payers & providers california edition – issue of june 2, 2011

8/6/2019 Payers & Providers California Edition Issue of June 2, 2011

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Of cials with managed care plans that beganto see a large in ux of elderly and disabledMedi-Cal enrollees earlier this week expressedconcerns that the costs of caring for this groupcould prove challenging to manage.

About 360,000 of what are calledseniors and people with disabilities knownas SPD will be transitioned into managedcare from Medi-Cal fee-for-service programsover the next year. The transition, which istaking place in 16 mostly urban counties, ispart of a federal waiver obtained by Californialate last year to expand Medi-Cal coveragewhile saving money. Enrollees will be movedinto managed care plans based on their birthmonths those with birthdays in May weremoved into managed care programs as of June1. They can choose the plan on their own, orwill be automatically enrolled based on theirrecent medical and provider history.

The plans will be paid relativelygenerously for the care they provide about$500 per enrollee per month, depending onthe region of California where they operate.Thats on average about 4.5 times more thanthey are paid for non-SPD Medi-Cal enrollees.

However, plan of cials say the populationis wracked with ongoing health issues. Asmany as 40% in Medi-Cal fee for serviceprograms require closely coordinated andoften costly mental healthcare services,of cials claim. And hospitalizations are farmore commonplace. The non-SPD Medi-Cal

population experience about 180 to 200 daysin a hospital bed per 1,000 members annually.By contrast, the SPD population ishospitalized about ve times more frequently.

They are much more chronically ill, inaddition to their socioeconomic issues, saidLeslie Porras , spokesperson for Anthem BlueCross of California . Anthem has about 1million Medi-Cal enrollees statewide, andprojects an in ux of about 60,000 new SPDenrollees.

Utilization is going to be tough topredict now, but I dont know if the paymentsare going to be enough, said Howard Kahn ,chief executive of cer of L.A. Care HealthPlan. L.A. Care. Kahn noted his plan received11,000 new enrollees for the rst month of thetransition, signi cantly higher than itsprojection of 9,000. L.A. Care expects about100,000 new SPD enrollees over the next year nearly a third of the statewide total

boosting the plans total enrollment byabout 15%.

We have far more behavioral healthissues, said Bradley Gilbert , M.D., chief executive of cer of Inland Empire HealthPlan, which provides Medi-Cal managed carein San Bernardino and Riverside Counties.Gilbert said that the new enrollees suffer fromschizophrenia and bipolar disorders at ratesfar higher than the national average oftenstubborn conditions that require pricey

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Payers & Providers Page 2

Top Placement...Bottomless Potentia l

Advertise Here

(877) 248-2360, ext. 2

In Brief

HHS Eases Premiums,Restrictions in Pre-Existing Condition

Coverage Pool

The U.S. Department of Healthand Human Services has easedbarriers on health coverage toenrollees with pre-existingconditions, dropping premiums in23 states and the District of Columbia where it runs theprogram by as much as 40% andeasing restrictions elsewhere.

The Pre-Existing ConditionInsurance Plan changes lives, andin many cases, literally saveslives, said HH S SecretaryKathleen Sebelius . These changeswill decrease costs and help insuremore Americans.

However, enrollment in theprogram has been tepid since itslaunch last year. As of the end of March, only 18,313 had chosen toenroll in the program, althoughHHS officials say enrollment hasbeen increasingly steadily sincethe fall. California, the mostpopulous state, had just over 1,500enrollees.

California runs its ownprogram, but now has theopportunity to drop its premiumsto make them more in line with theindividual insurance market. Also,applicants will no longer need tobe officially rejected by an insurerto obtain coverage; a letter from adoctor testifying to the medicalcondition will suffice.

Kaiser Wins NCQAMulticulturalCertification

Kaiser Permanentes SouthernCalifornia division has won

Continued on Page 3

NEWS

Medi-Cal (Continued from Page One)

medications to treat.Gilbert projected IEHP will receive about

35,000 of the 55,000 new SPD enrollees. It

received 3,200 its rst month. The planpreviously had about 20,000 SPD enrollees.Long Beach-based Molina Healthcare of

California is expected to receive theremaining enrollees in San Bernardino andRiverside Counties, which was con rmed by aplan spokesperson.

Welcoming and educating (enrollees) tothe added services and bene ts of their newplan will be the rst priority, said RichardBock, M.D., Molina Californias chief medical

of cer.Many of the plans have beefed up their

staffs. L.A. Care has increased its number of

employees by about 90, an approximately20% increase. Most are in the memberservices, utilization and care management andthe claims departments.

