17 April 2012

Midwest Edition
Calendar
April 25
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Midwest Launches Medicaid Pilots

Focus is on Improving Safety Net For Vulnerable
If health reform holds up in the Supreme Court, 32 million Americans could be covered through private and government insurance plans. But there will always be a need to care for at-risk populations. It is expected that 23 million individuals will remain uninsured after 2014. That doesnt include those who are underinsured who have insurance, but are unable to pay for care. The National Academy for State Health Policy has taken on the issue of caring for more vulnerable populations. The group has launched a Medicaid-Safety Net Learning Collaborative to support states trying to improve delivery systems with safety net providers. Six states have been selected to participate in the collaborative Alaska, Iowa, Maryland, Maine, Minnesota and Texas. They are working with safety nets and state Medicaid to identify new payment models for the providers, understanding barriers to safety nets being more involved with the overall delivery systems, and promoting collaboration between Medicaid and safety nets. NASHP will provide technology, networking opportunities, consultation and other services over the 13-month collaboration. In Minnesota, David Godfrey, director of the states Medicaid program, said they have been wrestling for some time with how to provide coverage for non-citizens. There are pockets of the state like Minneapolis and St. Cloud that have a large number of uninsured immigrants. In these areas, there is a large strain on safety net providers. Those taking part in the collaborative are Medicaid, the state Department of Human Services, the Minnesota Healthcare Safety Net Coalition, and the state Ofce of Rural Health and Primary Care. Godfrey said they are working to shore up resources to provide healthcare to this population. They are also trying to gure out how to provide coverage solutions for those that dont have coverage. We are trying to gure out how to better support the providers who serve these individuals, he said. They will likely look at grants that can be put toward federally qualied health centers and gearing excess disproportionate share funding that the state has toward providers serving this population. Half of our DSH allotment is not currently utilized, so we have some pockets of money around that we could look at for realigning, he said.
Continued on Next Page

April 27-28
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June 11-13
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WEBINAR
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.

Thursday, April 26, 2012

Noon, CDT

CLAIMS PROCESSING: A COLLABORATIVE EFFORT

Please join Kenny Deng, senior director of provider relations, Blue Shield of California, George Mack, vice president of provider relations, Hospital Association of Southern California, and Dan Martinez, director of patient financial services, Mission Hospital Medical Center, to discuss a joint hospital/health plan initiative to streamline claims processing and improve provider bottom lines.

http://www.healthwebsummit.com/pp042612.htm

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Payers & Providers

Top Placement... Bottomless Potential

NEWS
Pilot Projects (Continued from Page One)
In Iowa, the project will focus on maximizing the participation of safety net providers in their home health program, which focuses on creating medical homes. They are trying to enhance payment for primary care services with safety net providers. We are building on some pilots the state has to integrate primary and behavioral health programs, said Sarah Dixon Gale, lead contract manager at the Iowa Primary Care

Page 2

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In Brief
Ohio Selects New Medicaid Providers
Beginning next January, two new providers will serve Ohios Medicare recipients and some of its current providers will be ousted. The Ohio Department of Job and Family Services have chosen new insurers Aetna Better Health of Ohio and Meridian Health Plan, along with incumbent providers UnitedHealth Group, CareSource and Paramount Advantage to take part in the states Medicaid Managed Care program which covers children and families as well as aged and disabled residents. There are approximately 1.6 million people eligible for the managed care program in the state. Insurers Centene Corp., Molina Healthcare Inc., Amerigroup Corp. and WellCare Health Plans, Inc. all lost some of the states business next year. According to press release by Centene, the company plans to formally protest the states decision-making process.

Association. They are trying to get safety nets involved in value-based purchasing and help them become certied as medical homes. We are trying to see what barriers might be for safety net providers (to become certied), she said. We want to make sure they are able to meet those requirements and participate. We are thinking about solutions that would look different for them than other providers.

