payers & providers california edition – issue of october 20, 2011

8/3/2019 Payers & Providers California Edition Issue of October 20, 2011

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November 15-17

November 1-3

Calendar

20 October 2011

November 29

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the details of your event, or call(877) 248-2360, ext. 3. It will be

published in the Calendar section,space permitting.

California Edition

140,000 Booted From Medicare PlansRule Changes, Anthem Shutdown Behind Shifts

Continued On Next Page

The open enrollment period for Medicarebegan with what may be a shock for morethan 140,000 seniors in California: They willhave to drop their current coverage and nd

new health plans by the end of the year,according to government and insuranceindustry ofcials.

The booting of enrollees from MedicareAdvantage Plans offered by Long Beach-basedSCAN Health Plan and Anthem Blue Cross ofCalifornia is the result of governmentmandates and operational issues. SCAN has todrop about 30,000 Southern Californiaenrollees from a plan that offers coverage tothose with special needs due to a change inMedicare regulations. Anthem decided to shutdown a plan that will affect about 110,000enrollees for business reasons.

SCAN will continue operating the plan,which is called Healthy at Home and servesenrollees with chronic conditions such ascongestive heart failure and renal disease.Healthy at Home is a non-exclusive plan,which meant it could enroll people withoutspecial needs so long as their numbers did notexceed certain percentages tied to the levels ofspecial needs patients enrolled in Medicare.

However, the passage of the MedicareImprovements for Patients and Providers Act of2008 barred non-exclusive plans as of January2012. About 52,000 Medicare Advantageenrollees are affected nationwide, according

to the Centers for Medicare and MedicaidServices. That means the bulk of those affected

get their coverage through SCAN, which has atotal of about 140,000 enrollees in Californiaand Arizona.

SCAN spokesperson Sherry Stanislaw said

the affected enrollees have the option ofenrolling in another SCAN plan, enrolling inanother Medicare Advantage plan, or revertback to fee-for-service coverage.

We rst communicated with ourmembers in September about the change, andwere doing lots of followup, said Stanislawof SCANs efforts to retain its members.Although those enrollees have to leave theplan by Jan. 1, they have until the end ofFebruary to nd yet another plan should theychange their minds.

Anthem chose to discontinue its MedicareAdvantage Freedom Blue plan, which

provided coverage through a preferredprovider organization. Medicare RegionalAdministrator David Sayen said the plan was aregional PPO, meaning Anthem had to offeruniform access to providers and specialiststhroughout California.

Its difcult to provide a network for anentire state, Sayen said. He added thatAnthem was particularly challenged inmaintaining consistent access to specialists inrural areas such as Santa Cruz, Shasta andButte counties.
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Payers & Providers Page 2

Top Placement...Bottomless Potential

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In Brief

Prime HealthcareResponds to LatestCalifornia Watch

Report

Ontario-based hospital operator

Prime Healthcare has responded to areport last week by the investigative

journalism website California Watchthat it billed Medicare for raremedical conditions at rates far higherthan other hospitals in California.

The conditions encephalopathy, malignanthypertension and autonomic nervedisorders are rarely diagnosed athospitals. Based on a review ofmedical records Prime submitted tothe Ofce of Statewide HealthPlanning and Development, Primediagnosed and billed at rates 11 timeshigher than the state average formalignant hypertension; owns six of

the seven hospitals with the highestdiagnostic rates for encephalopathy;and treated nearly 80% of Californiasautonomic nerve disorder casesamong Medicare patients, eventhough it cares for less than 4% of thestates Medicare enrollees. In eachinstance, a diagnosis could reapthousands of dollars more per case,according to the report.

The for-prot Prime saidCalifornia Watch once again cherry-picked and misinterpretedcomplicated medical data and usedwhat the company believes are biasedor misinformed sources to create astory with little substance or

accuracy, although the lengthy reportincluded interviews with severalformer Prime employees andphysicians who conrmed thepractices were encouraged by thecompanys founder and ChairmanPrem Reddy, M.D.

Prime added that it has not beensingled out for wrongdoing foragencies that contract with theMedicare program to perform audits.

Continued on Page 3

NEWS

Medicare Advantage (Continued from Page One)

Anthems decision to discontinue thisplan was made after evaluating the changes tothe benets, the pricing and the regulatory

approval needed to make this plannanciallyviable in 2012 and beyond, health plan

spokesman Darrel Ng said in an e-mail. Theplan design changes, if approved, would haveresulted in a plan design and premium verydifferent from what the members who enrolledhad originally purchased, which may havecaused concern and confusion among ourmembers.

