payers & providers california edition – issue of september 15, 2011
TRANSCRIPT
8/4/2019 Payers & Providers California Edition – Issue of September 15, 2011
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Two California healthcare philanthropies haveawarded $4.1 million in grants to nineorganizations statewide to boost thedevelopment of community clinic-based
medical homes.Seven of therecipients –including the Medi-Cal managed careplans in the InlandEmpire and San Joaquin Counties –received $500,000apiece. Three otherorganizationsreceived $200,000each.
The money was
allotted by theHealth HomeInnovation Fund,managed by theCommunity ClinicsInitiative (CCI). It’sa joint venture of the Los Angeles-basedCalifornia Endowment, and The Tides, a SanFrancisco-based philanthropy. A total of 42organizations throughout California submittedapplications for funding.
According to CCI Managing Director JaneStafford, applicants focused on creating“unlikely coalitions” with hospitals, health
plans and more disparate entities such as foodbanks. The intent is to create medical homesfor those who frequent community clinics by July 2013. Those patients are usually low-
income individualswho cannot affordinsurance or thosewho do not receivecoverage from theiremployer, andtherefore experienceuneven preventivecare at best.
In addition topromoting severalentities working intandem, Stafford saidher organization was
also looking forchanges in thepayment streams formedical homeworkers.
“For the medicalhome concept to be successful, there needs tobe some payment reforms in place,” Staffordsaid. In particular, the promotion of fundingfor “patient navigators” who would ensure thathose enrolled in a medical home have
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September 21-23
October 17-19
Calendar
15 September 2011
September 19-21
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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.
www.lakesidecommunityhealthcare.com
California Edition
Millions Awarded For Medical HomesTen Grantees Are Encouraged to Foster Coalitions
Continued On Next Page
Grantees For Medical Home Creation
$500,000 Grants
1. Coalition of Orange County Community Clinics
2. Community Clinics Health Network 3. Health Improvement Partnership of Santa Cruz
4. Health Plan of San Joaquin
5. North Coast Clinics Network 6. San Francisco Community Clinic Consortium
7. Inland Empire Health Plan
$200,000 Case Study Grants
1. Redwood Partnership Health Plan/RedwoodCommunity Health Coalition
2. Los Angeles County Education Foundation3. Health Alliance of Northern California
Source: Community Clinics Initiative
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Payers & Providers Page 2
Top Placement...Bottomless Potential
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In Brief
UCLA-Santa MonicaReplacement Campus
Nears Opening
UCLA Santa Monica Medical Center is nearing closer to opening a $572
million replacement campus severalmiles southwest of its main campus inWestwood.
The 266-bed facility wasdedicated earlier this week, and willbe open to patient care early nextyear. It will feature an inpatientpediatrics unit and an orthopedicsbranch af liated with theOrthopaedic Hospital Institute.UCLA-Santa Monica previouslyopened a new emergency departmentand a 16-bed neonatal intensive careunit.
"This wonderful new facility notonly accommodates scientic andtechnical excellence, but also creates
an environment that is healing," saidDavid Feinberg, M.D., president of the UCLA Health System.
Once the new hospital is online, the 1950s-era patient tower –which was replaced in order toremain seismically compliant – willbe demolished. Landscaped gardenswill be put in its place, of cials said.
Roth Named NewSCAN COO
Former Cigna executive Bill Roth hasbeen named chief operating of cer of Long Beach-based SCAN Health Plan.
Roth begins in the newly createdposition immediately. He previouslyserved as Cigna’s president of thesmall business and individualmarkets.
“The Medicare marketplace isincredibly complex and will becomeeven more so given healthcare reformand the aging of our population,” saidSCAN Chief Executive Of cer ChrisWing. “Adding someone with Bill’saccomplishments and values helps
Continued on Page 3
NEWS
appropriate transportation to appointmentswas emphasized.
“The client has to have a seamless
experience no matter what door they enter,”Stafford said.
Specic information about what thespecic grantees would do remained sketchythis week, as an of cial announcement of thegrants has yet to be made. Stafford declined toshare specic grant proposals, noting theywould be ne-tuned until an of cial launch of the initiative in November.
Stockton-based Health Plan of SanJoaquin will team with two local hospitaloperators and San Joaquin County BehavioralHealth Services to place medical homes infour community clinics. The initial focus will
be treating diabetic patients who also havedepression – conditions that tend toexacerbate one another.
