payers & providers california edition – issue of june 28, 2012

7/31/2019 Payers & Providers California Edition Issue of June 28, 2012

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Calendar

28 June 2012

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California Edition

In a decision that brought a mixture of cheerand relief from Californias healthcare leaders,the U.S. Supreme Court narrowly upheld thelinchpin of the Patient Protection and

Affordable Care Act, requiring Americanspurchase health insurance or pay a taxpenalty. Much of the law was left intact as aresult.

The justices did strike down anothermandate requiring states expand theirMedicaid programs for millions more low-income Americans or lose program funding. Itis widely believed California will move toexpand the Medi-Cal program anyway.

Chief Justice John G. Roberts, Jr.surprisingly joined the liberal wing of thecourt in the 5-4 ruling to uphold the individualmandate, siding with Associate Justices

Stephen Breyer, Sonia Sotomayor, ElenaKagan and Ruth Bader Ginsburg.Associate Justice Anthony Kennedy, a

conservative who is often the swing vote insuch matters, dissented along with JusticesAntonin Scalia, Clarence Thomas and SamuelAlito and declared that the entire healthcarelaw is unconstitutional.

In writing for the majority, Roberts saidthe individual mandate could not be enforcedunder the commerce clause of the U.S.Constitution, but was legal as part of theoverall authority of Congress to levy taxes.

The requirement that certain individuals

pay a nancial penalty for not obtaininghealth insurance may reasonably becharacterized as a tax, Roberts declared.

Because the Constitution permits such a tax,it is not our role to forbid it, or to pass upon itwisdom or fairness.

The Courts ruling was in contrast to what

transpired during oral arguments in March,when many justices skeptically questioned theindividual mandate, leaving Solicitor GeneralDonald B. Verrilli halting and off-balance inmaking his case for the ObamaAdministration.

The ruling is expected to greatly reducethe number of uninsured in California. Thestate currently has nearly 7 million residentswithout coverage, about one in veCalifornians.

This is a great day in our opinion,because it sets the stage without a cloudtoward where were going, said C. Duane

Dauner, president of the California HospitalAssociation. Dauner noted that the highcourts ruling continued the organizations 20-year plan to improve the health ofCalifornians.

Dauner also believed California wouldmove to expand the Medi-Cal program by asmany as 2 million enrollees, receiving 95% ofthe funding to do so from the federalgovernment in the early years ofimplementation. While the state has one of thlowest rates of inpatient Medicaid payments inthe nation, Dauner said his constituents wouldrather have little money than none at all.

July 19-21

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Continued on Next Page

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In Brief

Kaiser Study DelvesInto Healthy Eating At

Schools

Healthy eating programs candramatically cut the amount of poorfoods on school campuses so long asproper steps are taken, according to anew study by Kaiser Permanente.

The study, which was funded bythe U.S. Department of Agriculture,concluded that using aparticipatory program that solicitsinput from from teachers, parent andstaff can cut the presence ofunhealthy foods and beverages onschool campuses by 30%. Thatcompared to an ongoing increase inunhealthy foods at campuses withoutsuch a program in place.

"Schools are an ideal place for

establishing lifelong healthy eatinghabits, but until now that's beeneasier said than done," said Kaiserresearcher Karen J. Coleman. Thestudy helped us understand howcommunitiesand schools could work together toget kids to eat healthier at school andhelp address childhood obesity.

The results of the study arepublished in the most recent issue ofInternational Journal ofBehavioralNutrition and Physical Activity.

OC Surgeons Start NewMedical Group

A group of Orange County physicianshas banded together to create aspecialty surgical medical group.

The organization, calledNewport Irvine Surgical Specialists,is based in Newport Beach. Itscomprised of specialty surgeons in

Continued on Page 3

NEWS

Dauners view was echoed by the Medi-Cal payer sector.

I feel condent that Gov. Brown and

legislative leaders will work with the ObamaAdministration to expand the Medi-Calprogram in California, said Howard Kahn,chief executive ofL.A. Care Health Plan,which provides coverage to nearly 1 millionMedi-Cal and Healthy Family enrollees in LosAngeles County.

Kahn said the ruling would not covereverybody in California, particularly sinceMedi-Cal reimbursement rates are so low, buthe and others agreed it was a game changer.

In the Los Angeles area, depending onthe region, one in four or one in ve peopleare uninsured. If that is cut in half, its huge for

hospitals, said Jim Lott, executive vicepresident of the Hospital Association ofSouthern California.

