Payers & Providers California Edition – Issue of December 1, 2011

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  ! # $% & ! '( ! )*'' ! + ! )*'' ! %,  ! -., &/ ! 0 ! -&1234 &/ ! -5%63/7389( ! ::; <397=7 ! .885.6 !  >$ &3#.8 ! ? .6=7 ! ;.& ! ;18@ & 8# ! .84 ! <A73%3=318B !  >8.7 3$ ! C.&&31==B !  >8 ! A.$38.=318 ! 1@ ! 8 D  ! 4 632 &,  ! $14 6/ ! .84 ! 38= 9&.=318 ! /=&.= 93 /B ! E'()FGHE'(IF*B ! ;63#J ! ? & ! @1& ! C1& ! K8@1&$.=318 !  >885.6 ! L15=7 &8 ! ;.63@1&83. ! ;KM ! N1&5$B ! ;.63@1&83. ! <841D$ 8=( ! :1/ !  >89 6 /B !  >  ! 611J ! .=  ! =& 84/ ! .84 ! % /=  ! O&.#=3# / ! 38 ! 7 .6=7#.& ! = #781619,B ! EP*HE'*GB;63#J ! ? & ! @1& ! C1& ! K8@1&$.=318 December 1 Calendar  1 December 2011 December 5-6 E-Mailinfo@payersandproviders.comwiththe details of your event, or call(877) 248-2360, ext. 3. It will bepublished in the Calendar section,space permitting. California Edition AIDS Mortality Plummets In California Deaths a Fraction of Past Rate; Disparities Persist Hospitalization data on California’s HIV andAIDS patients released by the Of   ce of Statewide Health Planning and Development show a steadily dropping mortality rate, butcases continue to rise and minoritypopulations are affected by the diseasedisproportionately.The report, released on the eve of WorldAIDS Day, shows that the number of Californians living with AIDS or the HIV virushas nearly tripled between 1988 and 2008, to107,000 from 37,000. However, far fewerCalifornians are dying from the disease.The mortality rate in 1988 stood at about230 per 1,000. But by 2008, it stood at around20 per 100,000.Of   cials with OSHPD and the CaliforniaDepartment of Public Health , which held a joint press conference on Wednesday toannounce the  ndings, credited the drop tothe use of antiretroviral drugs beginning in themid-1990s.“There was a time when men werebasically returning home from the hospital todie,” said CDPH director Mark Chapman ,M.D., who saw the onset of the epidemic  rsthand while practicing at a NorthernCalifornia hospital in the 1980s. “We’ve comea long way since that time. There have beenmiraculous advances in treatment.”Hospitalizations for treatment of thedisease also dropped, from 400 per 1,000 atits peak to less than 200 per 1,000 in 2008.The mortality rate of those who arehospitalized for HIV/AIDS-related conditionsdropped from 12.7% in 1988 to 5% in 2008.Although the news was encouraging, starkdifferences in how the disease affect certainminority groups persist. The percentage of those living with HIV/AIDS in California hasmore doubled among Latinos, which represent30% of its total population in 2008, comparedto 14% in 1988.African-Americans comprised 19% of theHIV/AIDS population in 2008, compared to12% in 1988. Among African-Americans, thedisease affected about 90 individuals per10,000 population, more than quadruple therate from the 1980s. African-Americans alsodie from AIDS at higher rates than all otherminority groups other than Native Americans.Asian-Americans had the lowest rate of the disease as a group, at around 10 cases per10,000 population.Latinos are also being diagnosed withHIV/AIDS far later than other groups, puttingthem at greater risk of dying from the disease.Chapman suggested such disparitiescould be addressed in part by  ne-tuningoutreach programs to address how speci  cminority groups address the disease.We’ve gotten progressive in certain areasof public health, but we still have a long wayto go,” he said. January 12-14 ;.63@1&83. ! ;7.O= & ! 1@ ! =7 ! ;166 9 ! 1@ ! <$ &9 8#,  ! -7,/3#3.8/ ! PG=7 ! .885.6 ! <$ &9 8#,  ! C 43#38 ! 38 !  Q1/ $3= ! #18@ & 8# B !  >7D.8 ! ?1= 6( !  Q1/ $3= ! R.=318.6 ! -.&JB !  >  ! 43/#5//318 ! 1@ ! =& 84/ ! .84 ! =& .=$ 8=/ ! .@@ #=389 ! <! ! #.& B ! EPSGHEST*B ! ;63#J ! ? & ! @1& ! C1& ! K8@1&$.