Payers & Providers – Issue of September 23, 2010

8/8/2019 Payers & Providers Issue of September 23, 2010

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The head of one of the nations largestMedicaid health insurers rebuked both hiscolleagues and Health and Human ServicesSecretary Kathleen Sebelius this week over

a mounting flap regarding the imposition oflarge premium increasesprior to healthcareexchanges becomingoperative in 2014.

It makes sense thatmany of these plans will tryand reset their rates with18% annual premiumincreases now, because it ismuch likelier that afterreform is implemented,they will be getting 3% or4% increases, J. Mario

Molina, M.D., told theCalifornia Conference ofthe Healthcare FinancialManagement Association ina sometimes brutally frankspeech in Long Beach onMonday.

Most officials with commercialhealthcare plans had denied such astrategy, telling enrollees any rate increasesthey sought were coupled to the highercost of delivering healthcare in a post-reform environment. This has also been theposition of the influential Americas Health

Insurance Plans lobby. Molina, who is chief

executive officer of for-profit Long Beach-based Molina Healthcare, sits on theAHIP board of directors.

Earlier this month Sebelius sent a

letter to AHIP Executive Director KarenIgnagni asking that healthplans tone down theirrhetoric linking reform tocost increases, or possiblybe excluded from theexchanges.

I found that verydisturbing, and a violationof our First Amendmentrights, Molina said. In aninterview immediately aftethe speech, Molinasuggested that Sebelius

threat about the exchangeswas an empty one,reflective of Washingtonsfractious political

environment.But in Wednesdays interview

Molina said he believed many insurersthat sought rate increases may havedamaged their already fragile publicimages.

He noted that recent rate increasesaveraging 16% received by Anthem Blue

Health Plan CEO Breaks From PackMolina Criticizes Colleagues, Sebelius on Premiums

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Payers & Providers Page 2

Top Placement...Bottomless Potential

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In Brief

Blue Shield FoundationCommits $1.9M To

Safety Net

The San Francisco-based BlueShield of California Foundation has

granted $1.9 million to 12 countiesstatewide to help expand publichealthcare and safety net coverage.

The recipients were healthdepartments and public hospitals inYolo, Sacramento, Fresno, SantaCruz, Santa Barbara, Riverside,Alameda, San Francisco, Placer,Merced , Santa Clara and San LuisObispo Counties. They range in sizefrom $90,000 to $225,000. Theywill be used to improve thecontinuation and coordination ofcare for low-income residents ofthose counties.

Californias counties have aunique opportunity to expand

health coverage to thousands ofpeople who need it today, saidBlue Shield Foundation ChiefExecutive Officer Peter Long.

Some CaliforniaInsurers Drop Children-

Only Policies

Anthem Blue Cross of California,Cigna and Aetna are among thosecarriers to stop writing new children-only insurance coverage in California,effective today, according to publishedreports.

The decision comes as newprovisions of federal healthcare reformkick in on Sept. 23 requiring allinsurers to cover enrollees under theage of 19, regardless of their pasthealth history. Insurers have claimedthis would cause them to bearexcessive medical costs.

Unfortunately, this has created anun-level competitive environment,Anthem Blue Cross of California saidin a prepared statement.

Continued on Page 3

NEWS

San Francisco-based Blue Shield of Californiahas claimed progress in running anaccountable care program pilot project itlaunched earlier this year in the Sacramentoarea.

Armine Fortunato, Blue Shields vicepresident of provider network management,reported at the California HealthcareFinancial Management Association annualconference earlier this week that the ACOhas reduced hospital admissions 4%, theaverage length of a hospital stay by 9%, andreadmissions by 24%.

As a result, the savings among the 38,000enrollees all retirees whose benets areprovided by the California Public EmployeesRetirement System and are treated by the HilPhysicians Medical Group in San Rafael habeen $31 per member per month, or theequivalent of $14.1 million per year.

Fortunato declined to discuss the data infurther detail after her presentation. BlueShield ofcials were unable to immediatelyable to comment further.

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Blue Shield Claims Progress On ACOReadmissions, ALOS Down, But Numbers May Differ

Molina (Continued from Page One)

Cross, Health Net and Aetna forindividual policyholders in California,although approved by California

Insurance Commissioner Steve Poiznerand therefore justifiable, were notnecessarily prudent.

In some respects, strategically, andpolitically, going after the rate increaseswas a mistake, he said. It might be agood idea (from a financial standpoint),but you need to be strategic and thinklong-term and maybe take a loss for ayear.

