21 August 2012

Midwest Edition
Calendar
September 6-8
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WellPoint At Bottom Of Hospitals List

Scores Least Favorite Payer Title In Latest Survey
By JAY HANCOCK
It is a truth universally acknowledged that health insurance companies can be a pain for patients. What may be a surprise is that hospitals often complain, too. For the same reasons: Denied claims. Low reimbursement. Late reimbursement. Thickets of red tape. Each year ReviveHealth, a hospital public relations rm in Santa Barbara, Calif., asks hospitals to name the most problematic payers. This years loser: Indianapolis-based insurance giant WellPoint, Inc. which managed to have some pretty intense negative opinion in the regions where it does business, said Revive President Brandon Edwards. That vaults them above or I should say below all the other health plans, even those that operate in all 50 states. Insurers called the report unscientic and biased, pointing to the agencys interest in cultivating hospital clients. (Here is Revives press release.) Edwards says the research was commissioned by Revive but performed by a third party Monigle Associates which contacted every hospital system in the country and received responses from more than 400. WellPoint ranked last in overall favorability and in the dealing with hospitals category. Cigna was rst in overall favorability while Aetna scored best in the dealing with hospitals category. We believe the Revive survey is inherently awed and without merit, said WellPoint spokesperson Jill Becher. We have a long history of working with providers to improve the accessibility, affordability and effectiveness of quality healthcare. Rising from the basement in previous surveys was Minneapolis-area insuer UnitedHealthcare, the countrys biggest private health insurer. United scored sixth out of seven in the dealing with hospitals category and fth out of seven in overall favorability. United certainly hasnt moved to a point where people say, Its a great health plan for me to deal with, but its only fair to acknowledge that theyve made some pretty big strides in improving their reputation in the provider community, Edwards said. Independent Blue Cross and Blue Shield plans ranked worst in hospital payment rates for the second year in a row. Allan M. Korn, M.D., chief medical ofcer for the Blue Cross and Blue Shield Association, defended the Blues relations with hospitals and doctors. Revive is a PR rm that represents medical providers in payment negotiations
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September 9-11
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October 3-5
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Top Placement... Bottomless Potential

NEWS
Health Plans (Continued from Page One)
with insurers and often creates a contentious public and media atmosphere around these talks, he said through a spokesperson. This survey is merely another tactic aimed [at] boosting payments for Revives clients without regard to the impact this has on millions of Americans who want and deserve affordable healthcare. The Independent Blues account for about 21% of the net revenue received by the health plans surveyed, according to Revive. WellPoint accounts for about 15% of the revenues, while UnitedHealth accounts for about 10%.

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The payment environment as perceived by hospitals is not expected to improve anytime soon. According to Revives survey, 76% of hospitals believe the ongoing implementation of the Affordable Care Act will reduce their reimbursements. Provided by Kaiser Health News (www.kaiserhealthnews.org). Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprot, nonpartisan health policy research and communication organization not afliated with Kaiser Permanente.

In Brief
UnitedHealthcare Drops Out of BadgerCare Program
UnitedHealthcare has opted to end its Medicaid managed care contract with BadgerCare, citing continued cuts in reimbursement by Wisconsin regulators. UnitedHealth cares for 174,000 Medicaid lives in Wisconsin and was paid $284 million for its service in the last fiscal year, which ended on June 30. Its contract terminates on Oct. 31. UnitedHealthcare was among four managed care plans to win BadgerCare contracts in 2010. However, the Wisconsin Department of Health Services began cutting its reimbursement rates as much as 7% in 1011. Its latest cut, just over 1%, was announced in May and was retroactive to Jan. 1. Meanwhile, state officials are eyeing another $372 million in cuts during the current fiscal year, which ends in June 2013. Another BadgerCare payer, Childrens Community Health Plan, told the Milwaukee JournalSentinel the reimbursement reductions had put it in the red. Although it may consider trying to pick up the UnitedHealthcare lives, officials with the plan said it could be fiscally unwise to do so.

