27 September 2012

California Edition
Calendar
September 28-30
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IHA Cites Medical Groups For Quality
47 Get High Marks For Health IT, Patient Experience
The Integrated Healthcare Association has issued its list of best-performing and most improved medical groups as part of its ongoing pay-for-performance initiative. Altogether, 47 medical groups were cited by the IHA – about one-quarter of the organizations that participate in the program. It was a slight improvement from last year, when 44 groups were cited. The medical groups were ranked in three specic areas: meaningful use of health IT, the overall care experience from the patient’s point of view, and clinical measures that focused on cardiovascular, diabetes, musculoskeletal, respiratory, and preventative health. Those ranked as “top performers” had scores based on the top 25% score for each measure. The data for the rankings were compiled for 2011. Many of those cited have long been among the IHA’s top performers, including Cedars-Sinai Medical Group, Monarch Healthcare, the Sharp Rees-Stealy Medical Group, the Palo Alto Medical Foundation, the Sutter Medical Group, and Brown & Toland Physicians. “Brown & Toland has emphasized providing the correct preventative measures at the right time, to both keep our patients healthy and reduce the overall cost of health care,” said Brown & Toland’s Chief Medical Ofcer, Andrew Snyder, M.D. “We also emphasize, and will continue to stress, improving the patient experience and providing our physicians with the electronic tools they need to improve care.” Groups new to the list included the MemorialCare Medical Group in Long Beach, Monarch Healthcare in Orange County, and Primary Care Associates Medical Group in Vista. Groups that dropped off the top performer list included Hill Physicians Medical Group in the Bay Area and Solano Regional Medical Group in Faireld. Eight groups also received “most improved” designations. They include CedarsSinai, Woodland Healthcare near Sacramento, St. Joseph Heritage Medical Group in Orange County, and Central Valley Medical Group in the Modesto area. Starting in 2013, the IHA will change its pay-for-performance methodology to include healthcare costs and use of resources in its evaluations. “Value-based pay-forperformance is a key step in holding organizations responsible for both the quality and cost of care delivered to their members, and is aligned with the national movement toward accountable care organizations,” the IHA said in a statement. The medical groups receive incentive payments from seven different health plans that participate in the pay-for-performance initiative. IHA said the payments are expected to total about $40 million this year. Over the past decade, the payments have totaled about $410 million.

October 11-12
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October 15-17

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WEBINAR

Thursday, October 25, 2012

10 A.M., PDT

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.

MEDI-CAL EXPANSION: 2014 AND BEYOND
Please join Lucien Wulsin, Executive Director of the Insure the Uninsured Project, and Elizabeth Benson Forer, CEO of the Venice Family Clinic, to discuss the challenges of Medi-Cal expansion under the ACA.

http://www.healthwebsummit.com/pp102512.htm a HealthcareWebSummit Event co-sponsored by PAYERS & PROVIDERS

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Payers & Providers
Top Placement... Bottomless Potential

NEWS

Page 2

Health Net Sued Again Over Denials
Plaintiffs’ Attorney Won Huge Judgment in 2008
An attorney who scored a $9 million arbitration victory against Health Net in 2008 has sued the insurer again, claiming it illegally denied care to two of its enrollees. Attorney William Shernoff’s suit has also been joined by the Los Angeles County Medical Association. It was led Sept. 12 in Los Angeles County Superior Court and claims Health Net abused the denition of medical necessity in order to deny care for treatment it should normally authorize. “This is a huge problem for thousands of policyholders who are routinely refused coverage for necessary medical procedures, like surgery, leaving patients holding the bag for medical bills,” said Shernoff, who practices in Claremont. According to the suit, Health Net denied enrollee Robert Mendoza a robotic procedure to treat his cancer at USC Norris Cancer Hospital because it was not medically necessary. Kalana Penner, another Health Net enrollee, was also denied care for her occipital neuralgia at Stanford Hospital & Clinics. Their treatments had been recommended by top clinicians at both facilities, according to the lawsuit. “Health Net continues to employ this same unlawful medical necessity standard to other insured’s (sic) throughout California as a matter of corporate practice…the good and trusting relationship between physician and patient becomes strained…defames the reputation of the doctor and interferes with the relationship between physician and patient,” the lawsuit said. Health Net did not comment on the lawsuit directly in a prepared statement. Instead, it said that it “strives in all cases to ensure our members receive the appropriate access to necessary medical care. Medical care is complex, and sometimes there are differing medical opinions as to what constitutes medically necessary care. In these instances, Health Net carefully follows the guidelines established by the state of California’s two regulators, the Department of Managed Health Care and the Department of Insurance. “These regulatory procedures provide a ready path for members to seek review of Health Net decisions by medical professionals who are not afliated with Health Net. If the independent, expert reviewer determines that the desired treatment is medically necessary, then Health Net covers it.” Shernoff won a $9 million judgment in arbitration against Health Net in 2008 for enrollee Patsy Bates, whose individual policy had been terminated after she was diagnosed with breast cancer. Bates faced $129,000 in medical bills and had to suspend her chemotherapy for months until she could nd a provider who would furnish it for free. A retired Los Angeles County Superior Court judge ruled Health Net had broken state law and had acted in bad faith. During the hearing, it was disclosed Health Net had paid bonuses to employees who had cancelled policies. $8.4 million of the judgment was comprised of punitive damages. The binding award so impacted Health Net’s net prots that it had made mention of it in a quarterly ling with the Securities and Exchange Commission. "Once again, we see a health insurance company putting prots ahead of patient health and lives," said LACMA Chief Executive Ofcer Rocky Delgadillo, a onetime Los Angeles City Attorney, of the latest lawsuit. “By deciding which medical treatments are necessary and which ones it will cover, Health Net is dictating medical care from the boardroom. Patient care should be decided by doctors, not business suits.”

