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Michigan Gov. Rick Snyder unveiled a
comprehensive program for health
improvement in his state last week that
underscores the responsibility of residents to
take better care of themselves.
In a 12-page plan released Sept. 14, the
freshman Republican
governor reminded
Michiganders to practice
four key healthy behaviors
diet, exercise, doctors
visits, and dont smoke
and linked the absence of
those behaviors to health
expenses. Costs from
coronary heart disease are
more than $5.9 billion a
year in Michigan, he pointed
out, and treatment of heart
disease consumes one out of
every six dollars spent.
At the same time, the
governors ofce released a
dashboard of 20 leading
health indicators, showing
whether Michigan was
experiencing a favorable or
unfavorable trend, depending on whether the
arrow is pointing up or down.
Childhood immunizations have increased
from 90.6% to 93.7% in the state, but obesity
among the adult population also rose from
30.3% to 31.7%. The number of primary-care
physicians per thousand residents is rising, an
upward turned arrow, while attempted suicide
is also going up, earning a downward arrow.
The governor said he strongly supports
establishing a health insurance exchange that
will emphasize free market principles and
serve as a competitive
marketplace. He is asking the
legislature to enact enabling
legislation to create the MI
Health Market-place so that the
federal government doesnt
impose a one size ts all
approach, as it is allowed to do
under the Affordable Care Act
in those states that dont create
their own exchanges.
Overall we are encouraged
by what we heard, said Kevin
Downey, spokesman for the
Michigan Hospital Association.
There were so many specics.
The emphasis on personal
responsibility for individuals
health, thats something we
tremendously support.
Rick Murdock, executive
director of the Michigan Association of Health
Plans, said that if implemented wisely, the
governors plans could help control costs and
increase access to high quality medical care
C<D'!F(22!F-*1E !
November 14-16
October 5
20 September 2011
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Michigan Governor Looks at Health
Snyder Asks Residents to Monitor Their Indicators
Continued on Next Page
Rick Snyder
Governor of Michigan
Payers & Providers Page 2
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In Brief
Alexian Brothers
of Chicago now
Belongs to Ascension
Alexian Brothers Health System will
become part of Ascension Health, the
largest Roman Catholic healthcare
system in the country.
Alexian Brothers is a Catholic
system based in Arlington Heights, Ill.
It operates three hospitals in the
northwest suburbs of Chicago, plus
two mental health centers. It has a
number of afliated primary care
ofces and immediate care centers.
Alexian Brothers also operates nursing
homes and rehabilitation services in
Missouri, Tennessee, and Wisconsin.
Ascension, based in St. Louis,
employs more than 113,000 people in
1,200 locations in 20 states plus the
District of Columbia.
The signing of a denitive
agreement to become part of
Ascension Health is a signicant step
forward in the evolution of Alexian
Brothers Health System, said Mark
Frey, executive vice president of
Alexian Brothers.
The two health systems announced
their letter of intent in April. The
agreement must now be reviewed by
the Illinois Health Facilities and
Services Review Board. Terms of the
acquisition have not been made
Monthly Premiums for
Michigan High-Risk
Pool to Drop 10%
Michigan will reduce the monthly
premiums in its high-risk pool by 10%
after the federal government approved
a request to ease the process of
documenting a pre-existing condition.
The states Health Insurance
Program, or HIP, was created after
passage of the Affordable Care Act last
Continued on Page 3
Snyder (Continued from Page One)
plans could help control costs and increase
access to high quality medical care for
Michigan families.
The association supports the governors call
for an insurance marketplace that does not
add bureaucracy or complexity to the
Murdock especially liked Snyders proposal
to review the operations and regulations
governing Blue Cross and Blue Shield of
Michigan. The statute under which the
Michigan Blues operate is 30 years old.
Blue Cross belongs to you and me, as a
charitable trust established for Michigans
residents, the governor wrote in his message.
It is time to take a fresh look at the way Blue
Cross operates and is regulated.
The existing law gives the company
signicant advantages over other health
insurers in the state, Murdock said. The
company has used those advantages to gain
market dominance and is now a defendant in
a federal anti-trust case concerning its hospital
contracting practices.
Blue Cross Blue Shield declined to
comment for this article. The company is not a
member of the health plan association.
Snyder, 53, was elected last November
with 58% of the vote. He made his career as a
tax accountant with the former Coopers &
Lybrand and later was an executive with
Gateway, the computer manufacturer. He
became a venture capitalist in 1997, based in
Ann Arbor. This is his rst elective ofce.
When Snyder ran for governor, Downey
said, he actually had a comprehensive
document like this that he developed during
his campaign. He seemed to be in touch with
these topics. He dealt with healthcare funding
and a lot of different issues. Even that was
impressive. He has lived it out.
Peter D. Jacobson, a professor of health
law and policy at the University of Michigan
School of Public Health, was not so sanguine.