IEHP added about 20 new employees.Both plans are conducting close intakeassessments of each new enrollee.

Anthem contracted with a New York-based rm, APS Healthcare, to closelymonitor the new enrollees and coordinatetheir care.

Blue Shield Chief Earned Nearly $5MPay For CEO And Colleagues is Far Above AverageThe chief executive of cer of Blue Shield of California earned nearly $5 million incompensation last year, far higher than anyother not-for-pro t health plan CEO inCalifornia, according to public records. Bruce Bodaken earned $4.6 million in2010, according to records released by theCalifornia Department of Insurance . The CDIdemanded the compensation levels of San

Francisco-based Blue Shields highest-paidexecutives as part of an examination of nancial records connected to recent

premium increases. Insurance CommissionerDave Jones has no authority to deny suchincreases, but can deem them unreasonable,particularly as they relate to executive pay.

Blue Shield of cials would not releaseBodakens compensation to Payers &Providers last year as part of a pay survey forhealth plan and hospital executives. BlueShield of cials claimed that although the planis a not-for-pro t, its structure as a mutualbene t corporation did not obligate it do so.

Most not-for-pro t organizations must release

the compensation of its top executives in itstax returns.

Along with Bodakens compensation, BluShield also released the compensation of itsnine other highest paid executives, althoughtheir names and titles were not disclosed. Thelowest salary was $749,643.

According to a Payers & Providers surveyreleased the last year, the average total

compensation in California for a health planchief operating of cer and chief nancialof cer typically the number two and threeexecutives in an organization was $789,530Total compensation for COOs and CFOs atnot-for-pro t health plans was signi cantlylower, averaging $524,387.

The compensation paid to Blue Shieldexecutives falls well within healthcare industrstandards, is based on performance, and relieson independent market research, said Stev

Continued on Next Page
https://www.managedcarestore.com/pandp/p&pblueprintebook.htm


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Page 3Payers & Providers

Longer ALOS!*

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(877) 248-2360, ext. 2

*For our ads, not your hospital

NEWS

In Brief

HEALTHCARES BEST ADVERTISING VA]

PAYERS & PROVIDERS reaches 5,000 hospital, health plan and nonpro t executives statewide. There is no better venue for marketing

your organization or conference, or recruiting new staff.

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The Oakland-based California NursesAssociation/National Nurses United won twomajor victories this week, renewing a laboragreement with the University of Californiahospital system and securing representation ata major Los Angeles-area hospital.

The CNAs membership rati ed a newcollective bargaining agreement with theUniversity of California on May 23, the rstnew one in a decade. About 11,000 nurseswork at the UC hospitals in Los Angeles, SanFrancisco, San Diego and Davis, as well asstudent health centers at other campuses.

In addition to winning concessionsregarding negotiations over patient safetyissues, the nurses will receive pay increasesthat will average at least 11% over the next 26months.

certification from the NationalCommittee for Quality Assurancefor its multicultural care.

Kaiser is the only Medicarepayer in Southern California toreceive the certification, which isknown as the Multicultural Health

Care Distinction. NCQA beganissuing them this calendar year.Plans are certified in fivecategories, including access andavailability to language services,the cultural responsiveness of itspractitioner network, and thereduction of healthcaredisparities. Kaiser earned 98.25points out of a total of 100rewarded.

"NCQAs work elevates theoutcomes of the U.S. healthcaresystem by constantly measuring,analyzing, and promoting higherperformance standards in qualityand service, said Patti Harvey , a

Kaiser senior vice president forquality and risk management.

CDPH Will Fine 12Hospitals

The California Department of Public Health will announce on

June 2 administrative penalties to12 California hospitals, accordingto a media statement.

The hospitals, located ineight counties Los Angeles,Santa Cruz, Orange, Contra Costa,San Diego, San Francisco, SanMateo and Stanislaus h avereceived administrative penaltiesranging from $25,000 per$75,000 per violation.

The CDPH issuesadministrative penalties forincidents that are out of compliance with hospitallicensing requirements and eitherare likely to cause or did causeserious injury or death in patients.

The CDPH declined to namethe hospitals prior to a 10 a.m.press conference.

Shivinsky, Blue Shields vice president of corporate communications. The company'sexecutive compensation package is designed

to be competitive with compensation paid byboth for-pro t and not-for-pro t companiesin the same markets where we compete forsenior staff...as a not-for-pro t company, wedo not offer stock options, so ourcompensation never has as high an upside asfor-pro t companies that provide options.

