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5 April 2012
the details of your event, or call
(877) 248-2360, ext. 3. It will be
published in the Calendar section,
The Department of Managed Health Care has
issued a unique contract to Consumers Union
to provide critiques of hikes in premiums
insurers submit to the agency.
Valued at $225,000 and funded with
money from the Patient Protection and
Affordable Care Act, the pact will permit the
San Francisco-based consumer advocacy
group to review rate hikes proposed by health
insurers for its enrollees.
“This partnership will help bolster
accountability and transparency in health plan
rate setting,” said DMHC Director Brent
Barnhart. “Consumers Union will not only
provide in-depth input on health plan
premium rate lings but will also help get
more Californians engaged in how plans set
The DMHC does not have the ofcial
power to reject proposed premium increases.
However, legislation that went into effect last
year, SB 1163, gives the agency the authority
to review proposed rate hikes before they go
into effect and make its own
recommendations. Insurers have reduced
some proposed rate hikes as a result.
Consumers Union works with healthcare
advocates in more than two dozen states,
although it does not work with any other
regulatory agencies in an ofcial capacity.
“This is the rst time that we’ve worked
directly with a state agency,” said Consumers
Union Staff Attorney Laurie Sobel.
Sobel said her organization would review
rates as they’re led with the DMHC, and
make public comment as necessary. She
added that it was possible the money would
also be used to hire an outside actuary to
scrutinize rate proposals.
“When we look at the proposals, we will
see what (actuarial) presumptions are
underlying it. If there’s a medical trend
assumption that’s out of whack, or if they’re
pooling it in an unusual way, we would want
to examine it more closely,” she said.
In addition to assisting with the public
comments on the DMHC’s behalf, Sobel noted
that Consumers Union would likely issue
press releases on its own regarding rate hike
The contract was awarded as the debate
about premium hikes and access to coverage
is approaching a high volume again. A bill to
legislate premiums died in the Legislature last
year. The advocacy organization Consumer
Watchdog is currently in the process to qualify
a regulation initiative for the November ballot.
The California Association of Health
Plans said the Consumer Union pact would
help show how much insurers spend on care.
April 30-May 1
Consumers Union To Assist DMHC
Group to Provide Input On Proposed Rate Hikes
WEBINAR Thursday, April 26, 2012 10 A.M. PDT
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
Payers & Providers Page 2
(877) 248-2360, ext. 2
County By County
A new study of the nation’s health
rankings on a county-to-county basis
shows a wide disparity of healthcare
outcomes in California.
According to the Public Health
Institute of California, Marin, San
Benito and Santa Clara Counties had
the highest rankings in health
outcomes statewide. Siskiyou, Del
Norte and Trinity County had the
lowest rankings. Among the health
factors that affect the outcomes,
Marin, Placer and San Mateo
Counties had the highest rankings,
while Tulare, Kern and Yuba Counties
had the lowest marks.
The study was conducted by the
Wisconsin Population Health
Institute and the Robert Wood
Johnson Foundation. According to
the Public Health Institute, which is
promoting the rankings in California,
residents of Trinity County are three
times more likely to die a premature
death compared to residents of Marin
"By highlighting these health
disparities across California counties,
the Rankings inform a larger and
critical discussion about what can be
done to reduce them," said PHI Chief
Executive Ofcer Mary Pittman.
Health Plans Criticized
A recently released report on the
quality of California’s health plans
was criticized by a drug treatment
advocacy group for a systemic failure
to get appropriate care for those
confronting substance abuse issues.
Continued on Page 3
CalOptima Moves To Oust PR Firm
Agency’s Head Tied To Inappropriate Remarks
As CalOptima’s reins are handed over to an
interim chief executive ofcer, more turmoil at
Orange County’s Medi-Cal managed care plan
has surfaced regarding its longtime public
A memo distributed earlier this week by
departing CEO Richard Chambers said
CalOptima was consulting with legal counsel
about terminating its contract with Laguna
Hills-based public affairs agency Laer Pearce
Associates immediately as opposed to
entering a 30-day wind-down period as
required in its contract.
