Florida Changes May Cost Counties

Gov. Rick Scott signs Medicaid billing changes; may cost counties $326 million

By Tia Mitchell
Miami Herald/Times Tallahassee Bureau

Against the wishes of counties and tea party leaders, Gov. Rick Scott signed a controversial bill into law Thursday that will change the way counties are billed for Medicaid costs and could set up a legal showdown.

If nothing changes, counties could be forced to pay the state an additional $325.5 million in the coming years in disputed Medicaid bills.

“Nobody really knows what this is going to mean to our budget,” said Gretchen Harkins, Broward County director of intergovernmental affairs. The Florida Association of Counties has convened a task force to recommend future steps, such as seeking an injunction or filing a lawsuit.

Scott took the unusual step of submitting a letter to the Secretary of State’s office explaining why he signed the bill, HB 5301. Scott acknowledged the counties’ concerns and vowed to work with them to resolve years of disagreements with the Agency for Health Care Administration on how much they owe for Medicaid.

“To that end, I have pledged to the counties that AHCA and my staff will work diligently with them to certify that any billings for which counties are charged are accurate and valid,” Scott wrote.

Representatives from AHCA will travel to each county to review the disputed amounts and discuss other issues with the billing process, the letter said. Counties say the system has been flawed for years, resulting in incorrect and duplicative statements.

Under the plan, counties can dispute the unpaid Medicaid bills in administrative hearings but are on the hook for paying back 100 percent of the backlog if they lose. Or, counties can agree up-front to pay back 85 percent of the disputed bills.

The state will withhold sales tax revenue sharing dollars from counties to cover past, as well as any future, Medicaid costs.

All but seven of the state’s 67 counties sent Scott letters urging him to veto the bill. They accused the state of tinkering with the Medicaid billing system in an effort to shift additional costs to local governments.

Florida Association of Counties President Doug Smith said the bill “represents the worst kind of body blow to taxpayers.”

“Rather than correcting Tallahassee’s error-ridden Medicaid billing system, HB 5301 codifies it and leaves local taxpayers with the bill,” said Smith, a Martin County commissioner, via email.

The Florida Tea Party Network, a coalition of about 80 groups, joined the counties in lobbying against the proposal. Henry Kelley of Fort Walton Beach, the Tea Party Network’s legislative liaison, said he was disappointed in the governor’s actions.

“From a tea party perspective (and) the issue of limited government, now you’re tying the hands of the counties,” he said. “But you’re also signing into law something where you know there’s a billing problem.”

Although the Medicaid billing issue drew the most attention, HB 5301 affected other areas of the state’s Medicaid program, which provides health care services to 3.2 million poor and disabled Floridians.

It cuts costs by limiting nonpregnant adults to no more than six emergency room visits a year and allows state employees to enroll their children in the KidCare health insurance program.

Scott also signed nine claims bills into law Thursday, compensating victims of government wrongdoing nearly $40 million.

Scott signed a $10.7 million claim for the family of Eric Brody, who was permanently injured 14 years ago when a speeding Broward County Sheriff’s deputy plowed into his car.

Most jury awards against government entities or employees — school bus drivers, hospital workers, police officers — have to be approved by the Legislature if they are in excess of $200,000.

The governor used his first veto this year to strike down a bill that would have given $1.4 million to a man who lost a leg in an accident with a Sumter County school bus, indicating that the amount was too high.

Herald/Times staff writer Toluse Olorunnipa contributed to this report.

Read more here: http://www.miamiherald.com/2012/03/29/v-print/2721744/gov-rick-scott-signs-medicaid.html#storylink=cpy

Hospitals Worry About Mandate Loss


Hospitals fear loss of insurance payments if coverage mandate is struck down

Leaders say situation would deteriorate further if Obama administration pushes ahead with reimbursement cuts even if provision is eliminated

By Peter Frost, Chicago Tribune reporter

11:21 AM CDT, March 29, 2012



Like their counterparts across the country, Chicago hospitals have invested millions of dollars preparing for the implementation of the federal health care law, potentially for benefits they may never reap if the U.S. Supreme Court strikes down key parts of the law.