Molinas own publicly-traded plan,which covers 1.2 million Medi-Cal andMedicaid enrollees in 10 states, mostlyhave its rates set based on

reimbursements states receive from thefederal government.

Its that difference between thestructure of Molina Healthcare andcommercial health plans that has enabledMolina to make such statements about hiscolleagues, according to industry

observers.Their business model is so different

from Blue Cross that Molina can be

independent. Theyre not restricted, saidJudy Dugan, research director forConsumer Watchdog, a Santa Monica-based consumer advocacy group.

An AHIP spokesman did notimmediately respond to a request tocomment on Molinas remarks.

Molina made some other pointedremarks to the HFMA audience, includinga recollection from 2008 that White HousChief of StaffRahm Emanuel, while still amember of Congress, had made aprofanity-laced presentation to officialsfrom AHIP that the Obama Administrationwould implement reform without theirinput.

I hope Emanuel leaves soon tobecome mayor of Chicago, Molina said,later adding that zealots within theObama Administration implementedhealthcare reform.

Continued On Next Page
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Page 3Payers & Providers

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NEWS

In Brief

A bill that has been sitting on Gov.Arnold Schwarzeneggers desk sinceSept. 9, AB 2244, would prohibitinsurers that cover childrenexclusively from dropping suchcoverage. Schwarzenegger has yet totake action on the bill as of presstime.

Health plans have claimed that

they cover very few children outsideof family coverage, and that otherprovisions of reform will allowchildren to seek coverage elsewhere.

SEIU-UHW Asks ForIntervention on Kaiser

Elections

The Service EmployeesInternational Union-UnitedHealthcare Workers West hasasked the National Labor RelationsBoard to intervene to reconsider its

decision to allow elections be heldby a nascent rival.

In a 389-page filing, the SEIU-UHW argued that the NLRBregional director used flawedreasoning to permit the electionsby the National Union ofHealthcare Workers.

They're spending millions ofour dues dollars on lawyers to tryto deny us our right to choose abetter union, said Emily Ryan, aKaiser employee and and NUHWorganizer. Why would anyonewant to be trapped in anorganization like that?

Currently, some 44,000 Kaiser

Permanente employees who belongto SEIU are voting to potentiallyalign with the NUHW, which wasstarted by former SEIU-UHWexecutive Sal Rosselli. More than2,000 unionized Kaiser employeeshave already switched to theNUHW, which has about 6 ,000members in total.

The mail-in election ends onOct. 4.

The medical group ratings released byIntegrated Healthcare Association this weekwere little changed from 2009, with the samenumber of organizations and virtually all ofthe same players receiving top ratings.

Altogether, 45 of the 219 medical groupssurveyed by the IHA in 2009 received topratings, one less than the previous survey.Added to the list were the Hill PhysiciansMedical Group for the Solano Region, MercyMedical Group and Sutter Medical Group,all in the Sacramento region. Arch HealthPartners in San Diego was also added to thelist. Twenty-seven of Kaisers PermanenteMedical Groups received top ratings.

Dropped from the highest performinggroups was Marin Medical Group, Mills-Peninsula Medical Group, Pioneer MedicalGroup, the Humboldt-Del Norte IPA andWoodland Healthcare.

The groups were measured for clinical

quality, patient experience, levels ofinformation technology employed, andcoordinated diabetes care.

In addition to the highest-rated groups,seven were named as most improved. Theyincluded two Hill groups, Sutter GouldMedical Foundation, San Bernardino MedicaGroup, Bright Physicians, St. Joseph HospitaAfliated Physicians and Encompass MedicalGroup.

Hill was the only group named as both atop performer and most improved. Were verpleased the hard work that goes on behind thscenes has a demonstrable effect on quality ocare and overall member experience, saidHill Chief Executive ofcer Steve McDermott

The amount of pay-for-performancemoney given to the providers by sevenparticipating health plans $52 million wasalso unchanged from the previous survey.

The ACO was launched on Jan. 1 incollaboration between Blue Shield, Hill,CalPERS and Sacramento-area hospitalsoperated by Catholic Healthcare West. It hasfocused on better coordinating care andcommunications among the physicians andthe hospitals. Among the initiatives is toautomatically schedule a followup physicianvisit within 10 days of a hospital discharge,as well as the use of electronic medicalrecords to guarantee that all the patientsproviders have access to the same data.

The providers agreed to keep costs at2009 levels. They retain whatver savings that

are reaped.However, a Hill ofcial suggested the

gures quoted at the conference may bepremature.