Its pretty ho-hum, he said. Its not
particularly bold. It does not push boundaries.
There is nothing about delivery change,
payments change, how were going to deal
with the access issues the state will face.
Jacobson liked the emphasis on prevention
and wellness but regretted that the governor
cannot do anything but exhort the citizenry to
take better care of itself.
One thing is clear: there is no money to
allocate toward achievement of these public-
health goals.
The governor also wants to take a hard look
at professional regulation of medical
practitioners. Pointing out that the state now
has 25 health profession licensing boards and
task forces, up from 17 a few years ago, he
wants to make sure that we are not
excessively regulating our health
The looming shortages of skilled health
professionals also drew his concern,
especially since if the health reform law is
allowed to go into effect as passed, the states
expected shortage of 4,400 to 6,000
physicians by 2020 could well quadruple.
The provision of insurance to the previously
uninsured population is expected to cause
demand for primary-care services to surge.
Snyder advocated the use of physician
extenders, such as advanced practice nurses
and physicians assistants.
With the collapse of the automobile
industry, Michigans economy has been on the
ropes for the past few years. Theres little
prospect that the state will feel ush again any
time soon.
To ease the scal burden, Snyder would
like to examine the alter the way dual eligibles
are cared for. The state has 205,000 residents
who are eligible for both Medicare and
Medicaid, who comprise about 12.5% of the
Medicaid population and consume $7.5
billion in health spending. They should be
moved from an uncoordinated fee-for-service
environment into a coordinated managed-care
environment, Snyder said.
The governor reserved a lot of his attention
to the problem of obesity. Michigans adult
obesity rate, 31.7%, is now eighth in the
nation, and 12.4% of its young people are
now obese.
To ght this trend, the governor has
directed the schools to improve nutrition
available to students. He has asked the
Department of Community Health to record
and report body mass index as part of the
Michigan Care Improvement Registry, which
tracks childhood immunization records.
Determining BMI is an important rst step in
managing pediatric obesity, the governor
noted. The proposed rule would apply only to
children under 18, but the governor wants to
expand the registry to cover all persons in the
A summit to discuss the obesity epidemic
will convene in Lansing, the state capital, on
Sept. 21.
Page 3
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In Brief
year. It is a bridge for people with pre-
existing conditions to obtain federally-
subsidized health insurance before
2014, when the full provisions of the
act come into effect.
People who apply to HIP Michigan
can choose among three options,
having deductibles of $1,000, $2,000,
or $3,500.
When new premium rates become
available Oct. 1, a 45 year old person
could pay $191 monthly for a $3,500
deductible; $227 monthly for a
$2,500 deductible, or $315 for a
$1,000 deductible. A person who is
19 would pay $103.
Under the new rules, applicants
will have to have been uninsured for
at least six months.
Michigans HIP plan had 565
enrollees as of Sept. 1, the majority of
whom are older than 45. The states
eventually hopes to cover 3,500
RAC Program for
Medicaid is Finally
Published by CMS

The Centers for Medicare and
Medicaid Services is stepping up its
enforcement of Medicaid fraud by
introducing a rule that it estimates
should save $2.1 billion in taxpayers
funds over the next ve years.
We simply cant afford to see
even one penny of our healthcare
dollars wasted and expanding this
program will help us reach that goal,
said Health and Human Services
Secretary Kathleen Sebelius.
The introduction of the rule on
Medicaid Recovery Audit Contractors
(RAC) is modeled after a similar
initiative applying to Medicare.
About $900 million should be
returned to the states, according to a
statement from HHS.
The rule implements section 6411
of the Affordable Care Act. It explains
how states can expect to pay their
share of the startup costs and
maintenance of the program.
It will take effect Jan. 2.

A coalition of businesses in Missouri and
Kansas announced it has avoided about $11
million in direct healthcare costs by giving
employees and dependents access to value-
based benets.
Fifteen employers participated in the three-
year program that gave insured employees
access to better health information, reduced
barriers to preventive care, and arranged
earlier treatment of chronic conditions.
The project was led by the Mid-America
Coalition on Health Care and involved
roughly 400,000 people in the Kansas City
metropolitan area. The employers altered their
benet designs to align incentives with
behaviors that reduced health risks, promoted
preventive care, and encouraged better health.
They relied on evidence-based practices.
In one year, nine employers, with 56,000
employees, reduced spending per employee
by $194 by concentrating on chronic diseases.
About half the employers charged lower
premiums to workers to completed a health
risk assessment, getting an annual physical,
quitting smoking, or losing 5% of their body
All the employers added healthy eating
options at the work place and nine out of 10
offered an onsite health club to raise physical
activity levels among workers.
About six out of 10 employers waived
prescription copays for for people enrolled in
chronic disease management programs.
Companies participating in the program
included Sprint, Hallmark Cards, H&R Block,
Cerner Corp., and American Century
Several large healthcare employers also
took part, including St. Lukes Health System,
Childrens Mercy Hospitals & Clinics, Blue
Cross Blue Shield of Kansas City, and the
American Academy of Family Physicians.
