!!!"#$$!%&!'(&)*+!,!'*-./0)*+!'1%2/+3/456!

778
Republican Sandy Praeger, 66, was elected
insurance commissioner of Kansas in 2002,
then re-elected in 2006 and 2010. Before that,
she served as a state senator from 1993 to
2003, during which she was chair of the
health committee. In 2008 she served as
president of the National Association of
Insurance Commissioners.
In this exclusive interview
with Payers & Providers
editor Duncan Moore, she
shares her views on health
reform and the difculties it
presents to pragmatic
solution seekers on the state
level. Part 1 of two parts.
What is your view on the
Patient Protection and
Affordable Care Act?
I think its a market
solution to getting everyone
covered. Its not a single
payer. Youve got the folks on
the far left who dont like it,
youve got the folks on
the far right who say its
a government take over,
which of course it isnt.
I think it strikes a
balance in using government to create
nancial assistance, to standardize the rules,
and create a more competitive private
marketplace with subsidies, which needed to
be done if were going to try to get everybody
covered.
It has challenges in implementation. The
individual mandate is the most controversial.
But the individual mandate or some method of
encouraging people to buy
coverage before theyre sick is
absolutely essential.
Do you think the act should
be repealed? Altered?
Revised?
If the mandate goes away
but we still have guaranteed
issue, there has to be some
method, like an open
enrollment period, or
penalties if you wait to buy in,
or health underwriting if you
try to come in later. Those
would be acceptable ways of
encouraging people to not
wait until theyre sick.
If you have
guaranteed issue, then
why would you buy in
until youre sick? We
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June 27-28
June 19-23
Calendar
14 June 2011
June 15-17
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E-Mail
info@payersandproviders.com with
the details of your event, or call
(877) 248-2360, ext. 3. It will be
published in the Calendar section,
space permitting.
Midwest Edition
In GOP, But For Universal Coverage
Kansas Insurance Commissioner on Health Reform
Continued on Next Page
Kansas Insurance Commissioner
Sandy Praeger
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Payers & Providers Page 2
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In Brief
Thomson Reuters
to Sell Michigan-based
Healthcare Division
Thomson Reuters, the international
information company based in New
York, has announced plans to sell its
healthcare division, based in Ann
Arbor, Mich., because it no longer
aligns with the companys global
strategic goals.
The division offers data, analytics,
and benchmarking solutions. It has
about 800 people in Ann Arbor, of
2,040 total employees.
Thomson Reuters publishes the list
of Top 100 U.S. Hospitals and the Top
10 U.S. Health Systems, proled in
Payers & Providers in April and June.
The division also publishes a group of
healthcare indexes and includes a
center for comparative effectiveness
research.
We believe we can achieve better
all-in returns for our shareholders by
divesting the healthcare business and
re-deploying the proceeds in our core
franchises, said Thomas H. Glocer,
CEO of Thomson Reuters, in a
statement.
The healthcare division is growing
and protable but lacks the global
scale of other business units, he said.
The division had 2010 revenues of
$450 million and operating margin of
around 19%, the company said. It
expects to divest the business unit by
the end of the year.
Antitrust Case Against
Michigan Blues May
Proceed, Judge Rules
U.S. District Judge Denise Page
Hood announced last week that she
will allow a lawsuit against Blue
Cross Blue Shield of Michigan
Continued on Page 3
NEWS
Sandy Praeger (Continued from Page One)
need to nd ways to make this work, so we
can keep the most popular aspects of it. Then
you have a marketplace that really can
function.
It also opens door to more innovation with
the Medicaid program. Then recipients could
buy products on the individual market and
through the exchange. Thats the only place
the subsidies are available.
So you think the law can be made to work?
With tweaks, I think so. I like the
individual mandate without medical
underwriting, except for age, tobacco use,
geography, and family status. Three of those
Im OK with. The age rating I have problems
with. When you do rating bands in three tiers,
as healthcare costs for the upper age range
increase, it pulls everybody up. It does mean
younger folks pay more than they would have
if rated on their own health status.