=318  ! # $% & ! '( ! )*'' ! + ! )*'' ! %,  ! -., &/ ! 0 ! -&1234 &/ ! -5%63/7389( ! ::; Payers & Providers Page 2 Top Placement...Bottomless Potential Advertise Here (877) 248-2360, ext. 2 In Brief  Prime’s Billing ForHeart Failure Examined Chino Valley Hospital has allegedlybeen billing Medicare to treatpatients for heart failure at rates farhigher than the national average,according to a recent report by California Watch .According to analysis of billingdata for Chino Valley, nearly one-third of its Medicare patients inrecent years suffered from acute heartfailure--a rate nearly six times theaverage for California. The facility isowned by Ontario-based PrimeHealthcare Services .California Watch, a non-pro  tinvestigative journalism organization,noted the hospital billed Medicare forvirtually no heart failure patients in2006, just prior to Medicare initiatinga rule change that allowed a bonusfor treating such cases. Between 2008and 2010, the hospital treated nearly2,000 patients for the ailment. Eight-eight percent of the time, thediagnoses was billed in a way thatwould trigger the extra payments.Prime of   cials disputed thereport by California Watch, whichhas been scrutinizing Prime's billingpractices. Anthony Glassman , aPrime attorney, told the organizationits analysis was faulty, unfair andbiased. He added that Chino Valleytreated such a large number of heartfailure patients because many areadmitted from nearby nursing homesand through the hospital's emergencydepartment. Blue Shield Sends OutPolicholder Credits San Francisco-based health plan BlueShield of California has begundistributing credits to itspolicyholders that range from 18% to54% of a monthly premium. Continued on Page 3 NEWS As Sacramento-based hospital system SutterHealth faces litigation over a breach of patient data involving 4.2 million patients itdisclosed last month, a new study of hospitalsystems indicates that the situation involvingcompromised medical data is getting worse,not better.The study of 75 healthcare systems bythe Michigan-based Ponemon Institute concluded that healthcare data breachesincreased 32% in 2011 compared to 2010.The average cost of such a breach is morethan $2.2 million – up around 9% from ayear ago. It also damages the brand of thehealthcare institution where the breachoccurs and leads to lost patients.In California, 19 healthcareorganizations reported breaches to the U.S.Department of Health and Human Services  in 2010, compared to 12 so far in 2011.Of such breaches, 49% involved a lost orstolen computing device, as was the case withthe Sutter incident. That’s up from 41% in2010.Ponemon Institute Chairman LarryPonemom indicated that safeguarding suchdevices – particularly smart phones – will beone of the biggest challenges facing healthcareorganizations in 2012.“Folks in the study have conceded that(portable devices) are not secure,” saidPonemon. Another challenge is safeguardingdata as its transferred from paper to electronicformat.Sutter disclosed the breach last month,which occurred as the result of the theft of adesktop computer. The device was password-protected but not encrypted.Law  rms in Los Angeles and Sacramento  led class-action suits last week against Sutter.One of the suits seeks more than $4 billion indamages. Patient Breaches Continue To Grow Little is Done to Address Portable Device Security Continued on Next Page Thursday, Dec. 15, 2011 10 A.M. PST California Healthcare:A 2012 Business Forecast Please join Steven T. Valentine , President of The Camden Group, Henry R. Loubet , Chief StrategyOfficer for Keenan, and Jim Lott, Executive Vice President of the Hospital Association of SouthernCalifornia, to discuss the trends that will shape California ! s healthcare business environment in 