Altogether, 110,506 enrollees will beaffected by the change, according to Ng. As isthe case with SCAN, Ng said they will havethe option of enrolling in other AnthemMedicare Advantage plans, with their

enrollment period has been extended to Feb.28.Anthems choices include a new local

PPO product that is being offered in 13

counties. A Medicare Advantage plan servedby a local PPO does not have the samenetwork requirements as a regional PPO.

This expansion is part of one of thelargest ever for our senior business and showour continued commitment to providingaffordable healthcare solutions to the peopleof California, said Anthem Blue Cross ofCalifornia President Pam Kehaly. We servethousands of seniors in California and we tapride in working hard every day to help ourmembers get and stay healthy.

In addition to its Medicare Advantagemarket expansion, Anthem purchasedCerritos-based insurer CareMore earlier thisyear. That plan provides coverage to about60,000 Medicare enrollees statewide, most

them categorized as special needs.Neither SCAN nor Anthem ofcials cou

say whether the affected enrollees would hato pay additional premiums for coverage.

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Recast Blue Shield Doles Out CashGives Nearly $300 Million In Refunds And Grants

Just months after being pilloried by consumeradvocates for multiple premium increases

within a calendar year, Blue Shield ofCalifornia is disbursing $295 million throughpremium refunds and community grants.

The San Francisco-based health insurerannounced last week that it would refund$283 million to its individual and grouppolicyholders. The credit, which will beawarded in December, will average $135 foran individual policyholder and $420 for afamily with individual coverage. For groupenrollees, the credit will average $195. Credits

for small employer groups will average $2per employee and $605 for a family of fou

The refund is intended to hew to a pleBlue Shield made to refund all prots in exof a 2% margin. The refund is based on anestimate of the non-prot Blue Shields 201surplus. Earlier this year, it refunded $180million based on its 2010 surplus.

"We made this pledge to help makecoverage affordable for our members," saidBlue Shield Chief Executive Ofcer Bruce

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Page 3Payers & Providers

Longer ALOS!*

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*For our ads, not your hospital

NEWS

In Brief

California Watch ignores thatwhen patients are accuratelydiagnosed, they have shorter hospitalstays and fewer repeat admissions. Inother words, the quality of careimproves and overall healthcare costsdecrease, Prime said. In the end, thissaves money and, more importantly,

saves lives.

CDC:Hospital ER VisitsJump In 2009

The number of hospital emergencyroom visits in the United States

jumped nearly 10% in 2009, topping136 million, according to data fromthe Centers for Disease Control andPrevention. Some 85% of those visitswere by patients with healthinsurance, and less than 10% wereconsidered to be for care that couldhave been delivered in an urgent care

or other medical setting.The report prompted a call for

medical tort reform by the AmericanCollege of Emergency Physicians,which is having its annual meeting inSan Francisco this week.

USC Pharmacy SchoolBeefs Up Clinic

Presence

The USC School of Pharmacy willdouble its presence at Los Angelesarea safety net clinics.

The school provides somesupport staff and services at 12 clinicsthat serve the poor and uninsured. Itwill not offer support at 24 clinics.School ofcials say the need for helphas increased due to the prolongedrecession and the growth in theregions poverty rates.

Since these economic problemsface the entire country, we are urgingour fellow pharmacy schools toincrease their outreach efforts as well,"said R. Pete Vanderveen, the schoolsdean.

Bodaken. "(This) provides more tangibleevidence that we're putting affordabilitybefore prot. We hope our action will inspire

others in the healthcare industry to look forways to make quality healthcare moreaffordable.

In addition to the refunds topolicyholders, Blue Shield also made asecond round of $10 million in grants todevelop accountable care organizations. It ispart of a $19.4 million effort to developACOs, with $10 million being disbursed in2010.

The grants ranged in size from $300,000

to $2 million, and averaged just over $1million. Blue Shield ofcials said theyreceived more than 60 applications for the

grants.Recipients included St. Johns HealthCenter in Santa Monica, which received $2million to facilitate better clinical integrationwhile using more generic drugs anddecreasing readmissions and patient days.Community Hospital of the MontereyPeninsula received $1 million to create aportable electronic health record for itsphysicians and develop a community healthinformation exchange.

Kaiser Permanente has more than tripled itsdiagnosis of hospital patients with sepsis at its21 Northern California hospitals, potentiallysaving lives.