The Laer Pearce rm itself has already
notied CalOptima of its intent to serve
notice, according to the April 3 memo.
The decision to part ways centers around
alleged conduct involving the rm’s president,
The memo alleged that Pearce, during a
phone call with a staffer for the Orange
County Board of Supervisors, made
“statements that are not consistent with
CalOptima’s decision or direction.” The
particular Supervisor was not named, although
sources say the communication involved a
staff member for Supervisor Bill Campbell. A
Campbell spokesperson conrmed Pearce has
called his ofce, but would not comment
The memo included an apology to the
CalOptima board of directors and the Orange
County Board of Supervisors “for any
appearances of inappropriate conduct by any
Laer Pearce Associates specializes in
communications consulting for public
agencies. Its client roster includes the
Metropolitan Water District and the City of
Yorba Linda, according to information posted
on its website. According to Chambers’
memo, it had been providing consulting
services to CalOptima for the past four years.
In e-mail responses seeking a comment
about the memo, Pearce denied that the
incident involved Campbell directly, but
suggested that he came under pressure from
Supervisor Janet Nguyen. According to an
article published earlier this week in the
online publication the Voice of OC, Nguyen
claimed Pearce had slandered her, and asked
for his rm’s contract to be terminated.
In another e-mail sent shortly before
presstime, Pearce provided a March 30 letter
of resignation to Chambers where he issued a
categorical denial of all of Nguyen’s
Pearce has been critical of Payers &
Providers reporting in February of potential
conicts of interest involving CalOptima
Chairman Edward B. Kacic. It was reported
that a philanthropic organization he headed
and an ad hoc organization he co-chaired
were vying for more than $20 million in funds
to provide care for CalOptima enrollees.
Nguyen criticized Kacic for his conduct,
and was part of a bloc of Supervisors that
voted 3-2 in late February to delay his
reappointment to the CalOptima board.
Another trustee’s reappointment was denied
after it was disclosed the organization she
worked for received ofce space and other
support from CalOptima.
Pearce said Payers & Providers publisher/
editor Ron Shinkman himself had a conict of
interest by slanting coverage in favor of the
Hospital Association of Southern California.
Shinkman provided communications
consulting to HASC between 2002 and 2008.
HASC supported a plan recently passed
by the Board of Supervisors and backed by
Nguyen to expand the CalOptima board to
include representation from hospital members.
The measure also extended Nguyen’s term on
the CalOptima board by one year.
Chambers is leaving CalOptima later this
month for an executive position with Molina
Healthcare in Long Beach. Chief Financial
Ofcer Michael Ingelhard is serving as interim
CEO until a replacement is found. Michael
Ewing has been retained through an outside
frrm and named interim CFO.
Chambers departure came just a few
months after an internal audit by an outside
rm was critical of CalOptima’s management.
Correction –!Last week’s issue of Payers & Providers incorrectly gave the name of a winning
archiectural firm in Kaiser Permanente’s small hospital design contest as Aditazz, Gresham Smith and
Partners. The firm’s correct name is Aditazz, and it is based in San Bruno. The article also said there
were three contest winners. Two of the three firms teamed for one of two winning entries.
Payers & Providers
(877) 248-2360, ext. 2
*For our ads, not your hospital
According to the report released
by the Ofce of the Patient Advocate,
only 13% of adults and adolescents
received appropriate treatment within
30 days of being diagnosed.
“This is the equivalent of getting
13 out of 100 on a test, and nobody
should nd that acceptable,” said
Phillip Greer, executive director of
the California Treatment Advocacy
Foundation. “The score is disgraceful
but sadly not a shock given that for so
long health plans have routinely
denied those suffering from substance
abuse access to the care they need.”