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In Brief
Wells Fargo Says Employee-Sponsored Claims Costs Will Rise Next Year
A survey by San Francisco-based broker Wells Fargo Insurance concludes that claims costs among employer-sponsored insurance plans will rise substantially during the coming year. According to the survey, which included more than 70 insurers nationwide, costs had remained stable this year, but are projected to rise into the high single digits in 2013. Indemnity claims costs are projected to rise 10.2%, PPOs, 9.3%, HMO costs, 8.5%, and prescription plans, 7.6%. “Despite ongoing efforts to control healthcare expenses the survey found that insurers are not expecting a drop in claim costs for 2013,” said Dan Gowen, senior vice president of Wells Fargo Insurance’s national employee benefits practice. “This means that employer premiums will likely rise, and it’s also likely consumers may pay more for their share of employer-sponsored healthcare plans.” Wells Fargo conducted the survey between July and August 2012.

El Camino Makes New Pact With Nurses
El Camino Hospital in Mountain View has come to terms on a new contract with the union that represents its registered nurses. The agreement with the Professional Resource for Nurses

MEET YOUR FELLOW READERS
Need to promote a conference? Your brand? Payers & Provider!s e-mail list for all editions is available for your marketing needs. Reach out to more than 12,000 healthcare professionals who read our publications. Call Claire Thayer at (877) 248-2360, ext. 3 or e-mail her at clairet@mcol.com.

Continued on Page 3

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Payers & Providers
Longer ALOS!*

NEWS

Page 3

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OSHPD Awards $2.9M To Train Docs
The Grants Will go to Family Practice Residencies
The Ofce of Statewide Health Planning and Development has awarded 29 grants to family practice residency programs around California in an effort to boost the number of primary care physicians in the state. The grants, which average just under $100,000, range from $51,615 to $206,460. Recipients include UC Davis, Harbor UCLA Medical Center, Kaiser Permanente’s San Diego hospital, and Pomona Valley Hospital. The grants, which were awarded as part of the agency’s Song-Brown training program. OSHPD also funds nursing, nurse practitioner and physician assistant training through SongBrown funding. The money is collected through fees levied on California’s hospitals. According to data from the California Medical Association, nearly three-quarters of California’s 58 counties currently have a shortage of primary care physicians. The shortage is expected to be exacerbated as the state’s population continues to simultaneously grow and age. And while more than 60% of those physicians who have their residency in California choose to practice in the state, only 41% of California residents who choose to become doctors can obtain a medical education in-state.

In Brief
includes a bump in matching payments for the 403(b) retirement plan and a 12% increase in the accrual of paid time off. El Camino ofcials also said they would work with PRN and another workers union, the Service Employees International Union, to create an employee wellness initiative. “We look forward to increased partnership in the coming year on the hospital's wellness initiative that will enable our nurses to participate in a variety of health screening and wellness programs,” said Tomi Ryba, El Camino’s chief executive ofcer.

