Payers & Providers – Issue of July 22, 2010

8/9/2019 Payers & Providers Issue of July 22, 2010

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A bill working its way through theLegislature would create an ombudsmanoffice to help Californians navigate thepost-reform healthcare environment.

However, health plans and advocates are atodds over whether such an office wouldduplicate protections offered by otheragencies.

AB 2787, authored by AssemblymanBill Monning, D-Santa Cruz, and co-authored by Sen. Elaine Alquist, D-SanJose, would establish the California HealthOmbudsman. Its duties would includeeducating Californians about theirhealthcare choices, helping them enroll inhealth plans, and obtaining tax creditscreated by the recently enacted nationalhealthcare reform. It would also operate a

24-hour hotline that would allowconsumers to call in with questions. Thehotlines number would be printed on themembership cards of all health planenrollees.

The ombudsman office would initiallybe funded through a portion of the $30million in federal funds made availablethrough the national reform legislation toboost consumer protections. However, itwould later be funded through a feeimposed on health plans, based on the sizeof their enrollment.

The bill has drawn the opposition of

the California Association of Health Plans,the states primary lobby for health insurers.

CAHP would prefer the federal funding beused to beef up existing consumerprograms operated by the CaliforniaDepartment of Insurance and theDepartment of Managed Health Care.

We oppose any legislation thatwould create another duplicative,expensive ombudsman that will likelyconfuse the public, said CAHP PresidentPatrick Johnston. He added that theSchwarzenegger Administration hasalready applied for the states share offederal consumer advocacy funding.

The DMHC, which is considered theleading government watchdog inCalifornia for HMOs, declined tocomment on the bill. But sources close tothe agency say there is concern that the

ombudsman would duplicate services italready provides, at an additional cost ofmillions of dollars per year.

Johnston said the health plans alsoobject to the fee that would be imposedon them. The already pay an annualassessment to help fund the DMHC, and ihas been ratcheted up in recent years tocompensate for the states budget deficits.

The shift has been from broad-basedtaxes to fees imposed on regulatedbusinesses that have no recourse but topay them, he noted. Those costs aregoing to have to be recouped elsewhere.

Ombudsman Prompts Head-ButtingHealth Plan Objections Are Slammed By Advocates

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July 25-28

July 22-24

Calendar

22 July 2010

September 22-24

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[email protected]

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

published in the Calendar section,space permitting.

Continued on Next Page

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California Edition

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Payers & Providers

Monning spokesperson Jody Fujinoted that the ombudsmans office wouldbe used to help consolidate the nine

different state agencies Californians cancurrently go to obtain assistance regardingtheir health plans. The legislation wouldrequire many of those agencies to makereferrals and coordinate and recordcomplaints in concert with theombudsman.

Johnston countered that agencieswhich already offer consumer protectionsclearly publicize services such as theDMHCs HMO Hotline.

The CAHPs position was blasted byAnthony Wright, executive director ofHealth Access, a Sacramento-based

advocacy group that supports the bill.Its not a surprise that insurers areopposed to having a place whereconsumers can complain about insurers,he said.

Although Health Access played a bigrole in getting the DMHCs HMO Hotline

Page 2

up and running several years ago, hecontended that most healthcare consumeprotections in California remain

fragmented.In the transition to reform, were

going to need as many resources aspossible to help consumers get throughthis, he said. We need a place forconsumers to be able to talk through theioptions. Im concerned about that insurernot be allowed to game things. Itsimportant we get that right, and gettingfeedback from consumers will beimportant.

The Senates version of the bill passedthe Health Committee last month on a 5-party line vote, with Democrats in

support. It is slated for a hearing in theAppropriations Committee at anunspecified date.

An older version of the bill passed theAssembly 76-0 in May. However, it hasbeen heavily modified in the interveningweeks, and must be voted on again.

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In Brief

L.A. County ApprovesNew King Operating

Agreement

The Los Angeles County Board ofSupervisors last week voted

unanimously to approve anagreement that would have thecounty reopen Martin Luther KingMedical Center in South LosAngeles with the University ofCalifornia by 2013.

As part of the agreement, thecounty will provide $50 million instartup funds, parceled out over thenext five years; $8 million inreserves, and a $20 million line ofcredit for operations. It will alsopay $13.3 million a year for thehospital to care for indigentpatients, and provide funding tohelp the hospital draw matchingpayments from the Medi-Cal

program.The University of California

will run all clinical operations atthe hospital, which is planned for120 beds. Both the county and UCwill be allowed to appoint twodirectors apiece to the hospitalsoperating board, and collaborate onappointing the three othermembers.