Data Still Lacking On P4P Programs

Conflicting Opinions as Medicare Ramps It Up
Medicares value-based purchasing program is scheduled to be implemented in late 2012. The idea of pay-for-performance design is already being piloted in various locations, but not a lot of data exists as to its effectiveness. The Premier Hospital Quality Incentive Demonstration, run by the Centers for Medicare and Medicaid Services, will be Medicares rst program to measure pay-forperformance. A study released this month in Health Affairs found that the demonstration project did not necessarily encourage quality improvement in low-performing hospitals and that higher performing hospitals did not improve more than others. The demonstration began in 2003 with 266 participating hospitals. The organizations subscribed to Premiers hospital benchmarking service, agreed to track their scores on quality measures and receive nancial incentives based on their performance. For three years, only the hospitals that performed the highest received incentives. In 2006, the markers were changed to reward for improvement and good performance across a larger range of measures. The change was meant to provide more rewards to lowerperforming hospitals. They found that the quality of the higherperforming hospitals improved more in the early part of the demonstration than in the second half. The study authors attribute this to possible factors including: they had reached a quality improvement ceiling, that the changes actually decreased incentives or that hospitals enthusiasm for the project wore off. As for the low-performing hospitals, the authors found that, even with the changes in incentives, these hospitals still failed to improve during the second half of the demonstration. This could be because their low scores still kept incentives out of their reach. Another possibility is that they used a majority of their resources in the initial years of the demonstration, making them unable to continue improvements beyond that time.

Ascencsion Teams With Hospitals In India To Open Caribbean Site

A scension Health Alliance has

HEALTHCARES BEST ADVERTISING VALUE

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partnered with Narayana Hrudayalaya Hopsitals of India to create a healthcare city in Continued on Page 3

PAYERS & PROVIDERS reaches 5,000 hospital, health plan and nonprot executives statewide. There is no better venue for marketing your organization or conference, or recruiting new staff.

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Payers & Providers

Longer ALOS!*

NEWS

Page 3

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HeartLab Focuses on Inflammation

Stresses Its Link to Many Cardiovascular Ailments
Cleveland HeartLab Inc. has created a new it campaign, aimed at informing the public about the link between inammation and cardiovascular disease. The it, or inammation testing, campaign focuses on awareness and education aimed at patients at risk or heart disease and their healthcare providers. The campaign includes advertising, brochures, reminder cards and educational materials providing information on the testing and its benets. The heart labs panel of tests provides broader prognostic coverage than traditional blood tests and enables a determination of the degree to which someone is at risk for a cardiovascular event, according to a press release by the organization. The company contends that arterial inammation is a better predictor of heart attack and stroke than cholesterol levels. Our new it campaign is designed to engage patients about the benets of inammation testing and its role in advanced cardiovascular risk assessment like theyve never been before, said chief medical ofcer Marc S. Penn, M.D., chief medical ofcer. The campaign will generate increased understanding of inammation testing and the signicant role it plays in the assessment of cardiovascular disease. Cleveland HeartLab Inc., based in Cleveland, Ohio, is a specialty clinical laboratory and cardiovascular disease management company providing diagnostic tests used in the management and prevention of heart disease.

In Brief
Grand Cayman, the largest of the Cayman Islands. The $2 billion, 15-year project is scheduled to break ground in August. The healthcare city will include a hospital, educational facility, biotech park and assited living community located on a 200acre site. Ascension will provide facilities planning, supply chain management and biomedical engineering. The hospital is expected to have 2,000 beds when completed and provide services to the area including heart surgery, organ transplants and orthopedics.

OSF-Rockford Call Off Their Merger

FTC Pressure Cited in Decision to Kill Hospital Deal
The leadership of OSF Healthcare and Rockford Health last week ended their efforts to merge the two health systems. The Federal Trade Commission won a court ruling last month to allow the organization time to pursue antitrust claims regarding the buyout. The FTC contested that merging two of the three health systems in Rockford, Ill. would reduce competition and allow OSF to raise prices. The FTC found that the merger would give OSF, based in Peoria, Ill., almost 60% market share of patient admissions; 64% of the market of patient days; and 37% of the primary care market. Initially, OSF and Rockford contested the antitrust claims, but said later in a statement that ghting the challenge would take two years and require a substantial commitment of nancial and human resources. They concluded that the resources would be better spent toward the provision of health care services. In a statement on its website, OSF and Rockford said, We remain condent that the afliation would have better positioned us to achieve the goals of increasing quality and safety while improving efciencies for this region, our patients and this community. The groups said that both health systems will explore other avenues to achieve efciencies and cost savings and improve quality.