Greer added that many health
plans have imposed heavy co-
payments and deductibles on
enrollees seeking substance abuse
treatment. His organization has
proposed broadening a bill currently
in the Legislature, AB 154, that would
expand mental health services to
include similar services for those with
substance abuse issues.
Medical Societies Warn
An afliate organization of the Board
of Internal Medicine and eight other
medical societies have ofcially come
out against unnecessary medical
testing, claiming it causes cost to rise
without a commensurate return on
The group of medical societies
say that unnecessary testing costs
upward of $250 billion a year, and
that the money could be better spent
elsewhere on other facets of care.
Among the procedures singled
out for potential overuse are x-rays for
lower back pain (it recommended
waiting six weeks before ordering
them), prescribing antibiotics for sinus
headaches, pap smears for women
under the age of 21,
electrocardiograms as part of annual
checkups and pre-operative x-rays
when a patient is ambulatory or has
not other conditions suggesting other
entered into settlement negotiations with the
entities in late 2010.
However, SCAN noted in documentation
that it was unsure whether a settlement will be
made, or if the company or any of its
employees might face criminal charges.
SCAN has 130,000 enrollees in
California. California Watch rst reported last
summer that the plan was under investigation
after state Controller John Chiang had accused
the plan of “eecing” as much as $339 million
after his department had conducted an audit.
Should SCAN reach a settlement near the
amount it set aside, it would be one of the
biggest recoveries in the history fo the Medi-
Cal program, according to California Watch.
Long Beach-based SCAN Health Plan has
disclosed that it has set aside $125 million to
settle allegations that it overbilled the Medi-
Cal and Medicare programs.
The disclosure, rst reported on
Wednesday by the investigative website
California Watch, was included in an
application SCAN submitted to state regulators
to serve 54,000 Medicare enrollees in Los
Angeles, San Bernardino and Riverside
SCAN has been under parallel
investigations by the U.S. Department of
Health and Human Services’ Ofce of the
Inspector General, the U.S. Attorney General
and the California Attorney General. It
Robot Surgery Has Better Outcomes
UCLA Says Patient Mortality, Complications Lower
SCAN Health Plan Sets Aside $125M
Money May Be Used to Settle State, Federal Probes
A new study by UCLA researchers and partly
funded by the U.S. Department of Defense
concludes that the use of robots to assist in
bladder cancer surgery lowers mortality
The research team examined records of
more than 1,400 traditional surgeries to
remove cancerous bladders versus 224
robotic-assisted procedures. The procedures
were performed at 1,050 hospitals in 44
states during 2009, the most recent year for
which information was available.
The traditional surgeries were linked to
a 2.5% mortality rate during hospitalization.
The robotic-assisted procedures were
associated with no mortalities at all. And
while patients who underwent the
traditional procedure experienced
complications at a rate of nearly 64%, the
complication rate among robotic-assisted
procedures was only 49.1%.
The average length of hospital stay for
both procedures was exactly the same: eight
The robotic procedures also cost an
average of $3,000 more. That was no surprise
to the researchers, who factored in longer
operation times, greater use of disposable
instruments and equipment maintenance.
"While we expected to see greater
expenses associated with the robotic
procedure for bladder cancer, we were
surprised to see the signicant reduction in
deaths and complications, particularly this
early in its adoption," said the study's senior
author, Jim Hu, M.D., the UCLA School of
Medicine’s director of minimally invasive
HEALTHCARE’S BEST ADVERTISING VALUE
PAYERS & PROVIDERS reaches 5,000 hospital, health plan and non-
prot executives statewide. There is no better venue for marketing
your organization or conference, or recruiting new staff.
CALL (877) 248-2360, ext. 2
OR CLICK HERE
Payers & Providers Page 4
A Ballot Initiative’s Lasting Legacy
Prop. 71 Will Lead to Future Stem Cell Breakthroughs
Jim Lott is the executive vice president of the
Hospital Association of Southern California.