The Missouri state ofcial who signed off on the
contract to hire SynCare LLC to evaluate
Medicaid eligibility later ended up working for
the company, the St. Louis Post-Dispatch
reported last week.
Christine Larsen, who was chief of the
Bureau of Program Integrity, was one of four
ofcials who looked at the 11 submitted bids to
service homebound disabled people in
Missouri. SynCare was chosen because it
offered a price much lower than the other
bidders, state ofcials said.
The states $5.5 million contract with the
Indianapolis startup lasted only three months
before state ofcials rescinded the award after a
torrent of complaints from beneciaries who
said the company was not providing the
contracted services.
Centene Corp., based in suburban St. Louis
and a leading national Medicaid contractor,
had made $400,000 in loan guarantees to a
Centene employee, Stephanie DeKemper, to
nance the purchase of SynCare LLC. Centene
makes substantial political donations to many
public ofcials and candidates, including
Missouri Gov. Jay Nixon, a Democrat.
SynCare was hired by Missouri to determine
eligibility for 50,000 persons who needed
treatment at home. They were to receive
assistance in bathing, cooking, cleaning, and
Mo. Official Had a Hand in Contract
Soon After, She was Working for Vendor She Chose
K.C. Employers Trim Benefit Costs
Initiative Covered 56,000 Local Employees
Payers & Providers Page 4
The chief complaint, the history and physical,
the differential diagnosis, the proper testing, the
treatment -- from Day 1, these are the pieces of
medicine that are hammered in to young
doctors' heads: the best way to treat this or that,
the best drug, widget or gizmo, the latest
advance. We learn which approach is better
than the other, which treatment to apply when
more conventional approaches can't be taken.
Each of these steps are drilled over and over
again in the hopes of crafting a strategy for each
clinical scenario a doctor is likely to encounter.
Yet while each of these steps are important in
their own right, they by
themselves wont entirely sustain
a doctors satisfaction in the
Because after the treatment
strategy or therapy is applied,
there's another vital part of
medical care that is often under-
appreciated: the closure.
Closure is the time in
medicine where we either revel
in our success or squirm in our
failure. It's where we must face
the music -- good or bad -- with
our patients. More often than
not, it's the moment that brings
meaning to our efforts and the
hours we work.
Closure can occur at different times for
different doctors. For specialists, closure usually
occurs in the post-operative or post-procedure
period. For primary-care doctors, closure
occurs during the follow-up visit after a
prolonged hospitalization or difcult illness. For
both types of doctors, its the chance to see the
good they did or bad they did rst-hand. Its a
time to validate their understanding of the
patient's ailment and the caliber of their
treatment plan. Importantly, its not the end of
the patients ongoing care but the conclusion to
a particular chapter of their care. For doctors,
its the moment when we grow as professionals.
Yet sadly, these moments of closure are
becoming rarer for both the patient and the
With doctors racing to perform more cases
in less time and in more locations to offset
declining payment rates, it's become harder
both logistically and nancially to justify
excessive post-operative time with patients after
their procedures. The money required to feed
our administrators, collectors, and quality-score
counters demands an ever-growing source of
To that end, specialist physicians have seen
post-operative care clumped together with the
pre-procedure and intra-operative care into one
big encounter that pays health systems only
once. Increasingly, policy makers are shifting the
risk of caring for patients to providers. Insurers
and policy makers like to call this a shift from
procedural-based payments to outcome-
based payments. In theory this sounds nice, but
its robbing the doctors of the closure time they
need in their profession.
For primary-care doctors who
now only see patients in their
ofces, the opportunity to see the
product of a continuous-care
strategy has been surrendered to
the hospitalist, robbing them of
closure time. And even for the
hospitalists who diagnose and say
adios from the connes of the
hospital, the opportunity see the
late consequences of their care in a
non-critical environment has been
lost to production quotas. No
fractious group medical home
care in the world can replace
this loss of closure inicted upon
primary-care and shift-working hospitalist
physicians or the patients for whom they care.
Our health policy analysts have assured us
these closure visits can be accomplished by
ancillary care providers. Technically, they are
correct. But there is no question that the loss of
these post-procedure visits by the treating
physician or operating surgeon robs them of an
opportunity to improve. Further, doctors lose a
chance to educate and re-connect with the
patient. Doctors need this time with their patients
just like patients like this time with their doctors --
maybe even more. It's what makes it worthwhile
to get up and do it all again.
Doctors Need Closure with Patients
Final Visit After Procedure Gives Satisfaction, Education
By Westby Fisher, M.D.
Westby Fisher, M.D., is an internist, cardiologist,
and cardiac electrophysiologist who practices
at NorthShore University Health System in
Op-ed submissions of up to 600 words are
welcomed. Please e-mail proposals to
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