FDA Promotes Restrictions On Antibiotics

The U.S. Food and Drug Administration has announced a voluntary initiative to reduce the amount of antibiotics used in food-producing animals. The organizations goal is to educate farmers and animal producers that antibiotics should be used only to address disease and health problems and not for production purposes like growth enhancement. The FDA created three documents published in the Federal Register. One is for the industry and recommends phasing out the agricultural use of antibiotics. The second is a guide for drug companies to change the labeling on the products and move toward veterinary oversight of the medications. Third is to educate veterinarians on their part in the process.

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Payers & Providers

OPINION

Page 4

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The Problem Of Seniors And Drugs

They Are Overprescribed, Creating Real Dangers
Late last month I was privileged to testify before who assist members in understanding the purpose the U.S. Senate Finance Committees of their medication regimen. With members, these Subcommittee on Health as part of a hearing case managers review medications on a regular addressing prescription drug abuse within the basis and help members better manage their Medicare and Medicaid medications. We also review marketplace. As our nation ages, pharmacy claims and notify a this will become an increasingly members physician of duplications important topic if we are to make or senior-inappropriate drugs. sure that seniors get the safe In addition to case managers, medications they need, and only SCAN employs certied geriatric what they need. pharmacists who ensure that all The culture in the United drugs covered in our formulary are States is to turn to prescriptions clinically effective for seniors. For for whatever ails us, but that can high-risk members, this clinical often lead to over prescribing or team also reviews all medication taking drugs that dangerously proles on a regular basis and interact with each other. This communicates directly with concern is particularly heightened members and their prescribing among older adults where it is not physicians about any drug therapy By uncommon for seniors to be issues that surface. And, as an Timothy Schwab, accredited provider of continuing taking eight or more medications simultaneous, sometimes medical education, we routinely M.D. prescribed by different physicians. offers physicians online A number of these drugs may be non-geriatric educational modules and tools focused friendly and as such put individuals at risk for specically on proper medication for seniors. dizziness, falls and motor vehicle accidents. Beyond these safeguards SCAN has joined with This is a very real problem which summons all other health plans who offer Medicare Part D our healthcare community to do a far better job in instituting a Fraud, Waste and Abuse program when it comes prescribing medications for the to detect and prevent fraudulent behavior.! This elderly. It is our moral, legal and societal initiative relies on data-mining programs, fraud obligation to ensure that all aspects of a seniors and abuse identication software, and other health are addressed and that includes sophisticated tools to determine whether appropriate medication therapy. The best way prescribing patterns are appropriate, identify to do this is through the establishment of potential problem pharmacies, and identify programs that are focused on drug utilization, enrollees with unusual or excessive prescription the monitoring of the appropriateness of utilization patterns. prescriptions and alerts to seniors and their Medicare beneciaries, particularly the frail physicians when potential risks are found. elderly, need coordinated, integrated care to Medicare Advantage plans play a assure their safety regarding prescription particularly important role in protecting seniors medications. The greatest danger to patients is the from the dangerous effects of prescription drug unintended consequences of drug-to-drug abuse. For 35 years!SCAN Health Plan has been interactions that can harm the very patients our focused on the unique needs of seniors. medical system is striving to help. Models that put Through a combination of care coordination, the patient at the center of care can go a long way utilization management, and a well-thought-out in assuring they receive the medication therapy formulary structure, we have put programs in that truly benets them. place which we believe go a long way toward ensuring safety in medication management and Timothy Schwab, M.D., is chief medical officer which, at the recent hearing, Senator Charles for SCAN Health Plan, which is based in Grassley (R-IA) called a pattern for everyone Southern California. else. SCANs Medication Therapy Management Op-ed submissions of up to 600 words are Program includes a team of 60 case managers
welcomed. Please e-mail proposals to editor@payersandproviders.com

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Payers & Providers

MARKETPLACE/EMPLOYMENT

Page 5

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