In a sign of our populist, ballot box-driven
times, Kamala Harris received more than 90
proposed statewide voter initiatives prior to
circulation for signature gathering to qualify
for the November election. Certainly, not all of
them will nd their way to the
ballot (26 is the current record).
Still, one has to wonder
what the late Gov. Hiram
Johnson – the early 20th
century father of our state’s
initiative, referendum, and
recall system – would say if he
saw how his idea of giving
California voters a degree of
direct democracy is being
Of those initiatives placed
on the ballot since the initiative
system was created in 1911,
which would have been
Johnson’s favorites and least
favorites? Would this liberal
Republican have embraced
Proposition 13, the 1978
initiative that robbed local
government of access to the well of
property tax revenue to dip ever deeper
into to fund ever-increasing demand for
costlier local services?
Similarly, how would Johnson have felt
about Proposition 98, which when approved
in 1988, grabbed about half of the state
budget for schools? Though perhaps he would
have supported the other Proposition 98, the
one that proposed limitations on the use of
eminent domain and the prohibition of rent
control that failed passage in 1998.
Of this I’m certain, Johnson and the
Progressives of the time would have heartily
embraced Proposition 71, which was passed
in 2004. Fifty-nine percent of the voters in
that election authorized $3 billion in bonds to
fund stem cell research in California.
That proposition passed during a
presidential election year. It was a clear
rejection of then President George W. Bush's
imposition of his personal ideology on federal
funding for stem cell research.
The eventual product of Proposition 71
was the California Institute for Regenerative
As stated on CIRM’s website, “stem cells
have incredible potential to treat disease.
Embryonic or iPS cells can turn into any cell
in the body, creating an endless resource for
replacing diseased or damaged tissue. Stem
cells within our own bone marrow, brains,
muscles and other tissues can repair damage
after injury if properly activated. In a lab dish,
stem cells can mimic human
diseases, pointing the way to
new drugs. The challenge in
generating a new therapy isn’t
whether or not the cells can do
the job, it’s understanding the
best way to get the job done.”
After overcoming legal
challenges in 2006, CIRM has
since set up shop. It has made
California home to the rst
clinical trials based on
embryonic stem cells. The
agency has funded the efforts
of more than 450 California
scientists with more than $1.2
billion. It also recently
announced a collaboration
with leading research scientists
in South America. That’s in
addition to existing
collaborations with Canada, the United
Kingdom, Germany, Australia, Japan,
China and India.
All of CIRM’s work has a single goal:
Develop new stem cell-based therapies for
incurable diseases and injuries. Forty-three
projects are now in various stages of progress
toward helping people with chronic diseases
and conditions in California and worldwide.
Because of Proposition 71, we are closer to
obtaining effective therapies if not cures for
chronic, debilitating and costly diseases like
diabetes. And it’s not beyond the possibility to
see patients with spinal chord injuries today
be freed from their wheelchairs and other
connements in their lifetimes.
This is a terric gift to the quality of life for
humankind. And for any naysayers out there,
this investment will do more than all other
interventions combined to reduce the rising
cost of healthcare plaguing our nation.
Op-ed submissions of up to 600 words are
welcomed. Please e-mail proposals to
Payers & Providers Page 5
DESERT SPRINGS JW MARRIOTT, PALM DESERT
Register Now For The
2012 CAPG ANNUAL
Online Registration Ends May 3rd
Join 1400+ attendees
for this comprehensive healthcare event.
Keynote speakers include:
º Founding CE0 of the lnstitute for Healthcare lmprovement, Donald Berwick, M.D.
º Acting Director of the hew America Foundation Health Polic] Program and author, Shannon Brownlee
º Executive Director of the Center for Healthcare 0ualit] and Pa]ment Reform, Harold Miller
For more information or to register, go to www.capg.org/conference2012
IF YOU PLAN TO ATTEND ONLY ONE CONFERENCE IN 2012, MAKE IT THIS ONE!