Breast Cancer Risks Downplayed
Kaiser: Most Treatable Form More Likely to Recur
A study undertaken by Kaiser Permanente’s Southern California division indicated that breast cancer patients were still in danger of dying from the disease a decade after being diagnosed, no matter how mild their original form of cancer. Kaiser studied 1,000 of its breast cancer patients in Southern California, focusing on the disease at the molecular level. It concluded that those with luminal A tumors – considered the type of cancer with the best prognosis for treatment and survival – were still at risk for a recurrence of the disease 10 years after their initial diagnosis and treatment. About half of all breast cancer victims have this type of cancer. Those with a more aggressive form of breast cancer – HER2-enriched – continued to have an elevated risk of a recurrence. “The ndings of this study indicate that it is important to consider breast cancer molecular subtypes in determining the optimal treatment,” Reina Haque, of Kaiser’s Department of Research & Evaluation and the study’s lead author. “Women with luminal A tumors could benet from extended treatment to improve their chances for long-term survival. It is important for women with breast cancer, even those diagnosed with the leastaggressive form of the disease, to be an advocate for their own health and speak to their doctors about treatment options.” Another Kaiser-funded study indicated that women who underwent partial mastectomies had lower rates of follow-ups with their physicians than those who underwent more radical forms of the surgery, potentially putting them at a higher risk for a recurrence. The study’s ndings were published in the most recent edition of the journal Cancer Epidemiology, Biomarkers & Prevention.
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Apollo Medical, L.A. Care Enter Into Deal On Hospitalists
Glendale-based Apollo Medical Holdings has signed a contract with Medi-Cal managed care insurer L.A. Care Health Plan to provider hospitalist services to its enrollees. The pact will place hospitalist physicians from Apollo afliate ApolloMed Hospitalists in some 22 hospitals in Los Angeles County – all facilities where hospitalist services are currently unavailable. The pact’s value was not disclosed. The use of a hospitalist – a physician who monitors inpatients to ensure they receive appropriate and coordinated care – is generally considered to accrue cost savings due to quicker discharges. However, some studies have suggested some patients who receive hospitalist care are more likely to be readmitted. “The addition of L.A. Care to our growing list of health plan clients is further validation of the success of our unique integrated medical management model. We are leaders in providing measureable results for our customers through new and innovative approaches to health care,” said Apollo Medical Chief Executive Ofcer Warren Hosseinion, M.D.

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Payers & Providers

OPINION

Page 4

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EHRs Increase Medicare Revenue
They Are Particularly Useful Navigating E&M Coding
The healthcare world is abuzz with The New • Documentation by Exception – Every EHR York Times revelation that Medicare billing has this feature allowing the documenter to rates seem to have increased by billions of click on one box usually at the top of the dollars in parallel with increased adoption of page which generates a professionalEHR technologies for both hospitals and sounding clinical sentence for each organ or ambulatory services. body part. If something is wrong with one or The culprit for this unexpected increase is two organs, the clinician can click the the E&M code. normal button and then edit the organs that Evaluation and Management is the are affected, obtaining documentation for a portion of a medical visit where the doctor complete review or examination. listens to your description of the problem, • Pre-lled Templates – These go by different takes a history, asks about social habits and names, but they are a huge time saver for circumstances, lets you describe your simple and common problems. Say you symptoms as they affect your various body have a URI patient and document the visit parts, examines you and proceeds with starting from a blank template, use all the diagnosing and treating the condition. previously described efciencies and The more thorough this evaluation generate a visit note for this patient. and management activity is, the EHRs will also load the patientBy more complicated your problem is, Margalit Gur- specic histories and merge them the more diagnostic tests are into your brand new note Arie reviewed, and the more counseling automatically. Two or three clicks the doctor gives you. will get you enough documentation Medicare has specied exactly how to to allow your EHR to calculate a very nice measure a doctor’s thoroughness by creating E&M code and generate enough ve levels of visits. Each level’s complexity is documentation to keep the payers at bay. dened in terms of an exact number of • Bring Forward – This works for complex questions a doctor asks, and an exact number patients with chronic disease that come to of organs and body parts that are addressed see you every few months or so. Not much during a visit. The more sanctioned questions changes in a few months and most likely and body parts are addressed, the more everything you will be documenting today is money the doctor gets from the payer. exactly what you documented six months During paper days, no physician would ago. Instead of starting from scratch every go to the trouble of actually writing down all time, EHRs make it possible for the these largely irrelevant things; most doctors documenter to load the previous visit note practiced “defensive billing” and consistently and edit and make changes based on today’s charged less than they should have. visit. Enter electronic medical records. There are other features in most EHRs that Before HITECH and meaningful, EHR are designed to improve reimbursement. vendors promised doctors an automated way Administrative functions embedded in larger of documenting a visit, so they would not EHRs allow physicians’ employers to ensure have to constantly write things down. Instead, that the docs click on all the necessary things a click on a couple of boxes would do that to ensure optimal billing and payment. for them. Furthermore, physicians won’t have So the “unintended consequences” of pushing to waste money on expert coders to go physicians to use EHRs seem to consist of through their scribbled notes and gure out a doctors actually using EHRs to document all visit level. The software will automatically the little details Medicare wants to see. calculate the appropriate E&M code, based on boxes clicked. Margalit Gur-Arie is the COO of GenesysMD, To make the entire process most efcient, an HIT company focusing on web-based EHR/ three methods of documentation have been PMS and billing services for physicians. developed to replace handwriting and to efciently minimize the need for extensive Op-ed submissions of up to 600 words are box-clicking:
welcomed. Please e-mail proposals to editor@payersandproviders.com

