Payers & Providers California Edition – Issue of January 5, 2012

8/3/2019 Payers & Providers California Edition Issue of January 5, 2012

1/6

!"#$"%&!'(!)*+)!,!)*++!-&!."&/%0!1!.%2345/%0!.$-64074#8(!99:

Calendar

5 January 2012

[email protected]

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

published in the Calendar section,s ace ermittin .

California Edition

Providers Win Round One On CutsFederal Court Stays Medi-Cal Payment Reductions

Californias hospitals and pharmacists won asignicant victory over state policymakers latelast month, convincing a federal judge to stayhundreds of million of dollars to cuts to theMedi-Cal program approved by the federal

government last fall.Preliminary injunctions issued Dec. 28 by

U.S. District Court judge Christina Snyderruled that the cuts would have deprived Medi-Cal beneciaries of skilled nursing care inrural areas of the state and put undue nancialduress on hospitals providing such care.Enrollees would have also suffered hardshipsin trying to ll their prescriptions. Snydersrulings also strongly suggested providerswould prevail in eventually restoring fullpayments.

From a healthcare services perspective,this ruling is important because the cuts very

likely would have caused many rural facilities,including entire hospitals, to close, saidLloyd Bookman, the Los Angeles attorneyrepresenting the California HospitalAssociation. The CHA sued the stateDepartment of Health Care Services and theU.S. Department of Health and HumanServices to block the cuts. Groupsrepresenting physicians, pharmacists anddentists led their own suits shortly after thehospitals took legal action.

From a legal perspective, this ruling issignicant because the court stopped a rate

cute that had been approved by federalMedicaid regulators, Bookman said, notingthat such decisions are usually extremelydifcult to overrule.

The cuts had been approved by the

Legislature and signed into law by Gov. JerryBrown last spring as a means of addressingongoing budget decits, but required federalapproval to take effect. The Centers forMedicare and Medicaid Services approved therate reductions last October.

The 10% cuts were intended to beretroactive to July 1 the start of the scalyear and was expected to save California$623 million annually. The cuts targetedpayments to skilled nursing facilities inhospitals, physicians and pharmacists, amongothers.

DHCS spokesperson Norman Williams

said the department strongly disagrees withSnyders ruling and intends to appeal to theU.S. Ninth Circuit Court of Appeals. Atimeline for the appeal was not immediatelyavailable from the agency.

According to Williams, an access surveyundertaken by DHCS concluded that the careof Medi-Cal enrollees would not be greatlyimpacted by the cuts. The survey results weresubmitted to CMS as part of the approvalprocess.

January 12-14

:"64;2%#4"!:7"?/%8/#@&!.7&04@4"#0!A'=7!"##$"6!>?/%8/#@&!B/54@4#/!4#!C20/?4=/!

@2#;/%/#@/D!E7F"#//!G2=/6(!C20/?4=/!H"=42#"6!."%ID!E!540@$0042#!2;!=%/#50!"#5!=%/"=?/#=0!";;/@=4#8!>J!@"%/D!KAL'MKLN*D!

:64@I!G/%/!;2%!B2%/!O#;2%?"=42#

January 23-24

./%02#"64P/5!B/54@4#/!Q2%65!:2#;/%/#@/!)*+)D!:2?


2/6

!"#$"%&!'(!)*+)!,!)*++!-&!."&/%0!1!.%2345/%0!.$-64074#8(!99:

Payers & Providers Page 2

Top Placement...Bottomless Potential

Advertise Here

(877) 248-2360, ext. 2

In Brief

CDPH Fines NursingHomes $190,000 For

Patient Deaths

The California Department of PublicHealth issued citations to two nursing

homes in Orange County and acombined $190,000 in nesstemming from preventable patientdeaths that occurred at the facilities.

The Newport Nursing andRehabilitation Center in NewportBeach was ned $100,000 andreceived the severest citation understate law for leaving a woman patientat risk for falls unattended in abathroom. She fell and later died.

The Emeritus at Yorba Lindanursing home was ned $90,000 andalso received the most severe citationwhen it failed to properly preparefood for a patient whose history ofstrokes had led to problems

swallowing. The patient choked on asandwich and died in an acute carefacility six days later.

Kaiser Receives TopMedicare Scores

Oakland-based Kaiser Permanentehad among the nations highest scoresin the National Committee for QualityAssurances Medicare dataset.