“The project will involve signicantmodications to the way care is provided,”said Health Plan of San Joaquin spokesman
David Hurst. It will include initiatives such the use of disease registries and the integratof psychiatrists into the community clinic
setting, he added. Inland Empire Health Plan, the Medi-Cmanaged care payer for San Bernardino andRiverside Counties, said it would use its$500,000 grant to improve care coordinatiothrough the use of a referral tracking systemand the use of electronic health records inconjunction with 10 community clinics. IEHhas more than 500,000 enrollees in Medi-CHealthy Families and related programs. Inaddition, IEHP is pledging another $178,00in it funds toward the initiative.
"Improving care coordination andcommunication in primary care sites is criti
to meet the challenge of delivering healthcato our members," said IEHP Chief ExecutiveOf cer Bradley Gilbert, M.D. "What we leafrom this partnership could set the stage forour developing future health homes formembers."
Medical Homes (Continued from Page One)
Blue Shield Begins Enrollee Rebates$180 Million Returned as Part of Profit Cap Pledge
Blue Shield of California will rebate as much
as 30% of a single month’s premiums topolicyholders next month.The San Francisco-based health insurer is
issuing to its policyholders credits totalingabout $180 million. The rebates are part of apledge by the not-for-prot carrier to limit itsnet income to 2% of total revenue.
"As a mission-based, not-for-prot healthplan, we made this commitment to help keepcoverage affordable for our members. Whilethese credits will help our customers, everyplayer in the healthcare industry must domore to reduce the cost of care," said BlueShield Chairman and Chief Executive Of cer
Bruce Bodaken.
Individuals and families that have
purchased non-group coverage will receive 30% credit, averaging $80 for an individualand $250 for a family of four. For smallemployer groups, it will be $125 peremployee. For large employer groups, theaverage will be between $110 to $130 peremployee.
The promise to cap prots and thesubsequent rebates have come as the result pressure from consumer advocates andregulators over multiple premium increasesBlue Shield has tried to impose in recentyears, in some instances as high as 85%.
www.healthexecstore.com
Continued On Next Page
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Page 3Payers & Providers
Longer ALOS!*
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*For our ads, not your hospital
NEWS
In Brief
assure that SCAN remains a strongpresence in the marketplace andcontinues to fulll our mission of serving seniors and others onMedicare.”
SCAN has 130,000 MedicareAdvantage enrollees in California andArizona.
AHF LaunchesCampaign Critical of
Obama
The Los Angeles-based AIDSHealthcare Foundation has launcheda television advertising campaign thatcriticizes the Obama administration’shandling of programs subsidizingaccess to anti-retroviral drugs to thosewho have tested HIV-positive.
The campaign, entitled“President Obama: Whose Side AreYou On?,” criticizes the president forexpanding the waiting list for the
federal AIDS Drug Assistance Programfrom fewer than 100 people in 2008to nearly 10,000 currently. The ad willrun on CNN in several markets wherethe waiting list is the largest.
“Though the President hasspoken eloquently about AIDS issuesat certain moments, his words havebeen pretty, but empty,” said AHFPresident Michael Weinstein. “SinceAIDS treatment can also reduce thetransmission of new HIV infections byas much as 96%, the President’sinaction on this issue is also hurtingefforts to prevent the spread of thedisease.”
Nurses Plan One-DayStrike
More than 23,000 registered nursesaf liated with the California NursesAssociation/National Nurses Unitedwill stage a one-day strike at hospitalsin Northern and Central California onSept. 22.
The work stoppage is aimedprimarily at facilities operated byOakland-based Kaiser Permanenteand Sacramento-based Sutter Health.The union objects to proposed cuts inretirement and healthcare benets.
Healthcare Bills Go To Gov. Brown
Physicians Receive Funds For Education, Promotion
Blue Shield (Continued from Page Two)
HEALTHCARE’S BEST ADVERTISING VALU]
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Meanwhile, the insurer sits on reserves thatexceed $3 billion.
“I think every Blue Shield member will
be happy to get that money back,” saidAnthony Wright, executive director of theadvocacy group Health Access and amember of the Payers & Providers editorialboard. “At the same time, it’s alwayspreferable not paying it in the rst place.”
Blue Shield was opposed to AssemblyBill 52, legislation that would have allowedthe Department of Managed Health Care
and the Department of Insurance to regulatelarge premium increases for individualpolicyholders. The bill was recently shelved b
its author, Assemblyman Mike Feuer, D-LosAngeles, due to lack of support in the Senate,even though it passed three Senate committeeby comfortable margins. Blue Shield and othepayers have contributed tens of thousands of dollars this year to senators who had a keyrole in that legislation’s path – something thatwill be probed in greater depth in next week’sissue.
Several bills that directly touch on healthcarepolicy in California were passed by theLegislature as it ended its session and nowawait signature by Gov. Jerry Brown.