2012: http://www.healthwebsummit.com/ppcalifornia121511.htm a HealthcareWebSummit Event co-sponsored by PAYERS & PROVIDERS CHA Tries To Enjoin Medi-Cal Cuts  Motion on Matter Will Be Heard Later This Month The California Hospital Association is seekinga federal court injunction against pendingreductions in Medi-Cal payments it believeswill seriously damage its constituents.The motion for an injunction, which willbe heard in Los Angeles on Dec. 19, comes astrade groups representing physicians, dentistsand pharmacists  led their own suits againstthe Department of Health and HumanServices and the California Department of Health Care Services for cuts in Medi-Calreimbursement expected to affect theirpractices. The reductions, which range from10% to more than 20%, are retroactive to June1 and were recently approved by the federalgovernment. If enacted, they would save theMedi-Cal program about $623 million peryear.“During months of conversations withstate and federal of   cials, hospitals across  ! # $% & ! '( ! )*'' ! + ! )*'' ! %,  ! -., &/ ! 0 ! -&1234 &/ ! -5%63/7389( ! ::; Page 3 Payers & Providers Longer ALOS!* Advertise Here (877)248-2360, ext. 2 *For our ads, not your hospital NEWS In Brief  Blue Shield announced thecredits earlier this year as part of apledge to limit its net income to 2%of its annual revenue. Blue Shield is anot-for-pro  t organization.“As a mission-based, not-for-pro  t health plan, we made thiscommitment to help keep coverageaffordable for our members. Whilethese credits will help our customers,every player in the healthcareindustry must do more to reduce thecost of care,” said Blue Shield Chief Executive Of   cer Bruce Bodaken .The average credit for anindividual plan enrollee is $135, witha family of four receiving about $420.Large and mid-sized group customerswill receive credits ranging from $195to $235 per enrollee, with smallgroups receiving an average of $220.  UCLA Nursing SchoolIntervention ProgramGets Federal Funding The U.S. Department of Health andHuman Services has chosen forfunding a program started by the UCLA School of Nursing that targetsminority teenagers who have givenbirth or are pregnant.The Public Health Nursing EarlyIntervention Program for AdolescentMothers provides education forexpecting Latina and African-American teen mothers regardingprenatal healthcare, childbirth andpreparation for motherhood. Theintent is to cut down on healthcarecosts for their newborns, many of which have low birth weights andother problems often requiringhospitalization.“The costs to the U.S. healthcaresystem are substantial — about $9billion each year — so it is in theinterest of the states to enhance thehealth outcomes for those teens whodo become pregnant and for theirbabies,” said Deborah Koniak-Grif   n ,a UCLA nursing professor anddirector of the university’s Center forVulnerable Populations Research. HEALTHCARE’S BEST ADVERTISING VALUE ] PAYERS & PROVIDERS reaches 5,000 hospital, health plan and non-pro  t executives statewide. There is no better venue for marketingyour organization or conference, or recruiting new staff. CALL (877) 248-2360, ext. 2OR CLICK HERE Kaiser Enters Breast-Feeding Pact Initiative Expected to Fight Childhood Obesity Healthcare system Kaiser Permanente hasentered into a pact with the Partnership fora Healthier America to signi  cantly rampup the number of children born at itsfacilities who breastfeed.The initiative’s aim is to reduce theskyrocketing rates of childhood obesity.Nearly 20% of American children areconsidered obese, a rate that has tripledover the past 30 years.Although breast-feeding a child duringthe  rst year of life is linked by someresearch to lower rates of obesity, only13% of children are still being breast-fedwithin six months of birth, according