The court, which wrapped up three days of hearings Wednesday, is considering whether a requirement that most Americans carry health insurance or pay a penalty violates the Constitution.

In their final day of hearings, justices indicated they may throw out other parts of President Barack Obama’s health care law if they strike down the mandate, which is expected to expand insurance to about 30 million Americans.

“This is one of those things where you have to be careful what you wish for,” said Dr. Lee B. Sacks, executive vice president and chief medical officer for Advocate Health Care, the region’s largest health group. “The consequences of striking down the law may be far worse than dealing with the changes (the law required) over a several-year period.”

The American Hospital Association argued in a brief to the court that the bill could hurt hospitals’ finances if the individual mandate is the only portion of the law to be struck down or altered.

Hospitals expected a wave of newly insured patients to offset cuts to government reimbursement for programs like Medicare and Medicaid called for under the law. They fear they may be squeezed by declining payments without the benefit of an influx of new patients.

If the court finds the law unconstitutional, the government may press ahead on plans to cut reimbursements in a effort to rein in spending, an initiative Sacks says “won’t serve patients and won’t lead to better access and more equitable care.”

“In the short term, there will be a significant number of uninsured (patients) that we won’t get compensated for, and that becomes a barrier to access and forces us to shift costs to other payers,” Sacks said.

Paula M. Noble, chief financial officer at Children’s Memorial Hospital in Lincoln Park, said the hospital is concerned that if the court strikes the law in its entirety, some of the hospital’s patients would lose benefits that have already been implemented. Specifically, she fears that they would lose their private insurance coverage because of pre-existing conditions or if they exceed lifetime caps on coverage.

Instead, she said, those patients would be forced to rely on Medicaid, a chronically underfunded program that is facing “devastating cuts.”

“This would create further challenges for Children’s Memorial, other hospitals and the state of Illinois,” she said.

At the same time, however, hospital executives argued that regardless of whether the law stays intact, a series of meaningful and transformative changes that it spurred in the industry will continue.

Combined with the economic recession, the 2010 law sharpened hospitals’ focus on driving efficiency by coordinating patient care and automating health care records, two initiatives that allowed hospitals to become more clinically integrated, said Mark Newton, president and chief executive of Swedish Covenant Hospital.

Those improvements help hospitals offer better care to patients and better value to payers, he said.

“Regardless if the law stands, there are certain changes occurring where I think some good things will result,” Newton said. “Even if (the court) throws the whole thing out, there are some residual positives that came out of this, and, if nothing else, it gives Congress a chance to go back and really look at what’s working and what’s not.”


White House Counts on Mandate

UPDATE 1-White House: no contingency plan if healthcare law rejected

Wed, Mar 28 2012

* Top officials have cited options in the past

* Analysts see vulnerabilities for Obama’s base

* Any action unlikely until after November vote (Adds quotes, details and background)

By David Morgan and Jeff Mason

WASHINGTON, March 28 (Reuters) – The White House said on Wednesday that it was not working on contingency plans for President Barack Obama’s signature healthcare law, in the event that the Supreme Court struck down all or part of the sweeping reforms.

After three days of landmark Supreme Court hearings that raised doubts about the law’s fate, White House spokesman Josh Earnest said the administration remains confident that the 2010 reform measure would be upheld when justices issue their ruling toward the end of June.

“There is no contingency plan that’s in place. We’re focused on implementing the law,” Earnest told reporters. “If there’s a reason or a need for us to consider some contingencies down the line, then we’ll do it then.”

A negative ruling from the court would be seen as a major blow to Obama in the middle of an election year, when Republicans are demanding the repeal of the Patient Protection and Affordable Care Act.