Kaiser received the top ratings innine out of 37 measures ratingeffectiveness of care, the most of anyhealth plan surveyed. It received thetop ratings for comprehensivediabetes care, breast cancer screeningand cholesterol management, amongother categories.

These ratings demonstrate thatour doctors and care teams excel inproactive prevention of illness, earlydetection of disease, and bettertreatment of ongoing conditions, saidAmy Compton-Phillips, M.D., Kaisersassociate executive director of quality.We are greatly honored that our

Continued on Page 3

NEWS

The Los Angeles Times reported that PrimeHealthcare Services deliberately disclosedthe medical records of a 64-year-old patientadmitted to Shasta Regional Medical Centerlast year to rebut allegations about thetreatment she received raising questions asto whether the Ontario-based hospital chainviolated federal law.

The allegations were reported bybusiness columnist Michael Hiltzik onWednesday. Hiltzik reported that Primeexecutives including Shasta Chief ExecutiveOfcer Randall Hempling and Chief MedicalOfcer Marcia McCampbell, M.D. had

shared the patients name and medicalrecords with the local newspaper, theRedding Searchlight-Record. Prime alsoforwarded the records to Hiltzik even thoughhe did not request them.

According to Hiltzik, the patient,Darlene Courtois, had never authorizedPrime to release her medical records. TheHealth Insurance Portability andAccountability Act bars the sharing ofpersonal medical records with parties notdirectly involved in that patients care withoutthe written authorization of the patient. Primehas claimed that the patient lost that right

when she disclosed them to the investigativjournalism website California Watch.(Shasta) was informed and believed th

the patient waived her HIPAA rights and thain fact she wanted her medical information be disclosed and examined, Prime said in astatement issued Wednesday.

In December, California Watch reportethat Courtois had been treated at Shasta inJanuary 2010 after a serious fall. During herstay, she had allegedly been treated forkwashiorkor, a state of malnutrition rarely seoutside of developing countries. However,Courtois, described in her medical records a

well-nourished, claimed she never receivesuch treatment, even though Prime billedMedicare for those services.

A resident of Shasta County, Courtois dnot have a listed phone number or e-mailaddress and could not be reached forcomment.

Prime has been the subject of state andfederal scrutiny following numerous CaliforWatch reports that it billed Medicare fortreating septicemia and kwashiorkor at ratesfar higher than state or national averages. Ithas vigorously denied the reports, andquestioned California Watchs credibility.

Prime Disclosed Patients RecordExecutives Shared Data to Dispute Media Report

Ruling (Continued from Page One)

However, Snyders ruling regardinghospitals noted that the agency overlookedthe likelihood nursing home patients

transferred to another facility due to a closurewould be traumatized or injured. In bothrulings, Snyder concluded that DHCSsongoing monitoring of access issues wouldnot prevent service disruptions and loss of

services to enrollees.Williams said the injunctions would not

immediately impact the departments nances

The DHCS had notied providers in earlyDecember that it would take action to recoupthe retroactive portion of the reductions, butthe injunctions had put that action on hold fornow.

HEALTHCARES BEST ADVERTISING VALU]

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

your organization or conference, or recruiting new staff.

CALL (877) 248-2360, ext. 2OR CLICK HERE


3/6

!"#$"%&!'(!)*+)!,!)*++!-&!."&/%0!1!.%2345/%0!.$-64074#8(!99:

Page 3Payers & Providers

Longer ALOS!*

Advertise Here

(877) 248-2360, ext. 2

*For our ads, not your hospital

NEWS

In Brief

Medicare plans have received suchexcellent ratings.

Anthem Blue CrossSpends $3.4 Million on

Charity Efforts

Anthem Blue Cross of Californiareported that its health plan, non-prot foundation and employees spent$3.4 million on healthcare-relatedcharity causes during 2011.

Among the recipients ofAnthems contributions included theBoys & Girls Club of America forprograms to ght obesity; the Marchof Dimess prenatal care toolkit; theGovernors Council on PhysicalFitness and Sports; and HealthCorps,a mentoring program created bytelevision personality Mehmet Oz,M.D.

I'm proud to lead a companythat contributed millions ofdollars and whose associates havevolunteered thousands of hours tocharities and community causes in2011," said Anthem Blue Cross ofCalifornia President Pam Kehaly.

Class Action Suit Filed inUCLA Data Breach

The University of California Board ofRegents has been served with a classaction suit stemming from a breach ofpatient data that occurred lastsummer.