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Payers & Providers

MARKETPLACE/EMPLOYMENT

Page 5

eCONSULT PROJECT MANAGER
L.A. Care’s Safety Net eConsult Program is seeking a dynamic PROJECT MANAGER to manage the 18-month eConsult program implementation in Los Angeles County. The Safety Net eConsult Program is a project in which L.A. Care is the lead and in collaboration with MedPoint Management and the L.A. County Department of Health Services to implement eConsult technology in Los Angeles county’s safety net community clinic community. eConsult in this context is a primary care to specialist communication or messaging to increase efficiency and create additional capacity for specialist offices. The eConsult Project Manager will work closely with L.A. County Department of Health Services in this county wide effort as well as other stakeholders during this project. ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned: • Creates and executes project work plans and revises as appropriate to meet changing needs and requirements. • Identifies resources needed and assigns individual responsibilities. • Manages day-to-day operational aspects of a project and scope. • Effectively applies project methodology and enforces project standards. • Prepares for engagement reviews and quality assurance procedures. • Minimizes exposure and risk on project. • Ensures project documents are complete, current, and stored appropriately. • Motivates team to work together in the most efficient manner. Keeps track of lessons learned and shares those lessons with team members. • Leads internal teams/task forces. • Suggests areas for improvement in internal processes along with possible solutions. • Performs other duties as assigned.

HEALTH INFORMATION TECHNOLOGY (HIT) PROGRAM MANAGER
As the nation’s largest public health plan, we are dedicated to helping Los Angeles County residents obtain health care for their families from doctors and health care providers. L.A. Care Health Plan is a community-accountable health plan that serves over 1 million Los Angeles County residents through four free or low-cost health insurance programs: Medi-Cal, Healthy Families, L.A. Care’s Healthy Kids. And L.A. Care Health Plan Medicare Advantage HMO. The Health Information Technology (Health IT) Program Manager will have responsibility for strategic planning and project management of technology enabled initiatives to improve clinical quality and operational outcomes for L.A. Care’s members in accordance with the Health IT strategic plan and federally supported project workplans. The Health IT Program Manager will lead in developing and overseeing project plans as well as the technical and analytical infrastructure necessary to miximize the use of health information technology and telehealth and effectively utilize the data to improve patient health outcomes and obtain available marketplace incentives. This position will have a key role in the development, project management and delivery of Health IT adoption and implementation support services to L.A. Care’s members and providers and will serve as liaison with HITECH-LA, working closely with their technology staff on statewide health IT issues and initiatives. The Health Program IT Manager will directly manage the collaboration across the Health Services department and other departments in coordinating Health IT programs. QUALIFICATIONS: Bachelor’s degree in related field required, Master’s preferred. PMP certification preferred. Minimum of 7 years of experience in health care information systems and project management. Primary Health Care services experience, Safety-Net and public health provider knowledge a plus. Knowledge of EHR systems and practice management. Knowledge of current healthcare landscape and awareness of existing and emerging state and national Health IT initiatives. Excellent communication (verbal and written) and presentation skills. Must possess excellent computer skills, particularly with all Microsoft Office applications, including Word, Excel, Access, PowerPoint and Outlook. Excellent client/ customer service orientation. Ability to deal effectively with a variety of people and work in a team environment. Ability to multi-task, priortize and work under deadlines. Must be detail oriented. Public Health and Safety-Net provider knowledge a plus. Qualified candidates please apply to clefebvre@lacare.org

QUALIFICATIONS: Bachelor’s degree in related field with a minimum of ten years experience in health care field and project management required. Project Management Certification preferred. Primary Health Care services experience, Safety-Net provider knowledge a plus. Knowledge of EHR systems and practice management. Knowledge of current healthcare landscape and awareness of existing and emerging state and national HIT initiatives. Excellent communication (verbal and written) and presentation skills. Must possess excellent computer skills, particularly with all Microsoft Office applications, including Word, Excel, Access, PowerPoint and Outlook. Excellent client/customer service orientation. Ability to deal effectively with a variety of people and work in a team environment. Ability to multi–task, prioritize and work under deadlines. Must be detail oriented. Preferred: History of EHR coordinating/training/implementation. Clinical experience in medical practices. Qualified candidates please apply to clefebvre@lacare.org

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Payers & Providers

MARKETPLACE/EMPLOYMENT

Page 6

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*New England Journal of Medicine, 2004.

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