Obama’s re-election prospects already face substantial challenges. A new Reuters/Ipsos poll shows that two-thirds of Americans, including a majority of Democrats, disapprove of his performance on another big issue: high gas prices.

The healthcare law and its unpopular individual mandate, which requires most Americans to have health coverage beginning in 2014, came under sharp scrutiny from the high court’s five conservative justices.

Doubts about its future deepened with tough courtroom questioning about whether the mandate exceeds the government’s constitutional authority.

Reform advocates contend that the mandate is vital to the law’s main objective of extending healthcare coverage to more than 30 million uninsured Americans.


Administration officials have spoken openly about possible contingencies in the past.

At a Reuters Health Summit last May, Health and Human Services Secretary Kathleen Sebelius said there would be a number of ways to expand health coverage if the mandate were overturned.

“There are all kinds of sign-up possibilities, auto enrollment and a variety of strategies,” she said.

But analysts say the week’s proceedings may have left Obama in too fragile a position to speak publicly about contingencies.

The White House could undermine his political base by openly preparing for defeat, particularly on the mandate, which is interwoven with popular consumer protections including a measure guaranteeing healthcare access for people with pre-existing conditions.

“They can’t risk having the president look like he’s folding, or giving up, or anything like that,” said Joseph Antos of the conservative American Enterprise Institute.

If the court struck down the law or its main provisions, analysts say the White House would likely postpone any decision on how to move forward until after the Nov. 6 general election.

They add that the loss of the mandate alone could leave the healthcare law at the mercy of congressional gridlock months after the election and raise doubts about the administration’s ability to usher key reforms into place by a Jan. 1, 2014, deadline. (Editing by Xavier Briand)

Primary care physician shortage looms in Louisville

Written by
Patrick Howington
The Courier-Journal
2:42 AM, Mar. 28, 2012

They are the quarterbacks of the health care system — generalists who monitor the entire body, give preventive care, spot problems early and send patients to specialists if needed.

Despite their key role, primary care physicians are in increasingly short supply, and a new study says the shortage is expected to become critical soon in Louisville — as it has been in many rural areas of Kentucky for years.

The impending Louisville shortage is due to a perfect storm of factors — an aging population that will need more care, a large number of doctors approaching retirement, and medical students shunning primary care practices for specialties with higher pay and better hours.

By 2020, Jefferson County will need 455 new primary care doctors — almost as many as the number that work in local medical practices now. The new doctors will be needed to replace current doctors who are expected to retire and to meet federal guidelines for serving the projected 2020 population, according to the study the Louisville Primary Care Association commissioned.

And that doesn’t take into account the extra demand for more doctors when health reform could cause millions more Americans to have health insurance in 2014 if upheld by the Supreme Court.

“We see a real workforce crisis in the future — in the immediate future,” said Bill Wagner, executive director of Family Health Centers, a group of community clinics serving low-income residents. “It is a perfect storm.”

Family Health Centers is a member of the primary care association. Others are the Park DuValle Community Health Centers, the Louisville Metro Department of Public Health & Wellness, and the University of Louisville’s dental school and primary care centers.

The study, conducted by REACH Inc. and based on a survey of local physicians, found that about one-third of all the primary care doctors — general internists, family practitioners and pediatricians — are 56 or older and plan to retire within 10 years.

The combination of impending retirements, expected population growth and the trend toward doctors working strictly inside hospitals or urgent-care centers rather than holding office hours means that:

• Jefferson County will need to attract 220 new family practitioners by 2020, or more than the current supply of 167 who don’t work solely at institutions such as the VA Medical Center or hospices.

• An additional 192 general internists and 43 pediatricians will be needed.

• While Louisville has 697 primary care doctors overall, only 517 of them are in typical office settings where they can have an ongoing relationship with patients — and 178 of those are expected to retire by 2020.