In the National
Association of
Insurance
Commissioners we
argued that age bands
should start out with a
broader range and
gradually narrow. But
Congress didnt accept
our viewpoint. Its
going to push young healthy people into
subsidies they probably wouldnt need.
How do you manage to implement the law
when your Republican governor and
attorney general are so strongly against it?
Our governor [Sam Brownback] and our
attorney general [Derek Schmidt] are still
ghting to repeal. They recognize that our
ofce is charged with implementing the law.
Until its repealed I have an obligation to
implement it in the fairest way possible.
If we are not ready to run an exchange by
2013, then the federal government would run
the exchange for us. While they dont like the
law, they do want us to stay in charge of the
process.
I do support the notion of everybody
having coverage. If you dont have insurance,
you dont get healthcare in the appropriate
time and the appropriate place, which is in a
doctors ofce, where they can manage your
condition. Or else you end up in an
emergency room.
This is a private solution. Its very similar to
what our beloved Sen. Nancy Kassebaum
proposed back in the mid 90s, when she was
chair of the Labor Committee, along with a
bipartisan group that created a centrist plan.
Its been mislabeled as a government takeover,
and I dont think it is.
She and Sen. Ted Kennedy, the ranking
Democrat at the time, got HIPAA through.
They were also working on a mainstream
coalition of health insurance reform. We dont
have that kind of crossing party lines today.
They were close friends. They worked in a
bipartisan way to create solutions.
HIPAA worked from state solutions for
small market reforms, and put them into
federal law. The Family and Medical Leave Act
came in that time. Reconstructive surgery for
breast cancer, mental health parity, the
prohibition against drive-by deliveries,
allowing women to stay at least two days in
the hospital -- they were also passed.
What is the most difcult aspect of the health
reform act, from your perspective?
Working in the absence of signicant
guidance from the
Department of
Health and Human
Services. An awful
lot of rules and
regulations have not
been developed that
will be need to
inform state
regulators, including
guidance around exchanges. Theyre just
beginning to give guidance to states on rate
review for states that dont have that authority.
HHS has been handed a huge
responsibility. I dont mean to pick on them.
Some of the issues might have been claried
by a conference committee, which never was
convened. So now you have to deal with them
through the rule and reg process. That just
takes time.
What is potentially the most valuable aspect
of the ACA, assuming it goes into full
implementation?
For me its a combination of no medical
underwriting, so you dont have people denied
coverage based on their health condition, and
the subsidies. As we sort through how we
make sure people dont game the system,
thats the big unanswered question, the ability
to get nancial assistance to buy a private
product. Were building on the private system
we have in this country.
Exchanges will level the playing eld, bring
greater competition, and add subsidies.
Theyre all linked together. Of all of those,
getting rid of medical underwriting is most
important.
If you dont have insurance, you
dont get healthcare in the
appropriate time and the
appropriate place, which is in a
doctors office.
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Page 3
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In Brief
alleging anticompetitive practices
to move forward.
The lawsuit, filed by the U.S.
Justice Department and the
Michigan Attorney Generals
Office, alleges that Blue Cross has
used exclusive contracts with
hospitals and physicians to
disadvantage competing health
plans. (Payers & Providers, 5 April
and 12 April issues.)
According to the government
case, Blue Cross contracts required
some hospitals to charge higher
rates to other insurers, known as
most favored nation clauses.
The Blues had argued in a
motion to dismiss that it is required
to accept all applicants for
insurance and that the MFN clause
had previously been allowed by
the state insurance regulators. The
insurer said these contracts help
keep the states healthcare costs
low.
Hood made her intentions
known during a hearing on a
related class-action lawsuit. She
indicated she was still drafting her
order and didnt say when she
would issue it.
Wishard Hospital Ends
Bariatric Surgeries
Wishard Health Services in
Indianapolis will no longer perform
bariatric surgery because the service is
taking room that is needed by low-
income patients.
