16 August 2012

California Edition
Calendar
August 19-21
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More E-Savvy For Medi-Cal Plans

L.A. Care, IEHP Roll Out Systems To Cut Costs
Two Medi-Cal managed care plans in Southern California have launched ambitious e-health initiatives both hope will help keep a lid on rising healthcare costs. L.A. Care Health Plan is focused on reducing unnecessary visits to medical specialists, while the Inland Empire Health Plan wants to better manage chronic conditions such as diabetes. L.A. Cares Web-based eConsult portal allows the health plans primary care and specialty physicians to directly communicate within one another, including the sharing of photos and other documentation. That permits more thorough patient evaluations prior to making a referral to a specialist. Pilot project testing of the platform reduced referrals in some specialty categories by as much as 48%. Thats a signicant money-saver, considering an unnecessary referral can cost as much $150 not including any duplicative tests that might occur. It more easily permits consultation with and education from the specialist, said Sajid Ahmed, L.A. Cares director of health IT and innovations. Along with the deployment of the portal, about 350 digital cameras have been sent to L.A. Care providers in order for them to take photos of their patients condition and send them on to the relevant specialist. At the same time, the portal will also help speed up specialty referrals for L.A. Care enrollees who need such a visit, according to Ahmed. The eConsult portal launched earlier this week with connections to L.A. Cares dermatologist and neurologist networks at seven different sites through the county. Both specialty panels receive a high number of patient referrals, according to Ahmed. By the end of the year, eConsult is expected to be available to all L.A. Care specialists via 53 clinic sites including all clinics operated by the Los Angeles County Department of Health Services. DHS is a partner in the project, along with the Community Clinic Association of Los Angeles County, the Health Care L.A. Independent Practice Association and MedPoint Management. L.A. County DHS also offered all encounter data from 6 million patients it has treated at its facilities for insertion into the eConsult system, making it more easy for network physicians to pull up complete medical histories of their patients. eConsult enables our primary care providers and specialists to communicate
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September 9-11
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September 28-30
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STORIES OF ONE HIGHLY LITIGIOUS PHYSICIAN

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NEWS
E-Savvy (Continued from Page One)
directly and manage a patients non-urgent needs without a face-to-face visit, and can shorten the wait time if a specialist appointment is needed, said Alexander Li, M.D., chief executive ofcer of the DHS ambulatory care network. Safety Net Connect, a Newport Beachbased healthcare software rm, supplied the software for both the pilot project and the buildout. The cost of deployment was about $1.5 million, according to Ahmed. At IEHP, about 5,000 enrollees with diabetes have entered into a vital sign monitoring telehealth project intended to better manage diseases such as diabetes. IEHP enrollees will be able to use electronic devices to monitor and gather glucose levels, nutritional intake and other variables. The monitors can interface with electronic gateways installed at the ofces of 600 providers in IEHPs network and be uploaded into a Web portal.

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In Brief
Employer Groups More Focused On Wellness Incentives
A new study by Aon Hewitt concludes that many employer groups are relying on incentives to get their workers to participate in wellness programs. The survey by the Illinois-based Aon of almost 2,000 employers with more than 2 million workers concluded that 51% provide incentives to employees who participate in programs meant to improve their health and wellness. And among those, 59% offer money incentives to their employees, up from 37% in 2011. A total of 58% also offer some form of incentive to their employees who complete lifestyle modication programs, such as to quit smoking or improve their diet. The data strongly suggest that businesses are trying to grapple with increasing healthcare costs associated with diseases such as adult onset diabetes, which is almost always linked to obesity. Employers know that eight health behaviors, including risks such as lack of physical activity and failure to complete recommended preventive screenings, drive 15 chronic conditions that lead to higher medical costs and increased absence from work, said Stephanie Pronk, a clinical health improvement leader Aons health and benets division. However, some disconnects between employers and employees remain entrenched. Although more than 80% of those rms surveyed supply a questionnaire to their employees to query them about their overall health, fewer than 10% offer an incentive to directly address the responses that are supplied.

The caregiver can set ranges with alarms on it that will automatically notify (them) if the patients data is out of range and hopefully avoid an ER visit, said Bret Morey, director of marketing for ForaCare, the Newbury Park-based rm that is providing the hardware and monitoring services to IEHP. Various studies suggest that the cost of treating unmanaged diabetes is more than eight times higher than keeping it under control. An IEHP spokesperson declined comment about the project, saying it was still in its initial stages and we are working through processes. L.A. Care provides managed care to about 1 million Medi-Cal, SPD and Healthy Families enrollees in Los Angeles County. IEHP provides the same coverage to about 540,000 lives in Riverside and and San Bernardino Counties.