Although hospitals are expected to benetmore widely from the decision thancommercial insurers which will have toguarantee coverage to all applicants thatsector was also pleased by todays ruling.

The Supreme Courts decision means thatCalifornia will continue to pursue the sharedgoal of helping as many citizens as possibleget healthcare coverage, said Patrick

Decision (Continued from Page One)

Johnston, president of the CaliforniaAssociation of Health Plans. Health planscontinue their commitment to effectively

implement the Affordable Care Act andconstrain the cost of care for all CalifornianJohnston added that the entire sector must focus on containing the costs of healthcaredelivery.

California Insurance Commissioner DaJones also praised the decision, stating it wwin-win-win for the states families andeconomy, and that it was a validation of theleadership of President Barack Obama.

Millions of Californians who have heainsurance will continue to enjoy benets suas keeping their kids on their insurance to a26, prohibitions on rescinding your insuran

elimination of lifetime and annual caps onyour benets, no co-payments for preventivcare, cheaper medications for seniors onMedicarethe list of immediate benets goon and on, Jones said.

However, Jones cautioned that the statwill need to enact legislation control theescalation of health insurance premiums. Aballot initiative on the issue is expected to bplaced before voters in November as theyalso make their decision whether to re-elecPresident Obama.

Other Reactions To ACA RulingWe can look toward 2014 with renewed energy. The results of the first two years speak for

themselves: 10,000 Californians denied coverage due to pre-existing conditions now have

coverage; 350,000 seniors got help in paying for their prescription drugs; and 435,000 young

adults are insured through their parents coverage. With our Latino population growing rapidly,

we must continue to educate our communities about the availability of these and other

coverage options, and todays ruling enables us to do so." Monica Blanco-Etheridge,

Executive Director of the Latino Coalition for a Healthy California.

The Supreme Court has ruled to uphold the Presidents Obamacare.!Despite being viewed asconstitutional by a narrow majority, this law will do great harm to our country by imposing new

taxes, burying job creators in new red tape and saddling future generations with debt they

cant afford. Rep. Darrell Issa, R-CA

"This is a victory for consumers and especially for California. No state in the nation had more at

stake. This removes the cloud. There will be no more political speeches in the Legislature saying

we should hold off on bills until the Supreme Court rules." Anthony Wright, executive director,

Health Access California

CMA vigorously supported the individual mandate to ensure universal insurance coverage for

the millions of uninsured Californians and the reforms on the for-profit insurance industry, and we

are pleased that those reforms were upheld...it does not guarantee that these newly insured

patients will have access to doctors because the Medicare and Medicaid programs were left

grossly underfunded. CMA was also strongly opposed to the ACAs creation of an

unaccountable Independent Medicare Payment Advisory Board, which will mandate arbitrary

spending cuts, force more physicians out of the program, and limit seniors treatment options.

James T. Hay, M.D., President, California Medical Association


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In Brief

the area. They have long had ties toHoag Memorial HospitalPresbyterians two campuses andOrange Care Memorial Hospital. Itwill be based on Hoag property inNewport Beach. The group alreadyoversees Hoags wound care center.

Healthcare is rapidly

changing, said Lincoln Snyder, M.D.,the groups president and an oncologyspecialist. Regardless of whathappens with the federal healthcarelaw, the practice of medicine and theway care is delivered is beingtransformed. The new landscapeneeds signicant physician leadershipto be shaped positively. Our groupplans to have a substantial role in thecommunities we serve in determininghow these changes play out.

Newport Beach-based SovereignHealthcare will provide managementservices to the group practice.

Workers CompensationInsurers Report Big

Losses For 2011

A new study by the CaliforniaWorkers Compensation Bureauestimated the states insurers lost $2.3billion in its operations during 2011.

Altogether, insurers paid out $7.7billion in claims and had another $5billion in overhead, including $4.4billion paid out in medical care about 48% of the $10.4 billion inpremiums collected, up from 43% ofpremiums in 2010.

Insurers in the state have had adifcult time keeping a lid onexpenses since 2008, when theybegan exceeding premiums. However,the red ink is still far below what wasreported in the late 1990s.

Insurers have claimed a numberof reforms ushered in by former Gov.Arnold Schwarzenegger have led tothe losses, although there is nolegislative initiative underway toreform the current system.

NEWS

STORIES OF ONE HIGHLY LITIGIOUS PHYSICIAN

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Scripps Healthcare Slashes Costs2010 Initiative Has Helped to Remake System

A major restructuring of care delivery atScripps Healthcare undertaken in late 2010has led to a dramatic improvement in itsnances.