Wishard is a safety net hospital and
operates at 98% of capacity.
The bariatric service, called
Indiana University Surgical Weight
Management Program at Wishard, did
about 100 procedures a year. Closing
the program will free up beds in
intensive care and medical-surgical
oors for other patients, notably those
covered by Wishard Advantage, a
program for people lacking insurance.
Wishard Advantage did not cover the
weight-loss surgery.
St. Johns Hospital in Joplin, Mo., might
rebuild the destroyed facility on another site,
its leaders said last week. A location and plan
for the new hospital will be presented to
board members in December, said Gary
Pulsipher, St. Johns president.
Meanwhile, St. Johns has established a
mobile hospital that is seeing about 130
patients a day in an emergency room. Other
hospitals in the region, including St. Johns
Hospital in Springeld, Mo., and St. Edward
Mercy Hospital in Fort Smith, Ark., have sent
supplies, equipment, and staff.
The 367-bed hospital was all but
demolished by the tornado on May 22 that has
now cost 151 lives. Engineers deemed the
structure unsalvageable.
Were not sure if!this hospital will be torn
down, but it is unviable for renovation,
Pulsipher said. The next step is to move from
the eld hospital to a temporary structure to
be built on the current campus within the
next 6 months. !A location for the permanent
hospital is being analyzed now, but will most
likely not be on the current campus.
Several survivors of the tornado have since
succumbed to a rare fungal infection.
Zygomycosis, also known as mucormycosis,
comes from soil or vegetable matter that is
driven into the skin by the force of the
tornados winds. Under normal circumstances,
healthy persons immune systems can repel
the fungus, but people who are immuno-
compromised or who have been severely
injured may become infected, and eventually
die.
Doctors estimated that at least nine injured
patients have the infection, and it has
contributed to at least two deaths. The fungus
aggressively necrotizes esh and shuts down
the blood supply to the skin, which must then
be surgically removed. One patient had an
arm amputated to try to control the fungus,
but still died.
The Springeld-Greene County Health
Department sent a memo to local providers
alerting them to the dangers of the unusual
infection.
The Cleveland Clinic announced last week that
it will shutter Huron Hospital in September
because of declining patient census and
mounting nancial losses.
Community leaders in the east side of
Cleveland vowed to ght the closure, saying
the largely minority neighborhood depends on
the hospitals emergency and trauma care, not
to mention the jobs and economic activity that
anchor the area. Occupancy declined from
78% of staffed beds in 2005 to 52% so far this
year, the Cleveland Clinic said. Since 2001 the
hospital has lost $77.5 million and has not
broken even in any single year. Losses in 2010
were $22 million.
The health system intends to open a
community health center in October as a
replacement for the inpatient facility. The
health center would still probably lose money,
but on the order of $6 million to $8 million.
Clinic ofcials said sufcient inpatient and
emergency services are available at the main
Cleveland Clinic campus or University
Hospital, both within 3 miles of Huron.
Cleveland Clinic to Shutter Facility
Community Leaders Oppose Huron Decision
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St. Johns to Rebuild on New Site
Rare Fungal Infection Endangers Tornado Survivors
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Payers & Providers Page 4
In the nearly 20 years I have been writing and
commenting on the business of healthcare, I
have prided myself on staying healthy and out
of the hospital. To my shock and surprise, I was
suddenly taken ill on a Tuesday evening in late
April. Within an hour I was incapacitated, and
though I was sure the spell would pass, within
three hours it was apparent that I
needed to go to the emergency room,
immediately.
I shufed into the nearest hospital
and, suppressing my nausea, said, I
think I have a kidney stone.
That night in the ER was followed
in three days by a second trip to the
ER culminating in admission. I hadnt
been a patient in an emergency room
since 1979. I hadnt spent a night in a
hospital since 1972.
As a professional observer of
medicine and hospitals, this offered
a fruitful, if unwelcome,
opportunity: What would patient-centered
quality care in one of the Thomson Reuters Top
100 hospitals (proled in the 5 April edition of
this newsletter) actually feel like?