It is unrealistic to expect that level ofsavings be achieved in the rst year of theproject because of ramp-up time to improveupon processes and the time it takes torecognize and realize improvements in qualitand costs, said Hill spokesman DanRobinson. The good news is, we are alreadybeginning to see savings that are encouragingleading us to believe that over the long haul,this level of savings is achievable.

Blue Shield (Continued from Page Two)

IHA Releases Medical Group DataPayouts Are Unchanged; Hill Only Double Winner

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I serve as a monitor of a San FernandoValley hospital that provides a wide rangeof acute care services and an emergencyroom accessed by a primarily poor andimmigrant community. In that and otherassignments, I evaluate and occasionallyoffer advice on improving the quality ofcare.

How will healthcare reform impactthe poor? is asked of me time and again.However, more and more these days it isasked by providers and professionalsnewly interested becoming

part of the Medicaid providersystem .Approximately 35 million

adults will gain healthinsurance through The PatientProtection and AffordableCare Act, (ACA). In California,Medi-Cal will enroll threemillion new adults from2014-2019. Over the nextnine years Medi-Cal will expandfrom approximately 8.5 millionto approximately 12 millionenrollees, with adult enrolment

expanding from 3.4 million in 2009 to 6.5million in 2019, according to the KaiserFamily Foundation.

This growth in Medicaid enrollment willgreatly impact a complex systemconsisting of providers totally dependenton federal and state funding andcharitable support. These providers formwhat is commonly referred to as the safetynet, which consists of:

For-profit hospitals often surrounded byfor-profit clinics that range from largemulti-specialty IPAs to small storefrontpractitioners

Regional teaching hospitals, religioushealth system hospitals, and nonprofitcounty and community hospitals

The Federally Qualified Health Clinics(FQHC clinics) that providecomprehensive healthcare to about170,000 managed care clients in LosAngeles County and about 500,000statewide.

Three of the greatest challenges ofproviding effective care to the previouslyuninsured poor are: (a) use of theemergency room as primary care provider,

(b) poor diet and wellness skills, and (c) thneed for more specialist and hospital stays

Greater clinical integration includingmedical homes, accountable careorganizations and other payment/servicesbundling programs is needed. Preventionquality primary care, and timely access tospecialist and acute care is a must. HeathEducation, integration with social servicestranslation skills and cultural sensitivity, aother social welfare services must be offer

A significant number of Medi-Calrecipients are enrolled in health p

that already provide services citedabove. Los Angeles and San Franchave highly regarded nonprofit puhealth plans, which provide fundinFHQP clinics and other capitatedmanaged care providers. Themovement away from Medicaid asthird-class care provided in storefrclinics with limited access to qualspecialist and hospitals is further

supported by ACA providing $11 billidollars nationally for community clinexpansion.Community clinics have far fewer

planning professionals and available capitfor expansion, yet across the providerspectrum I hear concern about addingcapacity. Everyone worries about findingenough primary care providers. With all thgood ACA will do for the safety net, it hastragically failed to address the health careneeds of the undocumented. They willcontinue to receive a paucity of services aremain a very costly burden.

Initially healthcare reform will a havepositive effect on the poor by adding dollaand good guidance to the safety net systemUltimately it may pull many from the safe

net and into accountable comprehensivehealth plans that any of us would be happjoin.

OPINION

Reforms Impact On The Safety NetCommunity Clinics May Have The Biggest Challeng

By Jerry

Seelig

Jerry Seelig is CEO of Seelig+Cussigh HCO,

Culver City-based hospital monitoring firm,

and publisher of the The Health Care

Innovators Forum newsletter.

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Op-ed submissions of up to 600 words are

welcomed. Please e-mail proposals to

[email protected],


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Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

SENIOR MEDICARE COMPLIANCE ADVISOR - Along with the Compliance Ofcer and Privacy & Information Security Ofceserves as the focal point for all Medicare Advantage compliance activities. Coordinates and communicates all assigned MedicaAdvantage compliance activities internally and with L.A. Care's contracted provider network. Along with the Compliance Ofcer,L.A. Care's liaison with Centers for Medicare & Medicaid Services (CMS) and other federal agencies concerning L.A. Care's MedicaAdvantage product(s). Ensures that L.A. Care and its subcontracted provider network is compliant with all CMS federal regulatorequirements. This is achieved by working with internal and external staff to correct performance deciencies, ensuring staff are awaof CMS reporting requirements and reports are submitted to CMS identifying internal areas for improvement. Responsible fperforming internal audits, monitors implementation of corrective measures, and interpretation of CMS requirements. Workinknowledge of federal and state requirements is required, as well as highly developed analytical skills and excellent written and verb

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Payers & Providers – Issue of September 23, 2010

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