The suit, led in Los AngelesSuperior Court, seeks $16 million indamages, or $1,000 for every patientwhose data was exposed. UnderCalifornia law, damages do not needto proven to collect such a nominalsum for a plantiff.

The breach stems from the Sept.6 theft of a hard drive from the homeof a physician working with the UCLAFaculty Group. The hard drivecontained encrypted patientinformation, but also taken was apiece of paper containing an accesspassword.

Blue Shield Reaches $2M SettlementPromises L.A. it Will Reform How it Rescinds Coverage

Nearly a quarter of Californias women lack

healthcare insurance and the overall numbersof those with employer-based coveragestatewide continues to drop in a weakeconomy, according to new studies by thePublic Health Institute and the CaliforniaHealth Care Foundation.

The study by Oakland-based PHIconcluded that the percentage of Californiaswomen lacking insurance climbed from 21%in 2007 to 24% in 2009 an increase of morethan 30% in two years. The overall total ofuninsured women reached 2.8 million.

The disparities hew closely to age, incomeand race. Thirty-four percent of women

between the ages of 18 and 29 lack coverage,and only 37% in that age group haveemployment-based coverage. Among those inthe lowest income brackets, 48% lackedcoverage, compared to just 8% among thewealthiest women.

Two-thirds of white women hademployment-based coverage, versus just 38%

of Latinas and 49% of African-American

women.Single mothers also had a hard timegetting coverage: 32% of them lackedinsurance in 2009, compared to 14% ofmarried women with children.

Meanwhile, the CHCFs annual EmploHealth Benets Survey concluded thatemployers offering healthcare coveragedropped to 63% from 73% between 2009 2011. Premiums for family coverage haveclimbed 153% between 2002 and 2011.

One of the studys researchers said thathe impending implementation of healthcareform could allay some of the trends.

The implementation of the AffordableCare Act is coming at a crucial time forCalifornia women," said Roberta Wyn, leaauthor of the PHI study and an afliate of tUCLA Center for Health Policy Research."These are challenging times, and it isimportant to move forward in expandingcoverage and access."

CORRECTION - It was reported in the Dec. 15 edition of Payers & Providers that the CalOptima

board of trustees was increased from 11 to 13 seats. The correct number was nine to 11. It was

also reported that CEO Richard Chambers paid himself a $73,000 bonus. The bonus was agreed

to and approved by the CalOptima board.

San Francisco-based insurer Blue Shield ofCalifornia has paid $2 million to settle alawsuit brought by the City of Los Angelesregarding its past rescissions of individualhealthcare policies.

The settlement, announced by late lastmonth by Los Angeles City Attorney CarmenTrutanich, was for a fraction of the $1 billionsought when his predecessor RockyDelgadilloled suit in 2008, claiming theplan had engaged in unfair business practicesand false advertising. Blue Shield did notadmit any wrongdoing.

The litigation claimed that the not-for-

prot Blue Shield had rescinded the policiesof more than 850 individual health plan

enrollees for capricious reasons.As a result of the settlement, Blue Shield

agreed to revise its health insurance

application form to comply with federalregulations, restrict its gathering of healthcareinformation from applicants to what isreasonable and necessary, and agreed to nolonger pay provide nancial incentives to itsinvestigators for rescinding coverage. BlueShield also agreed to not rescind any policiesunless it can prove the applicant committedfraud or misrepresented facts in order toobtain coverage.

Company ofcials said it chose to settle order to avoid the cost and distraction ofprolonged litigation. It also agreed to pay theCity Attorneys legal costs. The settlement wil

be split between L.A. city and countygovernments.Los Angeles also sued two companies

afliated with for-prot insurer Anthem BlueCross. That suit is still pending.

New Studies Show Insurance ErosioPHI, CHCF Surveys Document Coverage Losses


4/6

!"#$"%&!'(!)*+)!,!)*++!-&!."&/%0!1!.%2345/%0!.$-64074#8(!99:

Payers & Providers PageOPINION

Prime: The Story That Keeps On GivinChains Unique Corporate Conduct is Unpredictabl

Ron Shinkman is the publisher of Payers &

Providers.

;26$00$/!+."&/%0!1!.%2345/%0!40!

?$-6407/5!/3/%&!@7$%05"&!-&!."&/%0!1!.%2345/%0!.$-64074#8(!