Starting in 2008, the Kaiser hospitalsemployed new systems, including the use oftreatment algorithms, standardized order setsand ow charts and the standardization ofbest practices. Special mentors were alsoused to help train the medical staff abouttesting early for the condition, a bloodinfection that could ultimately lead tomassive organ failure and potentially death.

As a result of the changes, the number ofsepsis diagnoses rose from 35.7 per 1,000admissions in July 2009 to 119.4 per 1,000admissions as of last May.

The early diagnosis of sepsis isconsidered crucial to successfully treating theinfection, which affects an estimated 750,000hospital patients in the U.S. every year. Themortality rate is about 30%, and usually

exceeds 50% if there is a delay in diagnosingthe condition.

As a result of the earlier diagnoses ofsepsis, those patients who showedimprovement in their laboratory tests withinsix hours of beginning treatment improvedfrom 52% in 2009 to 92% earlier this year.

This is perhaps one of the best examplesof the impact a large organization can have

when focusing on the quality of care, saidLisa Schilling, vice president of nationalperformance improvement in KaiserPermanente. "When an organization developsimprovement capability and aligns leadershipattention to strategically important efforts, theresult is reliable delivery of care to an entirepopulation.

The results of the Kaiser study werepublished in the most recent issue of the JoinCommission Journal on Quality and PatientSafety.

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Kaiser Ramps Up Sepsis DiagnosesNew Protocols Spot Cases Sooner Than in Past

Blue Shield (Continued from Page Two)
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Payers & Providers PageOPINION

Optimizing Perioperative SchedulingThis Critical Service Line Should Run Highly Efficiently

Bonnie Barndt-Maglio is a vice president an

W. Richard Goddard is a consultant with The

Camden Group.

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Op-ed submissions of up to 600 words are

welcomed. Please e-mail proposals to

[email protected]

Perioperative services can contribute as muchas 40% of total hospital revenue.Therefore, optimizing thisresource is essential.

The management of operatingroom operations is typically adata-driven enterprise with closetracking of metrics, such as starttimes, turnover time, roomutilization, and other data tomaximize resource utilization.However, this approach is notsufcient to optimize operations.

There is a complexinterconnection of personnel,specialized space, equipment,and scheduling that must becoordinated concurrently tomake ORs function at peakefciency.

Scheduling is at the heart ofperioperative efciency becauseit impacts the rooms that areopen, the staff paid to operatethose rooms, the amount ofspecialized equipment needed,and the necessary personnel in

the pre-operative and post-operative departments to care forthese patients. Managing theperioperative schedule has thepower to not only improveperioperative efciency but canalso impact utilization throughoutthe hospital.

A successful method to managethe perioperative schedule isschedule smoothing. This processcan be dened as aligning theelective surgical cases with the resourcesavailable to support the patients during the

post-surgical course. Schedule smoothinginvolves gathering key OR metrics over a sixto twelve month period by case volume, typeof surgery, minute(s) per case, turnaround timeper case, and personnel and equipmentneeded by case type.

Each case should be pre- and post-operatively evaluated in the context ofpersonnel work hours, required bed type, andlength-of-stay. Average case times arecalculated by day of week to determine thetotal OR time needed.

The cases are then reviewed, and the posprocedure care requirements are

quantied by stage of recoverytime, inpatient bedrequirements, specialized careneeded, and average LOS. Thidata is used to determine bedavailability, personnel needed,and revenue per case by day oweek.

The subsequent data ismatched with ambulatorysurgical bed availability, targetinpatient unit average census,and discharging diagnosis todetermine the availability ofresources each day. A total coper case including personnelhours is then calculated todetermine if the post-operativepersonnel and spacerequirements are aligned withthe cases scheduled.

The process to transition tosmoothed schedule requiresmore than just calculations.Surgeon buy-in is essential to

the process and requires theirearly involvement in theplanning and data-analysisprocess. Surgeon and staffengagement in combination

with computer modeling ofsmoothed schedule variationsallow OR managers to control tcase ow more effectively. Thisresults in higher room utilizatiopersonnel expenses savings, andthe elimination of bottlenecks th

surround schedule peaks and valleys.Schedule smoothing benets are optimiz

when implemented for every elective case othe OR schedule. Choosing the services wita high level of service intensity for the initiaphases facilitates enterprise-wide involvemeand provides the greatest revenue impact.

By Bonnie

Barndt-Maglio

and W. Richard

Goddard


5/5

MARKETPLACE/EMPLOYMENTPayers & Providers Page 5

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*New England Journal of Medicine, 2004.

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payers & providers california edition – issue of october 20, 2011

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