Investment Dip Hits Kaiser Earnings

Net Income Down Double Digits For Quarter
Kaiser Permanente reported a bump upward in revenue and enrollment for the second quarter ending June 30, but its overall net income was down by 22%. Revenue for the Oakland-based hospital and health plan operator reached $12.6 billion for the quarter, up 6% from the $11.9 billion in revenues reported during the second quarter of 2011. Total net income was $514 million, compared to $663 million for the year-ago quarter. Kaiser spokesperson Laura Dunn attributed the dip to the organizations investments. Our non-operating income comes from our investment portfolio and consists of a broad array of xed income and equity products. These are subject to the volatility and uctuations in the market, as any investment would be, Dunn said in an e-mail. For the second quarter, the Dow Jones Index is down 2.5% and the Standard & Poors Index is down 3.25% our investments tend to mirror this. By contrast, operating income was up 8.1% for the quarter, reaching $424 million, compared to $390 million for the second quarter of 2011. Kaiser has spent $1.6 billion on capital investments during the rst half of the year, up from $1.4 billion during the rst half of 2011. The system has opened 13 new and replacement hospitals and 75 medical ofce buildings over the past ve years. Systemwide enrollment grew by 87,000 since the start of 2012, and is now 9 million.

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DOI Puts $1.7M Toward Fraud Fight

Grants Will Focus on Health, Disability Scammers
The California Department of Insurance has granted $1.7 million to county-level prosecutors for combating what it says is an increasing number of health and disability frauds. The grants went to six mostly urban counties in Northern and Southern California, including Los Angeles, Orange and San Diego Counties. They range in size from just over $106,000 to more than $611,000. Californias strained economy has resulted in an increase in insurance fraud schemes. Local district attorneys often have fewer resources at their disposal to ght fraud, said California Insurance Commissioner Dave Jones. These additional funds will assist district attorneys across the state in the ongoing ght to combat these types of fraud. Insurance Department spokesman Dave Althausen noted that most of the frauds seen by his ofce have been carried out by individuals, primarily seeking to collect payments from disability or workers compensation insurers. He added that occasionally there is fraud involving medical groups or other providers. The Obama Administration has said that Southern California is one of the nations hotspots for healthcare fraud. The U.S. Department of Health and Human Services has held two workshops in the region on the topic since 2010. Federal prosecutors have also announced numerous arrests in California, primarily providers submitting bogus claims to the Medicare program. The Department of Insurance collects money for the grants in the form of a 10-cent per person assessment for every individual enrolled in a group health or disability plan, collected from paid premiums. Legislation is currently pending that would increase the current 10-cent-per-person assessment to 20 cents, DOI ofcials said. According to DOI data, every $1 it contributes toward fraud initiatives leads to $94 worth of prosecutable charges.

In Brief
DMHC Takes Control Of Dental Plan
The Department of Managed Health Care has seized the assets of an Arcadia-based dental plan. The DMHC also appointed a conservator for American HealthGuard Corp., which also operates as CentaGuard Dental Plan. It provides both commercial and Denti-Cal coverage. The DMHC took action on Aug. 10. According to DMHC documents, American HealthGuard had failed to maintain sufficient capital since 2009, and had a total capital deficiency of more than $400,000 in August 2011. The plan also failed to meet minimum tangible net equity requirements. In March, it met positive cash flow requirements only by failing to pay its insurance and capitation fees to providers. Enrollment in the plan has tumbled from more than 24,000 three years ago to less than 17,000 last spring. The plan also failed to make monthly reports to the DMHC, which the agency required about a year ago.