Feds Expanding Home Healthcare

Projects Expected To Improve Health, Cut Costs
The Centers for Medicare and Medicaid Services has undertaken a project to expand home health services to the elderly. The Independence at Home Demonstration Project is designed to provide Medicare beneciaries with comprehensive primary care services in their homes. The current home health benets only cover limited services skilled nursing care and therapy for existing conditions. The goal of the project, according to a release by CMS, is to allow healthcare providers to spend more time with their patients, perform assessments in a patients home, and assume greater accountability for all aspects of the patients care. Home-based care is designed, according to CMS, to improve overall quality of care and quality of life for patients served, while lowering healthcare costs by forestalling the need for care in institutional settings. During the project, chronically ill patients will be receiving home-based primary care for three years. The beneciaries care experiences and services received will be tracked during that time. Beneciaries had to have at least two chronic conditions; be covered by original Medicare; need assistance with at least two functional dependencies like walking; and have been hospitalized and received rehabilitation during the past year. The practices taking part in the program were required to demonstrate experience providing home-based care to chronically ill patients. The groups are primary care teams that include pharmacists, social workers and other staff. Providers will receive incentive payments in the program if they are able to meet quality standards and create Medicare savings (i.e., if their expenditures are less than what CMS expected costs are for the beneciaries). Participating providers in the Midwest region include: Cleveland Clinic Home Care Services Medical Care at Home Program (Independence, Ohio) Visiting Physicians Association, P.C. Flint/ Saginaw/Marysville (Flint, Mich.) Visiting Physicians Association, P.C. Lansing/Ann Arbor (Okemos, Mich.) Visiting Physicians Association, P.C. Milwaukee (West Allis, Wis.) Innovative Primary Senior Care LLC (Skokie, Ill.) TAMMY WORTH

HCCA Says Not-ForProfits Much More Likely To Be Audited

Not-for-profit healthcare institutions experience audits from

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Retail Clinic Use Continues To Grow

RAND Study Chronicles Huge Increase in Demand
A recent study by the Rand Corp. has found that retail-based health clinics are providing more preventive care and being used more frequently by older patients. The visits to retail medical clinics rose four-fold between 2007 and 2009, from 1.48 million to approximately 5.97 million visits. Between 2000 and 2006, only about 7.5 percent of patients visiting the clinics were 65 or older. From 2007 to 2009, that number rose to 14.7 percent. Prevention, specically providing u vaccines, increased from 21% of care provided to almost 48% of care over the same two time periods. The number of vaccines given reached more than 1.9 million in 2009. Other ndings of note include that the number of visits for acute medical problems dropped from 78 to 51 percent in 2009. Also, more than 60 percent of patients visiting the clinics said they did not have a regular primary care provider. The study, published online in the journal Health Affairs, also found that almost half of all clinic visits fell on the weekend or when physician ofces are closed. The rapid growth of retail clinics makes it clear that they are meeting a patient need, said the studys authors. Convenience and after-hours accessibility are possible drivers of this growth. TAMMY WORTH

In Brief
outside entities at a rate more than 50% higher for-profits, according to a new study by the Minneapolisbased Health Care Compliance Association. Not-for-profits experienced an average of six audits per calendar year, compared to fewer than four audits per calendar year among forprofits. The survey also found 42% of not-for-profits had undergone audits from either the U.S. Department of Health & Human Services' Office of Civil Rights, Office of Inspector General, RACs or other outside agencies. Only 25% of for-profits experienced such audits. The amount of government and healthcare resources devoted to these audits is staggering. And if that was not enough, I would not be surprised if these numbers increased significantly in the next few years, said HCCA Chief Executive Officer Roy Snell.

Upton Queries CMS On Exchanges

GOP Lawmaker Criticizes HHS Near Silence
Rep. Fred Upton, R-Mich. sent a letter on Monday to the Centers for Medicare and Medicaid Services seeking more information on regulations regarding insurance exchanges and Medicaid. Some of the regulations have not been nalized and the Congressman said the uncertainty has crippled states and health providers in their ability to plan for future Medicaid expansions or state insurance exchanges. Upton said states are asking questions about basic requirements including essential health benets and actuarial value, which have not yet been claried. The near-silence from HHS on these critical issues is all the more alarming given that the department has required states to submit an exchange application by Nov. 16, 2012, and we are less than 100 days away from this deadline, the lawmaker said in his letter. Upton said that both the Republican Governors Association and the National Association of Medicaid Directors have queried HHS about specics of the ruling. The groups requested clarication on 60 issues the states need to know before deciding whether or not to move forward with the Medicaid expansion or exchange. He said that CMS may be delaying announcements until after November, but states do not have the luxury of procrastination. Upton requested that CMS responds to the questions in the RGA and NAMD letters by September 3. Also that CMS provides them with an outline of all outstanding questions regarding exchanges and Medicaid and when those will be answered. Upton chairs the House Committee on Energy and Commerce.