Bodakens counterpart at for-pro tAnthem Blue Cross of California, PamKehaly, earns about $800,000 a year,according to the Los Angeles Times.Oakland-based Kaiser Permanente CEOGeorge Halvorson earned about $6.7 millionin total compensation, although his job also

includes overseeing the operation of dozens

of hospitals nationwide.Bodakens pay package was blasted by the

Santa Monica-based advocacy group

Consumer Watchdog , which has beensupporting a bill currently in the Legislaturethat would allow the DOIs Jones and hiscounterpart at the Department of ManagedHealth Care to reject premium increases theyconsidered excessive.

"When a nonpro t insurance company'sCEO makes more than four million dollars ayear, but patients can't keep up with ratehikes, then something has to change," saidConsumer Watchdog Executive Director DougHeller . "Blue Shield's CEO has become theposter child for the insurance company greedthat must be stopped.

Nurses Union Has Two VictoriesRenegotiates UC Pact, Wins at Saint Johns

UC spokesperson Dianne Klein told theSan Francisco Business Times that the pact wafair.

Additionally, the CNA won the right torepresent about 500 nurses employed at the268-bed Saint Johns Health Center in SantaMonica. The nal vote was 269 to 149, with22 challenges. The union had been trying towin representation at the hospital for severalyears.

CNA Executive Director Rose AnneDeMoro noted that nurses were the victims of"excessive aggression...for years for wanting tohave rights to advocate for theirpatients demonstrating why nurses need aunion."

Saint Johns is a member of the Sisters oCharity Leavenworth Health System .

Blue Shield (Continued from Page Two)
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Payers & Providers Page 4OPINION

Make EHRs A Branding Opportunity An Ad or Subsidy-Driven System Will Drive Usage

Andre Vovan, M.D., is a critical care physicianin Newport Beach and founder of the EHRvendor firm Mitcochon Systems.

9-21:) !;6!


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MARKETPLACE/EMPLOYMENTPayers & Providers Page 5

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Call (877) 248-2360, ext. 2Or e-mail: [email protected]

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HEALTH PLAN MEDICAL DIRECTOR (Los Angeles)Physician licensed by the State of California, with board certi cation in primary care or medical subspecialty.Have ve (5) years of Medical Director experience in a managed care setting, such as a HMO or IPA/Medical Group.Medical oversight and physician liaison in the areas of: Utilization review, credentialing, quality improvement, peer review, casemanagement, and disease management.

Works under the direction of the CMO to ensure the delivery of high quality and ef cient care for all members. ProvideAdministrative Management of patient care with speci c responsibility to provide direction and assistance in achieving optimal

medical performance in an ef cient manner. To participate and lead in the review of all inpatient admissions. Direct and reviewall inpatient utilization activity at hospitals by interfacing with the clinicians and UR nurses. Oversee the review process of priorauthorization (medical and pharmacy) requests in a timely manner. All denials must be individually reviewed and signed by theMedical Director or physician reviewer.

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HEALTH PLAN, MANAGER, MEDICAL MANAGEMENT (So. California)Graduate from an accredited RN program with three or more years of recent acute hospital nursing experienceThree or more years of recent managed care utilization management and case management experienceThree or more years of staff supervision/management experience. The Manager of Utilization and Case Management is responsiblefor the day to day operations of the utilization and case management department, including the Medi-Cal and Medicare Programstaff. The Manager of UM /CM collaborates with the Director of UM/CM and the Team Leader and with the staff Medi-Cal WaiverCase Management Programs to promote continuity between programs, teamwork and collaboration.

Maintains effective administration of UM and CM functions. Coordinates staff schedule to assure effective coverage of UM andCM functions, including after hours, weekends and holiday coverage by Nurse Advice. Trains, implements and evaluates UM andCM policies and procedures, guidelines and action plans. Monitors and evaluates through monthly quality assessments theperformance of the Case Management and Utilization Management staff against established productivity and quality guidelines.Provides timely educational feedback to staff on performance Assists the Director of UM/CM to ensure the programs are compliantto DHCS contractual and regulatory requirements for Medi-Cal and to CMS regulations for Medicare.

Please Contact:Executive Search & Placement

Sonia Varian at 818.707.7118, or [email protected]


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Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

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payers & providers california edition – issue of june 2, 2011

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