99:A!B#!"##$"6!4#54345$"6!0$-0C%4?D42#!40!EFF!"!&/"%!GE+=F!4#!-$6H!$?!D2!+*!

0$-0C%4-/%0IA!>D!40!5/643/%/5!-&!/JT!&2$!52!#2D!%/C/43/!&2$%!400$/!2T!."&/%0!1!.%2345/%0!-&!+!.AVA!2#!

@7$%05"&(!?6/"0/!C"66!GPQQI)=PJ)RS*A

Op-ed submissions of up to 600 words ar

welcomed. Please e-mail proposals to

[email protected]

Whenever I think Ive been in the sameprofession for too long, Prime HealthcareServices reminds me why it may be thegreatest gift ever given to healthcarejournalists.

I always get a chuckle from the steadyow of press releases from the Ontario-basedhospital chain slamming the investigativewebsite California Watch. Its massivereportorial effort showing that the Prime hasbilled Medicare for cases of septicemia andmalnutrition at far higher levels than average isprobably the best ongoing documentation ofhealthcare malfeasance

since the Los AngelesTimes won a Pulitzer Prizefor reporting on theinstitutional dysfunctionoccurring at Martin LutherKing-Drew MedicalCenter. That hospitaleventually shut its doors.By contrast, Prime nevershuts its mouth.

The Prime releaseshave a tone I have neverseen in nearly 20 years ofcovering healthcareentities: defensive, testy ifnot downright hostile.Sometimes they go beyondspinning the truth: as Payers &Providers reported in 2009,Prime issued a release stating itreopened the gerio-psychiatricward at Sherman Oaks Hospital after it hadbeen closed down by the prior owner. If youignore that the California Attorney Generalsued Prime for closing the unit in violation ofa covenant it made to keep it open after it tookover, that assertion was completely true.

Aside from making me wonder whosgetting paid to write these releases, theysuggest Prime will never hirethe type of PRrm that specializes in (mostly) straight talkand making nice with the media.

Michael Hiltziks column in yesterdaysL.A. Times attested to that. It reported that twoPrime executives Shasta Regional MedicalCenter Chief Executive Randall Hempling andChief Medical Ofcer Marcia McCampbell,M.D. showed up on the doorstep of the localnewspaper to persuade it to not to publishanother California Watch report. This one

documented how a 64-year-old patientclaimed she had never been treated formalnutrition during a January 2010 stay athospital even though Medicare was billed doing so. They shared the patients medicarecords with the newspaper to prove theirpoint. The problem was it was done so witthe patients express written consent. And aHiltzik reported, this was likely in violationfederal law.

The irony made me shake my head.Anyone whos been around journalism lonenough knows Hiltzik wound up exiled to

Timess business section ne

20 years ago for hacking inthe emails of his co-workeHe was suspended and hiscolumn temporarily takenaway back in 2006 for posbogus responses to critiquehis blog. Hes pretty much Prime doppleganger.

Nevertheless, Hiltzilapses are those of ethicsrather than accuracy, so Imgoing to presume his repowas correct. Hempling andMcCampbell have thereforcommitted a blatant violatof the Health Insurance

Portability and Accountability AcPrimes claim that the patient waher right to keeping her patientrecords condential by sharing twith California Watch is dead wr

Federal regulations governing HIPAAexplistate all authorizations to release medicalrecords for non-medical purposes must beobtained in writing from the patient or therepresentative.

Although this may be the beginning ofend of Hempling and McCampbells hospicareers, I suspect the Prime story will keepgoing. Sometimes this publication will be part of it, and sometimes it wont. Either wit will always be interesting. And everyonewant to know what happens next.

By

Ron Shinkman
http://edocket.access.gpo.gov/cfr_2002/octqtr/45cfr164.508.htmhttp://edocket.access.gpo.gov/cfr_2002/octqtr/45cfr164.508.htmhttp://edocket.access.gpo.gov/cfr_2002/octqtr/45cfr164.508.htmhttp://edocket.access.gpo.gov/cfr_2002/octqtr/45cfr164.508.htmhttp://edocket.access.gpo.gov/cfr_2002/octqtr/45cfr164.508.htmhttp://edocket.access.gpo.gov/cfr_2002/octqtr/45cfr164.508.htmhttp://edocket.access.gpo.gov/cfr_2002/octqtr/45cfr164.508.htm


5/6


6/6

Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

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 January 5, 2012

Documents

Transcript of Payers & Providers California Edition – Issue of January 5, 2012