To replace those retirees and add other new doctors to meet federal guidelines calling for 100 primary care physicians per 100,000 people, the study projected that 455 new primary care doctors will be needed by 2020.

And not enough younger doctors are in line to fill that gap.

Shift to higher pay

Saddled with $100,000 or more in medical school loans, graduates in recent years haven’t chosen lower-paying primary care as often as older generations did, statistics show.

In the past 15 years, the number of U.S. medical school seniors who entered residencies in family medicine has fallen from 17 percent in 1997 to 8 percent last year, according to the Association of American Medical Colleges. However, the number has rebounded slightly since 2009.

The picture is similar at the U of L School of Medicine. The number of entering medical students the school believed would go into primary care upon graduation, based on statements at the time of admission, has declined 50 percent in the past 11 or 12 years, said Dr. Steve Wheeler, associate dean for admissions.

“The debt load in medical school has increased, the ability to repay debt is influenced by salary once you get out, and primary care is at the low end of that spectrum,” said Wheeler, who is also associate professor of family and geriatric medicine.

On average, primary care doctors are paid as little as half as much as specialists, such as radiologists and invasive cardiologists, according to a national compensation survey.

Yet they typically see many more patients a day and must complete exhaustive paperwork to oversee patients’ overall care.

The time demands and administrative burden are perhaps as important as the pay gap in students’ decisions to shun primary care in recent years, experts said.

“I think it has become a much more difficult environment to enjoy working with your patients in,” Wheeler said.

“It’s more difficult, more stressful, and less rewarding” than it used to be, Dr. Greg Ciliberti, a Louisville internist for 26 years. “And then you’ve got the other stress of, you’re trying to run a business and you never get a raise.”

Not just rural

In Kentucky, physician supply has typically been seen as a rural problem, given that some counties are served by a handful of doctors — while Louisville is home to large hospital companies and a university medical school.

But both in Louisville and nationwide, “I don’t think there’s any question that it’s not just a rural issue,” said Dr. Dan Varga, chair of the Kentucky Medical Association’s physician workforce committee.

“No matter where you’re talking about, we clearly have an aging primary care workforce,” because primary care has been “so unpopular” a career choice in recent years, said Varga, chief medical officer of Kentucky’s St. Joseph hospitals and a former Louisville internist.

“There just aren’t as many students who see that as their call,” Wheeler said.

Given that trend, Wagner said he doubts that medical schools will train enough primary care doctors to fill the gap.

Wagner said his clinics already have a difficult time recruiting primary care doctors in the face of competition from higher-paying hospital operations that increasingly are hiring doctors as full-time employees.

That can leave doctors at Family Health Centers and similar clinics stretched even further to handle their patient load.

“There’s not enough of us,” said Dr. Sarah Fortuna, a staff doctor at FHC’s Iroquois clinic on Taylor Boulevard, during a brief break between seeing patients, updating charts and conferring with a medical technician. “We’re getting more and more patients, but we’re not getting any more staff.”

Fortuna said she probably doesn’t get enough time with her patients.

“I try,” she said. “But is the clock ticking in the back of my head? Yes. I know I have to get to day care at the end of the day, and my techs have other things they have to get to as well.

“I try to stop long enough to give them the time, but there’s days when I go home and go, ‘I know I’ve made (patients) come back in three weeks because I want to talk to them more.’ ”

Fortuna, 39, a single mother and former Air Force doctor, said she doesn’t regret her decision to go into primary care. She likes treating a wide variety of conditions and is “a people person, so I wanted to have long-term relationships with my patients.”

Making the switch

Fortuna said it would be nice to make more money, but that’s not enough to make her switch to a specialty.

But many primary care doctors have done just that.

Fortuna said she trained in a group of eight primary care residents at Eglin Air Force Base in Florida, ending in 2003 — and four of them have since entered specialties.

“They were faced with longer and longer hours in private practice, and most of them didn’t want to do that,” she said. “They wanted to have a life. So they opted out.”