to the U.S. Surgeon General’s of   ce, whichblamed the trend in part on poor planningby hospitals. “Barriers to breastfeeding arewidespread during labor, delivery, andpostpartum care, as well as in hospitaldischarge planning,” read a SurgeonGeneral’s report issued in January.Under the agreement, Kaiser said byearly 2013, all of its hospitals that offermaternal services would either bedesignated as “baby-friendly” based oncriteria provided by the Baby FriendlyHospital Initiative , or participate in the Joint Commission’s perinatal coremeasures program. That requires eachhospital to report breastfeeding rates atdischarge. Those rates will also be includedin Kaiser’s quarterly quality scorecard.Fewer than half of Kaiser’s hospitals nowhave the “baby-friendly” designation.Kaiser could not provide speci  c dataon what percentage of children born at itsfacilities leave breastfeeding. California hasone of the higher rates of breastfeedingchildren in the U.S. Kaiser Permanente's commitment tomake breastfeeding a priority for each childborn in one of their hospitals has potentialto make a very big impact,” said LawrenceA. Soler , chief executive of   cer of Partnership for a Healthier America. “We'repleased they are such a strong partner in  ghting childhood obesity. California provided compelling evidenceabout the impact these cuts will have onaccess to care for our most vulnerablepatients,” said CHA President C. DuaneDauner . “We believe that the cuts are inviolation of federal Medicaid law andwithout regard for the welfare of thousandsof patients with complex medical needs.”The CHA, which  led suit against thestate and federal government last month,wants to block rate cuts for skilled nursingfacilities operating within hospitals. Accordingto a recent survey of its membership, half would close their skilled nursing facilities,while more than a third are ponderingreducing beds or closing such services toMedi-Cal enrollees.In addition to the CHA suit, the CaliforniaMedical Association , California DentalAssociation , California PharmacistsAssociation and the National Association of Chain Drug Stores sued late last month. CHA (Continued from Page One)  ! # $% & ! '( ! )*'' ! + ! )*'' ! %,  ! -., &/ ! 0 ! -&1234 &/ ! -5%63/7389( ! ::; Payers & ProvidersPage 4 OPINION Employers As Tough Benefit Managers Little Attention is Paid to Making Coverage Perform Cyndy Nayer is president and chief executiveof the Center for Health Value Innovation.  <165$ ! =( ! >//5 ! ?? -., &/ ! 0 ! -&1234 &/ ! 3/ ! @5%63/7 4 ! 2 &,  ! A75&/4.,  ! %,  ! -., &/ ! 0 ! -&1234 &/ ! -5%63/7389( ! ::;B !  C8 ! .885.6 ! 38432345.6 ! /5%/#&3@D318 ! 3/ ! EFF ! . !  , .& ! GE'?F ! 38 ! %56H ! 5@ ! D1 ! '* ! /5%/#&3% &/IB ! >D  ! 3/ ! 4 632 & 4 ! %,  ! J$.36 ! ./ ! . ! -!K ! .DD.#7$ 8D( ! 1& ! ./ ! .8 ! 6 #D&183# ! 8 L/6 DD &B  C66 ! .42 &D3/389( ! /5%/#&3% & ! .84 ! 43D1&3.6 ! 38M53&3 /N GOPPI ! )?OJ)=Q*38R1S@., &/.84@&1234 &/B#1$ T.36389 ! .44& //N O'O ! UB ! V166,L114 !  W.,( ! X53D ! YY5&%.8H( ! ;C  ! F'Z*Z  W %/3D  LLLB@., &/.84@&1234 &/B#1$ K.# %11H  LLLBR.# %11HB#1$[@., &/@&1234 &/ AL3DD &  LLLBDL3DD &B#1$[@., &/@&1234 &/ \43D1&3.6 ! Y1.&4 XD 2 8 ! AB !  <.6 8D38 ( ! -& /34 8D( ! A7 ! ;.$4 8 ! ]&15@^1// ! ]164% &9( ! >$$ 43.D ! -./D  ! -& /34 8D( ! :1/ ! ^1%6 / ! V1/@3D.6 ! .84 ! T 43#.6 ! ; 8D &T.&H ! K385#.8 ( ! T.8.9389 ! !3& #D1&( !  C62.& _ ! 0 ! T.&/.6V 8&,  ! :15% D( ! ;73 R ! XD&.D 9,  ! `RR3# &( ! a 8.8 C8D718,  !  W&397D( ! \b #5D32 ! !3& #D1&( ! V .6D7 !  C## // ! ;.63R1&83. -5%63/7 &[\43D1& ^18 ! X738H$.8 @5%63/7 &S@., &/.84@&1234 &/B#1$>R !  ,15 ! 41 ! 81D  ! & # 32 !  ,15& ! 3//5 ! 1R ! -., &/ ! 0 ! -&1234 &/ ! %,  ! ' ! -BTB ! 