The San Diego-based Scripps, whichoperates four hospitals and a variety of clinicsand medical groups in the region, reported theoverhaul which favored an integration of itshospitals and clinics versus the prior siloedapproach saved the organization $77 millionin its last scal year.

Among the changes:

ER patients are immediately assessed by a

nurse, with followup by a physician. Thishas reduced the average waiting times atScripps hospitals to 30 minutes or less. ERcapacity has expanded as a result toaccommodate another 21,000 patients andgenerated an additional $19 million inrevenue.

Scripps renegotiated its contracts andcentralized the purchasing process for itspharmacy operations, saving $14 million todate. It expects to save another $5 million inthe coming years via technological updates.

Laboratory services were centralized at asingle location in San Diego, cutting costsby $6 million a year

Cardiac surgery outcomes were improved,saving $3.3 million a year

Contracts were renegotiated with a varietyof ancillary vendors, including ones formedical transcription, servicing elevators,operating the systems blood bank andconducting tests to assess vitamin levels inpatient. The initiatives have saved $6 million

a year.

Single-used medical devices are beingresterilized. Its saving about $350,000 ayear in a single cardiac lab, and is beingslowly rolled out systemwide.

Scripps has also implemented genomicscreening for patients prescribed Plavix, whiis used to treat heart conditions, andinterferon, which is used to treat leukemia,hepatitis c and other conditions. Such drugscan be ineffective in patients with certaingenetic makeups. Such screenings may be

extended for other medications in the futureDespite the dramatic changes, a Scrippsspokesperson said no jobs have been cut.

We're knitting together what has been fragmented delivery system through a focus streamlined management in the hospital andambulatory setting, said Scripps ChiefExecutive Ofcer Chris Van Gorder.

Many hospitals and healthcare systemshave been launching such efciencycampaigns in order to make it easier to issuebonds and attract other forms of capital,according to James LeBuhn, senior director the healthcare division for ratings rm Fitch,

Inc.Organizations have been really focuse

on cost control and ongoing efciencyinitiatives, LeBuhn said.

However, the savings Scripps has achievhave been fairly dramatic, adding about 3%its overall operating margins in its 2011 scayear.

Van Gorder noted that such sweepingchanges will be mandatory for the U.S.healthcare system if it wishes to endure.

Healthcare in this country is alreadychanging and must keep evolving,because it's broken, he said.
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Payers & Providers PageOPINION

Sound ACO Deployment QuestionsTheyre The Wave of The Future, But Tough to Get Rig

Phil Dalton is the chief executive officer of

MDS Consulting.

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MARKETPLACE/EMPLOYMENTPayers & Providers Page 5

MANAGER ENCOUNTER DATA

JOB SUMMARY: Manages and coordinates encounter dataacquisition, validation, submission, and remediation. Providesexpertise in encounter processing to support business andanalytical projects. Responsibilities include interaction with theprovider partners, vendor management, inter-departmental col-

laboration, and supervision of staff.ESSENTIAL JOB RESULTS: Manages operations of encounterdata processing by coordinating and overseeing staff, prioritiz-ing tasks and resolving issues. Manages encounter data vendorrelationships by monitoring their performance and guidingthem through issues and priorities. Maintain Encounter DataProcessing System and Encounter Data Portal by guiding tech-nical staff, including timeframes, requirements, and testing.Provide expertise and guidance for all encounter data analyt-ics and reports by ensuring all data is accurate, reports aredelivered timely and consistently. Collaborates with inter- andintra-departmental teams and groups though meetings, emails,and various workgroups. Maintains staff by recruiting, selecting,orienting, developing, and training employees. Maintains staff

results by communicating job expectations; planning, monitor-ing, and appraising job results, counseling and coaching employ-ees; initiating, coordinating, and enforcing systems, policies, andprocedures. Maintains a professional business and technicalknowledge of encounter data processing requirements andregulation by attending regulatory conferences, participatingin industry workgroups, and monitoring announcements fromregulatory agencies. Contributes to team effort by accomplish-ing related results as needed.

QUALIFICATIONS:Bachelors Degree in business or healthcarefield, or equivalent experience. 3 - 5 years of healthcare dataprocessing experience. Supervisory or management experiencerequired. Knowledge of CMS Encounter Data Processing and

risk adjustments preferred. Strong technical, verbal, and writtencommunication skills. Ability to exercise independent and pro-fessional judgment and decision making skills. Ability to handlemultiple tasks simultaneously; excellent organizational skills andstrong commitment to details. Excellent windows based com-puter and MS office skills are required, and experience in MSSQL is preferred.