The hospital, which originallyopened in the early 1970s, shutdown in 2007 after it was barredfrom participating in the Medicareand Medi-Cal programs. It oftenprovided substandard and evenindifferent healthcare in the two

decades prior to its closure.

DMHC Bars Agent ForEnrollment Abuses

The Department of Managed HealthCare has barred a Folsom insuranceagent from selling Medicare Advantagepolicies due to deceptive marketingpractices.

Ombudsman (Continued from Page One)

Continued on Page 3

NEWS

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Anthem Comes To End For MargolinShe Leaves Months After Reaching Out to Hospitals

Anthem Blue Cross of California PresidentLeslie Margolin left the insurer on Monday.

Although both Margolin and Anthemsparent company, WellPoint, Inc., say thedeparture was a mutual decision, it comesafter the states largest insurer came under reearlier this year after trying to raise rates on its800,000 individual policyholders by as muchas 39%. The proposed increases whichaveraged 25% were used as politicalleverage by the Obama Administration to helppass federal healthcare reform in March.

Intense scrutiny by the CaliforniaDepartment of Insurance (DOI) and its

outside actuary, Axene Health Partners,discovered some mathematical errors inAnthems rate hike application. Axeneestimated that its average rate increase requwas about 40% higher than necessary.

Anthem and WellPoint ofcials hadinitially defended the rate hikes, thenpostponed them, then withdrew them almosimmediately after Axene published itsanalysis. It has since submitted much more

Continued on Next Page
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Page 3Payers & Providers

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NEWS

In Brief

Nadia King, 35, apparentlyenrolled at least 11 people into aMedicare Advantage plan sherepresented without obtaining theirconsent, often after approaching themunsolicited. Some experienced delaysin receiving medical care as a result.One customer accumulated $6,000 in

out-of-pocket expenses.The DMHC is committed to

protecting Medicare recipients fromthese abusive tactics, said agencydirector Cindy Ehnes.

Payers & Providers toLaunch National &Midwest Editions

Payers & Providers will launch amonthly national print edition inthe fourth quarter of 2010 and anelectronic regional editioncovering the Midwest in the first

quarter of 2011. Ron Shinkman, current editorof the California edition, will editthe national edition. It will focuson healthcare news of nationalimport, and will contain in-depthstatistics and opinion pieces.

The Midwest edition willappear weekly, covering healthcarenews in Illinois, Indiana,Minnesota, Wisconsin, Missouri,Ohio and Michigan. A weeklyOpinion page will also featuremembers of its editorial board andother contributors.

The Midwest edition will beedited by Chicago-based

healthcare journalist J. DuncanMoore. A veteran ofBloombergNews , Modern Healthcareand theKansas City Star, Moores work hasalso appeared in the Wall StreetJournal, the Los Angeles Times anda variety of other publications.

The expansion of Payers &Providers was the next logical stepafter it entered into a strategicalliance with MCOL last month,Shinkman said. I am very excitedto help make this happen.

Same Sex Couples Lack CoverageLess Likely to Have Insurance Than Other Household

A new study by UCLA researchers concludesthat same-sex couples have access toemployer-based health insurance at a muchlower rate than their heterosexualcounterparts.

The study, based on data from the 2001,2003 and 2005 California Health InterviewSurveys, concluded that partnered gay menare just 42% as likely to be fully covered byone partners employer-based healthinsurance. Lesbian couples are 28% as likelyto have insurance coverage. The studycovered more than 110,000 men and women.

We found no strong evidence to suggestthat California employers are discriminating inproviding health insurance to gay and lesbianworkers as individuals, said UCLA professorNinez Ponce and co-author of the study.

modest rate increases, which are still underreview by the DOI.

Margolin herself had been personally

criticized by U.S. Health and Human ServicesSecretary Kathleen Sebelius, and faced mostlyhostile lawmakers in Sacramento during aFebruary hearing.

That Margolin had been called out soadamantly was a departure from hermanagement style. She kept a low proleduring her time at Anthem and gave fewmedia interviews.

Margolins tenure was also by far theshortest in her career, having joined Anthemin January 2008 after spending nearly 20 yearsin senior management positions at KaiserPermanente and Cigna.

