendly for both patand doctors. It will improve individual pacare by providing health services throughnetwork of physicians who use the latesthealth information technology to track patreatments and share intelligence to guidepatient care decisions.! The CongressionaBudget Office has estimated the savings fa currently proposed national ACO pilotprogram at $2.3 billion.

Californias physician groups aamong the few throughout thcountry that have beenpracticing within an account

care model for the past 20 yeThe California physicians whhave organized themselves iMulti-Specialty Medical Groand Independent PracticeAssociations (IPA) represent exact Accountable CareOrganization approach thatnow in-limbo House and Senbills have tasked the Center

Medicare and Medicaid Services tospread across the nation.!!With the baby boomers scheduled toThe ACO model is best equipped to

handle the intense coordination of healthservices required to meet the needs of anaging patient population battling diabetesother chronic diseases. The ACO model walso provide the infrastructure and costcontainment measures needed to insure 3million more Americans in the next decadwithout overwhelming our healthcare sys!Even though broad healthcare reformseems to be slipping away, we still have aextraordinary and unique opportunity to ma very real difference in the lives of millioof people. Congress should seriously conthe ACO experiences in California and us

them as a roadmap for any healthcare refmeasures proposed in the future.

OPINION

A Reboot For Healthcare ReformNew Efforts Must be Focused on ACOs and Costs

By

Donald

Crane

Donald Crane is the President and CEO of the

California Association of Physician Groups, wh

employs or contracts with nearly 60,000

physicians who provide care to 15 million

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