FT position, M-F 8 AM to 5 PM, with extended workhours and occasional travel, as needed. Please apply to

www.scanhealthplan.com | Job opportunities | Req. # 12-728

COMPLIANCE SPECIALIST

JOB SUMMARY: Ensures compliance and adherenceregulatory requirements by monitoring internal policies aprocedures and state and federal regulations and advismanagement on needed actions.

ESSENTIAL JOB RESULTS:Ensures compliance westablished internal control procedures by examini

records, reports, operating practices, and documentatand providing information to the Director for approvEnsures compliance with state and federal agencies studying existing and new legislation; auditing for adhence to requirements and participating in cross-functioteams to advise management on needed actions. Ensucompliance by performing standardized audits and recomending new policies and procedures. Provides guidanand information by interpreting policies and proceduranswering questions and requests, and upon Directoapproval forwarding to functional key contacts.

Maintains customer confidence and protects operatio

by keeping information confidential. Prepares reports collecting, analyzing, and summarizing information atrends. Satisfies training needs by providing end-utraining. Maintains compliance database by entering abacking up data. Maintains company reputation by comping with regulatory requirements in collaboration with tCompliance Department. Provides support to the SenCompliance Specialists for completion of specific prects. Maintains professional and technical knowledge attending educational workshops; reviewing professiopublications; establishing personal networks; participing in professional societies. Contributes to team effortaccomplishing related results as needed.

QUALIFICATIONS: Bachelors Degree, or equivalent exrience required. 2 years of experience in managed caDemonstrated understanding of HIPAA Privacy. Abilto work effectively and participate in a team environmeAbility to handle and prioritize multiple tasks simultaneousProficient in MS Word.

FT position, M-F 8 AM to 5 PM, with extended workhours and occasional travel as needed. Please apply to

www.scanhealthplan.com | Job Opportunities | Req. # 12-70


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Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

HEALTH PLAN/HOSPITAL CONTRACTING CONSULTANT(flexible hours)

A dynamic and growing medical group in the Los AngelesCounty area is currently seeking a highly experienced con-tracting consultant for the purpose of leading and success-fully negotiating and renegotiating health plan and hospitalcontracts. The ideal candidate will have an understandingof all product lines within the managed care industry, bewell-versed in contractual language, excel at maintainingpositive working relationships internally and externally, anddemonstrate an understanding of legal, financial and opera-tional processes that meet company objectives. Flexiblehours and telecommuting are available.

If interested, please email your cover letterand resume to:[email protected]

Casa Colina Centers for Rehabilitation, a nationally recognizeleader in the field of medical rehabilitation located in Pomona, iseeking to fill the vital role of Controller to oversee the Financand Accounting functions for the entire rehabilitation continuumwith a total bed complement of 178 beds, and consisting of hospital, brain injury program, 3 long term care facilities, an AduDay Health Center and outpatient childrens program.

The selected candidate will be responsible for all financial, payroand A/P activities. Oversees internal controls to ensure revenucycle effectiveness, expenditure management and safeguardinof assets. Prepares financial statements in a timely, accuratand efficient manner. Supervises all accounting and payroll stafResponsible for tax returns and regulatory filings. Requirementinclude a Bachelors degree in Accounting or Business relatefield, two (2) years of supervisory experience, prior hospitalhealthcare accounting experience, and a working knowledge oaccounting software programs. CPA background is strongly preferred. Excellent work ethic and motivation required.

Competitive compensation and excellent benefit optionsavailable. To apply, visit us at www.casacolina.org/jobs.

Principals only at this time.

CONTROLLER/

DIRECTOR OF FINANCE

It costs up to $27,000 to fill a healthcare job*

will do it for a lot less.

Employment listings begin at just $1.65 a word

Call (877) 248-2360, ext. 2

Or e-mail: [email protected]

Or visit: www.payersandproviders.com

*New England Journal of Medicine, 2004.


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SEEKING A NEW POSITION?

CAN HELP.

We publish advertisements for those seekingnew career

opportunities for just $1.25 a word.

If you prefer discretion, well handle allresponses to your ad.

Call (877) 248-2360, ext. 2, or [email protected].

payers & providers california edition – issue of june 28, 2012

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