Minnesota Auditors Drop Thousands From State Insurance Roles

The state of Minnesota has dropped health insurance coverage for more than 3,000 dependents of state employees after an eligibility audit was conducted by the states Management and Budget Agency. However, there have been complaints that more than half of those dropped lost their coverage peremptorily without any prior notification or request for clarification, or they may have thrown out paperwork necessary to maintain their coverage because the thought it was junk mail. The AFSCME labor union, which represents a large bloc of state employees, has filed a grievance against the state, claiming many dependents had their coverage terminated incorrectly.

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OPINION

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Medicares Chronic FFS Condition

Taxpayer Funds Wasted In Current Treatment Modes
The Medicare program reects the popular done without an ofce visit. understanding of medical care 50 years ago: For example, diabetes management requires primarily treatment by doctors of acute regular checking of blood sugar and episodes such as pneumonia. medications and checking eyes, kidneys, and Medicares design was based on the historical limbs for early signs of damage that can be demands of the medical profession for feearrested before disaster strikes; and advice on for-service payment: free choice of lifestyle modication and self-management. treatment without accountability for quality Heart failure requires regular monitoring and outcomes; Medicare to pay the doctors of weight and adjustment of medications to usual and customary fees; solo practice and prevent the gradual uid buildup in the lungs. physician autonomy (without coordination or It is preventable if the patient is tracked by a teamwork). nurse who monitors daily weight. Fee-for-service means more money to the Medicare does not pay for most of this doctor for doing more and more costly (unless people pretend the doctor saw the services. The doctor who prevents the patients patient.) Likewise, phone calls and emails, costly medical problem or solves it quickly often preferable to frail seniors challenged by and inexpensively does not prosper traveling to frequent doctor By in this model. appointments, are not covered. As a Primary care, the building block result, patients often are told to schedule Alain for most cost-effective systems, is also Enthoven appointments just to get their lab results undervalued in comparison to or have simple questions answered. and Alan procedures and specialist services, What these patients (and the resulting in visits that are too short to Glaseroff, taxpayers) need is mostly not ofce visits meet the needs of patients with to solo doctors; it is care through M.D. complex problems. Continuous physician-led teams that are organized healing relationships, which include to provide the necessary support to prevent telephone and other contacts between visits, acute exacerbations, supported by a periodic are not covered at all. per capita payment that covers all necessary Additionally, Medicare is open ended, care regardless of who provides it. Such team which means no provider or patient feels any care is primarily delivered through integrated imperative to shepherd a limited resource delivery systems that organize and deliver wisely. Medicare spending is on track to continuous services to the chronically ill. double in the next 10 years. It is scally These systems typically cost some 20% less unsustainable. One way or another, it will be (premium and out of pocket) than traditional curtailed. FFS. Medicares focus on acute episodes of care, The leading exemplar systems include which leads it to pay for doctor ofce visits Kaiser Permanente and the Group Health rather than continuous healing relationships, Cooperatives, Intermountain, Geisinger is now out of date. Health and others. Seniors main medical problems now, There could be many more such systems, from a cost and health point of view, are and these systems could cover many more chronic conditions. In 2002, 93% of Medicare people, if the insurance market were spending was associated with beneciaries congured so they could market their superior suffering from three or more chronic performance and economy. conditions, including, diabetes, congestive heart failure and coronary artery disease. Alain C. Enthoven is the Marriner S. Eccles These problems persist over years, and their Professor of Public and Private Management, acute exacerbations can lead to very costly Emeritus, Stanford University. Alan Glaseroff, acute episodes which largely could be M.D. is a clinical professor of medicine at prevented by proper team-based management. Stanford. The management of these conditions usually requires ongoing support, disease monitoring, adjustment of medications, and Op-ed submissions of up to 600 words are welcomed. Please e-mail proposals to lifestyle modication, most of which can be
editor@payersandproviders.com

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