My observations:
If you can avoid it (I obviously couldnt) do
not allow yourself to be admitted to an
inpatient unit at 11 p.m. on a Friday. Virtually
nothing will happen all weekend.
I got perfectly ne nursing care, but my
medical care was haphazard, uncoordinated,
and impossible to follow. A stream of medical
residents rounded and asked the same
questions over and over. None were able to
explain my case or give an overarching
explanation of what was happening. They did
agree that I did not have a kidney stone, and
offered a wide variety of theories that might
account for my symptoms. They didnt seem to
talk to each other. No one seemed to be in
charge.
In the emergency room I had been promised
a consult with a urologist the next day. Yet no
urologist appeared, or any other senior
physician who seemed concerned that my
condition was not improving. In my frustration I
started yelling at the medical residents.
Me: Nobody seems to be managing my
case. Do I have a care plan?
Resident: Yes, of course.
Me: I dont believe you. I want to see it.
Resident: Its in the computer.
Me: Show it to me.
Resident: I cant.
Me: Why not?
Resident: The computer is in the hallway.
Me: Cant you make a printout?
Resident: No, we dont have printers on the
unit computers.
Me: Dont you have a laptop you
can bring in here?
Resident: No. I will see what I can
do.
I never saw or heard from this
medical resident again.
In desperation I called my personal
family practice physician, who had
sent me to the ER in the rst place, to
see if he could shake something loose.
Im sorry, I cant help you, he
said. I dont have privileges at that
hospital.
What I had been led to believe
would be an overnight stay
gradually morphed into three long, delirious days,
punctuated by replenishments of my morphine
drip. My girlfriend recently told me she thought I
was going to die.
It is difcult from this remove, six weeks later,
to recall the sense of helplessness, defeat, and, for
a while, hopelessness, that overwhelmed me.
Would I just drift on, day after day, unable to eat
or drink, getting progressively weaker, sicker,
thinner, more drug dependent, with nobody able
to gure out what was wrong with me? Would I
get an infection? Would I never leave this bed?
So forget about patient-centered care, at least
on the weekend. Fifteen years after the birth of the
quality care movement, what you will get is
institution-centered and physician-centered care.
Even in the nominally best hospitals, you still
have to be your own advocate.
If you dont have a family member to look out
on your behalf, or if that family member is unable
to do it, then you are in trouble.
OPINION
Dont Enter the Hospital on a Friday
Patient-Centered Care Doesnt Exist on Weekend
Duncan Moore is the editor of Payers &
Providers. He is a former correspondent for
The Kansas City Star, Modern Healthcare, and
Bloomberg News.
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Op-ed submissions of up to 600 words are
welcomed. Please e-mail proposals to
dmoore@payersandproviders.com,
By Duncan Moore
!!!"#$$!%&!'(&)*+!,!'*-./0)*+!'1%2/+3/456!778
MARKETPLACE/EMPLOYMENT
Payers & Providers Page 5


luyors & lrovdors und MCCL prosont koundtubo lntoructvo. lt dobuts Murch 20|| n tho luyors & lrovdors Nutonu odton.
Cur roudors uvuys vunt to knov vhut s on tho mnds ol houthcuro's c-suto oxocutvos. Conloroncos und trudo ovonts olton
ony uov lor crucu momonts to ntoruct vth thoso thought oudors. \th koundtubo lntoructvo, you' cut through tho
promnuros und mmodutoy knov vhut's on thor mnd.
Lvory koundtubo lntoructvo v louturo u C&A sosson conductod by luyors & lrovdors lubshor kon Shnkmun. Hs
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1opcs lor upcomng koundtubo lntoructvos ncudo:
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mpcutons n toduy's onvronmont:
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Modcuro ACC pots: Doos tho dolnton ol ACCs nood moro spoclcty, or s t prolorubo to huvo u bg tont ol
ncuson:
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