Payers & Providers
SENIOR HEALTHCARE ANALYST
JOB SUMMARY: This position will support the HCC and
Encounter Team in Health Care Informatics by collecting and ana-
lyzing healthcare related data by performing data management,
quality improvement studies and by conducting statistical analysis
and generating reports for the organization’s decision makers.
ESSENTIAL JOB RESULTS: Support operational needs by
performing complex analyses on a wide range of organizational
data - investigate and uncover root causes, identify trends, etc.
and propose solutions. Achieve results by effectively leverag-
ing expertise in healthcare/managed care data including, but
not limited to, membership, provider, claims, authorizations,
pharmacy, and financial information. Commitment to customer
service achieved through timely, accurate, and supportable
deliverables. Support customer needs for what-if scenario
analysis by developing analytical tools/models. Ensures under-
standing of customer needs by proactively clarifying scope and
requirements and keeps customers apprised of project status
through effective communication. Achieves high-quality deliv-
erables by assuring accuracy and thoroughness in executing
projects. Manages multiple (department) projects by effec-
tively prioritizing work and communicating workload issues to
management. Develops and maintains up-to-date knowledge
of the Data Warehouse and other organizational data sources.
Maintains professional and technical knowledge by attending
educational workshops; reviewing professional publications;
establishing personal networks; participating in professional
societies. Contributes to team effort by accomplishing related
results as needed.
QUALIFICATIONS: Bachelor’s Degree, or equivalent experience
required. 4+ years of proven analysis experience highly pre-
ferred, or 2+ years of proven analysis experience in a Healthcare/
Managed Care environment highly preferred. Ability to effec-
tively interact with, and present findings to customers at all levels
of the organization including operational managers, medical direc-
tors and executives required. Proficiency with MS SQL (queries)
highly preferred. Clinical code knowledge related to claims/utili-
zation highly preferred. Experience with managed care contract
terms/analysis a plus. Experience in a Medicare Advantage envi-
ronment a plus. Experience with MS BI products a plus. Expert
skills in MS Office productivity software, especially MS Excel.
Excellent technical, interpersonal, written and oral communica-
tion skills required. Superior analytical skills required.
FT position, M-F 8 AM to 5 PM, with extended work hours and
possible travel, as needed. Apply to www.scanhealthplan.com –
Job Opportunities – Req. #11-540
MARKET EXPANSION PROFESSIONAL
JOB SUMMARY: Plan, design, and complete processes to
achieve business objectives for network and membership
growth via market expansion. Manage and perform a broad
range of tasks using resources effectively and efficiently to
meet identified timeframes for planned product and service
expansions. This includes coordination of efforts and collabora-
tion with external entities to meet all regulatory requirements
and to ensure market expansion filings are fully compliant and
ESSENTIAL JOB RESULTS: Coordinate and execute complex
tasks related to network and membership growth via market
expansion, in order to ensure the successful completion of
ongoing cycles of work. Utilize detailed work lists to manage
the timely completion of tasks for each phase of a particular
market expansion process and provide necessary updates to
management, escalating risks as appropriate. Develop and
maintain positive relationships with internal departments and
external entities, creating partnerships to achieve program
objectives. Effectively communicate and assign deliverables
and timelines. Monitor and manage the assigned tasks to
achieve timely completion. Monitor quality of tasks per-
formed, develop and recommend process improvements for
implementation. Assure a quality market expansion process
outcome by making sure that each finished task meets the
required level of quality. As needed, troubleshoot issues and
provide innovative solutions, focused on continuous quality
improvement. Maintain professional and technical knowledge
by attending educational workshops; reviewing professional
publications; establishing personal networks; participating in
professional societies. Contribute to team effort by accom-
plishing related results as needed.