18 ! A75&/4.,( ! @6 ./ ! #.66 ! GOPPI)?OJ)=Q*B   Op-ed submissions of up to 600 words arewelcomed. Please e-mail proposals toeditor@payersandproviders.com Healthcare is like no other U.S. industry.Employers do not manage their health costslike they do every other supplier or vendor;you’d be hard pressed to  nd another examplewhere companies pay millions of dollars forservices without requiring quality or evenresults, for that matter. As one of the largestpurchasers of healthcare, employers must takeresponsibility to combat rising costs and poorquality by demanding and measuring qualityand value for every dollar spent with theirvendors (i.e. health plans and providers).According to recent research released bythe non-pro  t Center for HealthValue Innovation (CHVI),healthcare bene  ts are under-managed. A focus on outcomes –missing from most bene  t programs-- could produce better results.CHVI’s efforts over the past  veyears have con  rmed thatengagement and accountability aresorely lacking across all of thestakeholders in the health supplychain, including consumers,employers, providers and healthplans. Payment reform has beenpromoted to manage the rising costsof inpatient and outpatient services,and outcomes-based contracting(aligning incentives across allstakeholders) has taken a major stepforward to align payment with metrics thatmatter (adherence to safety and clinicalguidelines, for example). Outcomes-basedcontracting puts a part of a service agreementat risk and then uses bene  t design incentivesto drive patients to the higher-performingservice providers, improving engagement andaccountability.Many employers spend millions of dollarson healthcare without understanding theirengagement and outcomes patterns. In theseall-too-common scenarios, healthcare servicesare purchased on a rate per employee. Forinstance, medication coaching may bepurchased for $10 per diagnosed employee formanagement of diabetes. (Numbers here areused only for illustration and not related toactual costs.) If there are 100 diagnoseddiabetics in the population, then theemployers pay 100 times $10, or $1,000.Yet who is managing the deliverables? Insurveys and seminars I have led for over 15years, employers often tell me that less than10% or even 20% of their targeted populationis engaged in these programs.Translated to common purchases, bananasare sold at about $1 a pound and there aretypically four bananas in a pound. If you pay$1, you expect four bananas. What if you onlyreceived one banana? Would you want arefund? Would you want the grocer to “go atrisk” to guarantee you get the bananas? Why isthis not the case for healthcare?Even acknowledging that some folks willnever engage, you might expect 75%engagement in the programs. Perhapswe could be comfortable with threeof the four bananas. But todayemployers are often settling for areturn of only one or two bananas.This lack of oversight leads tosigni  cant waste. Employers areworn down from the past severalyears of economic turmoil, the fearof changing insurance plans orbene  ts advisers during the healthreform ramp up, and thedownsizing of bene  ts staff at manycompanies.Employers must begin to take amore active and disciplined riskmanagement approach for healthbene  ts. Employee health screeningsshould be their  rst step. After that,employers should offer guidance to employeeson the goal-setting and tracking of prescribedtreatment; build accountability throughoutcomes-based contracting by creating aprototype contract for services, data andmeasures; and identify and implement bestpractices that improve accountability foroutcomes.We must treat employee bene  ts andhealthcare expenses like any other businesspractice. We need to align responsibilities tocontrol healthcare and absence costs in a waythat encourages good performance and goodhealth. ByCyndy Nayer
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