The bills include:
• SB 222 and AB 210 These bills wouldrequire maternity care as a covered benetin all health plans (many plans, particularlyindividual policies, exclude them for at least
a period of time after enrollment). They arecompanion pieces of legislation, eachrequiring the passage of the other to beenacted.
• AB 922 This would expand theresponsibilities of the Of ce of the Patient
Advocate to provide counseling forenrollees in Medi-Cal and other plans nocurrently covered by the agency.
• SB 51 This bill would require plans tocomply with the medical loss ratiomandates of federal healthcare reform.
• SB 866 It would require insurers to usestandaridized forms for prior authorizatioof care. The forms may also be submittedelectronically for a prompt response.
• SB 846 It would require insurers to coverspecic forms of therapy for autisticpatients.
Brown has until Oct. 9 to veto or sign thelegislation into law.
Correction
It was reported in the Sept. 8 issue of Payers & Providers that UCSF Medical Center
was the first hospital to receive five administrative penalties from the Department
of Public Health. Southwest Healthcare System in Riverside County has received
seven administrative penalties to date.
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Payers & Providers PageOPINION
CMS To Medicare Fraudsters: BewarProactive Detection is Keeping Crime in Check
David Sayen is Medicare’s regional
administrator for California, Arizona, Nevad
and Hawaii.
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Op-ed submissions of up to 600 words are
welcomed. Please e-mail proposals to
People talk a lot these days about the risingcost of healthcare. How much of a role doesfraud play in this?
A signicant one, unfortunately. The factis that criminals steal billions of dollars eachyear from Medicare, Medicaid, and theChildren’s Health Insurance Program (CHIP).This is taxpayer money that should be going tomedical treatment for some of our most vulnerable citizens,including seniors, low incomefamilies, and kids.
Fraud hurts everyone bydriving up healthcare costs. Italso undermines the nancialsustainability of federalhealthcare programs upon whichmillions of Americans depend.
What’s the federalgovernment doing to stop it?Plenty, especially with the newtools we have under last year’shealth reform law.
For one thing, we’rebecoming more proactive aboutkeeping criminals out of federalhealthcare programs in the rst place. My
agency, theCenters for Medicare & Medicaid
Services (CMS), has adopted a more rigorousscreening process for new providers andsuppliers. This is intended to weed out crooksbefore they can start submitting fraudulentbills to the government. Later this year and in2012, the CMS will have also implementedmeasures to streamline the certicationprocess down to 10 business days, and allowlarge enterprises such as hospitals to submitmultiple applications through a single uniedInternet portal.
Under the Affordable Care Act, we cannow also use sophisticated new technologies
and innovative data sources to identifypatterns associated with fraud. We also havethe authority to temporarily stop enrolling newproviders and suppliers when we detectpatterns that may indicate a signicantpotential for fraud.
When there’s a credible allegation of fraud against a provider or supplier, we cantemporarily stop payments to them while aninvestigation is undertaken.
In other words, CMS is moving away fromthe old “pay and chase” model of doing
business – paying out claims and then tryingto recover the fraudulent ones. We’re alsoeducating the provider community withregular regional summits about fraud and hoclinicians and even enrollees can avoidbecoming its victim through identity theft another means.
Of course, we know that most providersdoctors, hospitals, nursinghomes, home healthcareoperators, and others – arehonest. But we’re becomingmore vigilant about thedishonest few. And those whodefraud federal healthcareprograms will face tougherpenalties.
The Affordable Care Actincreases the federalsentencing guidelines relatedto healthcare fraud offensesinvolving $1 million or morelosses to federal programs. ThAct also allows the governme
to impose stronger civil andmonetary penalties against those
who commit fraud. And crooks kicked out o
one state’s Medicaid or CHIP program willnow be kicked out of all states’ Medicaid orCHIP programs.
Is Medicare making progress in the ghagainst fraud? Yes, we are. For example, thefederal government recovered $4 billion lastyear from people who attempted to defraudseniors and taxpayers. That’s a record amounIn a payer program the size of Medicare, thewill always be some levels of criminal activitIt’s simply too great a temptation among somindividuals to believe Medicare is a giant camachine that is generally immune to therelatively small losses they create. However,
the coming years as more crooked vendors aput out of business and put into jail, it will bclear that Medicare may no longer beperceived as a sleeping giant.
B David Sa en
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MARKETPLACE/EMPLOYMENTPayers & Providers Page 5
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will do it for a lot less.
Employment listings begin at just $1.65 a word
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Or visit: www.payersandproviders.com
*New England Journal of Medicine, 2004.
SEEKING A NEW POSITION?
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If you prefer discretion, we’ll handle allresponses to your ad.
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Payers & Providers MARKETPLACE/EMPLOYMENT Page 6
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