Accountable IPA Issues Statement

Response to DMHCs Cease And Desist Order
A Signal Hill IPA ordered by a state regulator to stop using non-medical professionals to make prior authorization care decisions for patients has simultaneously defended its conduct while saying it is trying to resolve the matter. The Accountable Health Care IPA initially did not respond to repeated requests for comment from Payers & Providers prior to its reporting on Aug. 2 about the Department of Managed Health Cares cease and desist order. That order was issued to Accountable and nine health plans it contracts with, including Blue Shield of California and Anthem Blue Cross of California. According to the order, Accountable Care was using two non-medical professionals, including the son of its chief executive ofcer, George Jayatilaka, M.D., to make such determinations. Since the initial report, which was also reported on Aug. 6 by the investigative website California Watch, Accountable has retained Sitrick And Co., a Los Angeles public relations rm known for its crisis PR acumen. All medical necessity decisions at Accountable Health Care are made by a licensed California physician in compliance with state law, George Jayatilaka said in a prepared statement issued by Sitrick. While the nal decision is the physicians, other competent healthcare professionals also participate in the review process. This has been our practice for many years, and it is the process used by many other independent practice association service providers. The statement added that we have met with the Department of Managed Health Care and explained our process. And we will continue to work with the department on any revisions to our process that will assure the department of Accountables continued compliance with all applicable laws and regulations.

Kaisers Farmers Markets Top 50

Kaiser Permanente, which has encouraged the growth of farmers markets as a way to promote healthier lifestyles, has recently opened its 50th market nationwide. The latest market is being operated outside of Kaisers Oakland headquarters weekly. Kaiser has also opened markets throughout California and in Ohio, Maryland, Hawaii, Oregon and Maryland. We are thrilled that our markets are thriving and expanding, said Preston Maring, M.D., a Kaiser physician who helped conceive the project about a decade ago.

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Payers & Providers

OPINION

Page 4

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Joining An HIE Without Hitting The Wall

These Tips Can Make a Tricky Implementation Easier
applications can improve communication with Many healthcare organizations are faced IT staff, vendors, and other healthcare leaders. with the challenge of multiple information For example, there is a difference between a technology systems, including disparate clinical data warehouse and a health electronic health records, practice information exchange. The two concepts, management applications, clinical and however, are interrelated, as an HIE can be a nancial decision support applications, major supplier of data to a clinical data document repositories or registries, and warehouse. Both types of software might even more. be marketed, sold, and implemented together, In lieu of standardizing all the thus confusingly appearing as one solution. applications onto complimentary platforms, many organizations choose to implement Integrate Organizational Silos. While building enterprise software to exchange data consensus and buy-in is important, do not let between different systems, part of a health the desire for decision-by-committee supersede information exchange. It is a growing niche the need to integrate all organizational within the larger health information initiatives that need to leverage the HIE. It is technology industry segment. common advice to nd champions for IT For organizations that have decided to projects when strong supporters are identied implement an HIE, there are roles and and promoted, they work to help By responsibilities for many staff groups shepherd along initiatives. Crossboth in and out of the IT department. Wren Keber pollinate initiatives with champions Executive leadership has the ultimate that sit on multiple committees, so responsibility to ensure the success of the that one group can communicate their needs implementation and reduce complications and priorities with others. For major initiatives, which may be paramount given the convene a steering committee overseeing investment of human and nancial resources multiple initiatives that will use the HIE. involved. Here are four high-priority Think Big, Start Small. There are grand recommendations to avoid common pitfalls possibilities to conceptualize when IT systems during this major endeavor: work together through an HIE. The big picture Take Inventory. An important task that's outcome for an HIE implementation is to often skipped at the beginning of an HIE enable a vibrant network of users circled implementation is to take inventory of all the around high-quality and accessible clinical data systems in the organization. Ensure that data, no matter where it is stored. Healthcare the chief information ofcer or HIT staff organizations can realize efciencies, report on creates an authoritative and comprehensive quality indicators, and improve accessibility list of what systems exist throughout the and accountability of clinical data. Thinking organization. In addition to documenting outside the physical walls of a hospital or major known systems, it is good practice for practice, there are positive implications in the the CIO or IT staff to interview key community with afliates, owned practices, stakeholders who will use the HIE. emergency service providers, and more. The Stakeholders will have knowledge of any possibilities can be daunting, so grounding the "workaround" systems, data repositories, or vision with a dose of reality keeps project system peculiarities adapted for their own scopes in-check, resulting in small wins that specialized reasons. For example, if a build consensus and lead to a larger, more practice management platform does not sustainable success. support a custom billing code, ofce staff may have created an alternative database to Wren Keber is a manager with The Camden track it, and thus ultimately that nancial Group, an El Segundo-based healthcare data might not be available through the HIE. consulting firm. These interviews are also prime territory to build consensus. Learn the Lingo. While technical terms may be frustrating and difcult to grasp, learning the differences between major classes of
Op-ed submissions of up to 600 words are welcomed. Please e-mail proposals to editor@payersandproviders.com

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