Just last January, Margolin had engineered a$6 million pledge from Anthem Blue Cross tothe states three regional hospital associationsto help improve patient safety. Hospitalofcials had praised Margolins efforts to tryand improve sometimes frayed relations

Margolin (Continued from Page Two)

between Anthem and Californias providercommunity.

Hospital Association of Southern Califor

Executive Vice President Jim Lott said onWednesday the quality improvement effortremained in place.

Margolin, an attorney by training, said shwill head a coalition of hospitals, physiciangroups, health plans and medical groupscalled Transforming Health Care. Thecoalition does not have a website. An Anthspokesperson said it is not related to thepatient safety coalition.

We cannot afford to ght each other anlonger. I took on the challenge of bringing tparties together as Anthem's President, andam grateful to have had the platform to beg

this process, Margolin said in a preparedstatement.Margolin will be replaced on an interim

basis at Anthem by Mark Morgan, the insurvice president of small sales in California.

Expert Healthcare Communications

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Clarification

It was reported in last weeks edition of

Payers & Providers that critical use hospitals

had been excluded from all federal

stimulus funding to incentivize the use of

electronic medical records. The exclusion

applied only to Medicaid funding.
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Payers & Providers Page

According to a recent study published inthe Journal of American MedicalAssociation , nearly one in every threechildren ages 2-19 is overweight or obese.

While parent and child certainly beara share of the responsibility when a childis overweight due to poor diet and asedentary lifestyle, we must ask ourselves:Who makes lifestyle choices anddecisions in families? From where do theyget reliable information? How well-equipped are they to obtain, evaluate,understand and implement this

information? What role doestheir healthcare providerplay in teaching them how tomake good choices?

The truth is, the roots ofthe current childhoodobesity epidemic run muchdeeper than just kidschoosing and parentspermitting too many candybars. Only about 12% of ouradult population has thenecessary health literacy skills toeffectively navigate our healthcare

system. For parents of heavy kids, thisincludes the ability to:

Read and understand the nutritionfacts label on most packaged foodswe buy Understand the links betweenobesity and chronic illnesses such asdiabetes, heart disease, and stroke

Know what a healthy portion size is

Recognize the danger of excessivesugar in kids diets, from sodas, desserts,snacks and other food

Studies show that if we take thetime to expose parents to the informationneeded to keep their kids fit and healthy,they can use it to make informed, healthychoices. But we need to know how to dothat first.

Plenty of resources exist thataccomplish just that, but we need to alldo our part to make it happen.

Providers need to spend the time withparents and use techniques such as theteach-back method to ensure that theyunderstand and know how to use the

information given to them.Educators need to ensure that the

materials they are developing areappropriate for adults who cannot readabove an 8th grade level, and use graphicand design techniques that aid incomprehension, not impede it.

Families need access to information materials that they can understand and usand support in learning new skills such asreading the Nutrition Facts label, knowingwhat is an appropriate portion size, and hto differentiate between foods that are

nutritionally dense and ththat provide empty calorieEarlier this year, the WhitHouse Task Force onChildhood Obesity submiits Report to the Presidentoutlining an action plan end the problem ofchildhood obesity within generation. The secondpillar of the Report,

Empowering Parents andCaregivers; First Lady MichelleObamas national Lets Move!

campaign; and the recent rollout ofthe National Action Plan to ImprovHealth Literacy align directly withnationwide efforts to increase healtliteracy and to reverse the trend ofchildhood obesi ty.According to a 2004 Institute of

Medicine study, most information provideto patients is well beyond their ability toread and understand it. So, lets get busyfixing that information so that its readablunderstandable, and usable by the majoriof the population who have had trouble wit. This will put us in position to reap the

promise of that ounce of prevention onceand for all.

OPINION

Closing The U.S. Health Literacy GapObese Americans Lack Info For Changing Lifestyle

By

Gloria

Mayerand

Michael

Villaire

Gloria Mayer is the chief executive officer an

Michael Villaire the director of programs and

operations for the Institute for Healthcare

Advancement, a health literacy advocacy

group in La Habra.

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^-4!X3/4G:(4)0/B-*S=(&)*+(40=*-./0)*+?A-: Op-ed submissions of up to 600 words are

welcomed. Please e-mail proposals to

[email protected], or call (87

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Payers & Providers – Issue of July 22, 2010

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