QUALIFICATIONS: Bachelor’s Degree required. Preferred area
of study: Business or Health Administration, Management
or Process Engineering. Experience within Healthcare/
Managed Care, preferred. Demonstrated interpersonal skills
with the ability to compromise, persuade, and negotiate,
be well-rounded and have excellent communications skills.
Solid leadership skills, excellent written and verbal com-
munications skills and ability to establish effective working
relationships with many different people, ranging from man-
agers, supervisors, and professionals, to administrative and
support staff personnel. Analytical, detail-oriented, flexible,
and decisive. Ability to coordinate several activities at once,
quickly analyze and resolve specific problems, and manage
deadlines. Ability to work with minimal supervision, so need
to be self-motivated and disciplined. Expert skills in MS
Office productivity software and strong computer skills are
FT position, M-F 8 AM to 5 PM, with extended work hours and
possible travel, as needed. Must maintain valid driver’s license,
automobile insurance and reliable transportation. Apply to
www.scanhealthplan.com - Job Opportunities – Req. #12-612
Page 7 Payers & Providers
Since 1959, Presbyterian Intercommunity Hospital
of Whittier has been committed to building a mutu-
ally supportive health care team consisting of
patient care givers, medical staff, volunteers and the
board of directors that have ensured our local popu-
lation the highest quality of medical services in Los
Our Home Health & Hospice department
is currently seeking an
ASSISTANT DIRECTOR OF PATIENT SERVICES.
The Assistant Director of Patient Services is respon-
sible and accountable for services provided to
patients through Home Health and Hospice. With
direction from the Director of Patient Services, the
Assistant Director will assess and assist the Director
in all areas of operations, compliance, professional
standards and IDS relationship.
Requirements include: Bachelor’s degree in Nursing
or other health-related field. Valid CA RN license;
BLS certification. At least 7 years of experience,
5 of which must be in a home health agency. 3
years of experience in a supervisory or administrative
capacity. Able to direct nursing, therapy and social
work within the framework of regulations to care for
patients while understanding the rationale of rule-
making in the industry. Must have an active interest
in improving current level of skill and knowledge.
Beyond the benefits that come with working for
the area’s leading community health care provider –
one that also recognizes the need to ensure patient
safety and comfort – you’ll enjoy an extremely com-
petitive compensation and benefits package. Plus,
we use team concepts to encourage professional
growth and development.
Please apply online at www.pih.net,
Providence is calling a
SENIOR FINANCIAL ANALYST OF REPORTING,
BUDGETING & PRACTICE ANALYSIS
to Providence Medical Institute, Torrance, CA.
In this position you will: Develop and maintain monthly
financial reporting, prepare the annual budget, and support
Operations management to identify and resolve financial
opportunities in physician practices. The position will also
create, manage and track results of the annual Operating
Budgets. Analyze physician compensation based on RVU
Required qualifications for this position include: 5 to
10 years of experience within a large healthcare organiza-
tion. Bachelor’s Degree in Accounting or Finance. Strong
analytical skills with and expertise in using Microsoft
Office Access, Excel, PowerPoint, & Outlook. Knowledge of
Lawson Financial Software.
Preferred qualifications for this position include:
Physician Compensation Analysis experience. Medical
Providence Health & Services Southern California is further
developing its physician integration strategy. Historically,
the largest asset has been Providence Medical Institute, a
medical foundation that provides administrative and other
support services to affiliated medical groups. Providence
Medical Institute is expected to grow significantly in the
next several years, bringing with it facilities, staff and phy-
sician growth to support that objective.
PROVIDENCE IS CALLING!
For immediate consideration, qualified candidates are
encouraged to apply on-line at www.ProvidenceIsCalling.jobs.
Payers & Providers
It costs up to $27,000 to fill a healthcare job*
will do it for a lot less.
Employment listings begin at just $1.65 a word
Call (877) 248-2360, ext. 2
Or e-mail: email@example.com
Or visit: www.payersandproviders.com
*New England Journal of Medicine, 2004.
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