Dr. Dan Garcia, a Louisville allergist, was a pediatrician for 17 years before becoming an allergist in the early 1990s — a move he said he made for his health and to see his family.

With long hours at the office combined with hospital rounds, “I wasn’t getting to see my children” because of caring for other people’s children, said Garcia, 64.

“We had our fifth child, and I came down one morning … Patrick was about 4 months old, and he looked at me like I was a complete stranger, because I hadn’t seen him for over a week,” Garcia said.

A heart bypass operation convinced Garcia he needed a slower pace, and he underwent two years of training to become an allergist. Instead of working 12 hours or more a day, he now works 8 to 10.

“It’s been well worth it,” he said. “The tail doesn’t wag the dog any more.”

Cost of solutions

Though there is a consensus that more primary care doctors are needed, the solutions aren’t easy — and often call for money that isn’t there.

Medical associations have advocated repaying emerging doctors’ medical-school debt as an incentive for them to enter primary care. The National Health Service Corps has such a repayment program, but only for doctors who agree to practice in underserved areas.

And national proposals to increase medical schools’ federal funding for training primary care physicians have lost out to deficit-cutting measures in recent years, said Christiane Mitchell, director of federal affairs for the Association of American Medical Colleges. She said the organization’s top priority is to avoid cuts to existing funding, though it believes federal training money should actually be increased.

With pay levels persuading many doctors to leave primary care or not enter it, some private health insurers and the federal Medicare program are moving to boost reimbursements for primary care physicians compared with specialists.

Last year, the Obama administration established a Medicare pilot program, called for under the 2010 health reform law, to pay primary care doctors to supervise teams of “physician extenders,” such as nurse practitioners, to treat target populations. The so-called “patient-centered medical home” program would directly reward primary care doctors for their time-consuming role in coordinating patients’ care.

Health insurer Aetna announced a pilot program in January to give extra monthly pay to physicians whose practices qualify as patient-centered medical homes, while last July Louisville-based Humana announced a program to award nearly $10 million to primary care practices that show quality improvements.

WellPoint, the parent company of Anthem health plans, also announced a national program in January to pay more to some primary care doctors who keep patients healthy.

But Anthem’s Kentucky organization took a broader and earlier approach in 2008 by boosting all primary care office-visit reimbursements to a level higher than specialists get, said Mike Lorch, an Anthem vice president.

“What we’re counting on, and what we firmly believe, is that … as you improve reimbursement so they can take better care of the patient, you’re going to see a payback in cost of care,” Lorch said.

Without regular access to a primary care doctor, he said, “a lot of times you’re going to end up in the (emergency room), and that’s the most expensive setting.”



Supreme Court’s Medicaid Decision Could Reach Far Beyond Health Care

by for NPR

After Tuesday’s judicial fireworks, the Supreme Court wraps up arguments on the new health care law Wednesday by focusing on two questions. The first involves what would happen if the “individual mandate” — the core of the law that requires most people to have health insurance — is struck down. Would the rest of the law fall, too, or could some provisions stay?

But it’s the second argument the court will hear about the Affordable Care Act that could potentially have the most far-reaching consequences. At issue is whether the health law’s expansion of the Medicaid program for the poor unfairly forces the states to participate.

If the justices find the federal government is coercing the states, that decision could reach far beyond health care.

Medicaid is already one of the nation’s largest providers of health care services, says Diane Rowland, executive director of the Kaiser Commission on Medicaid and the Uninsured.

“It provides health insurance coverage to 1 in 3 American children, so it’s a fundamental part of the way in which we deliver health care services today,” she says.

But as large as the program is, Medicaid today in most states is still not available to people simply because they are poor. They have to be poor and something else — such as a child, a pregnant woman or older than 65. Under the health law, however, that would no longer be the case.

“Medicaid changes from a program that covers certain categories of low-income individuals to a program available for health coverage for all individuals,” Rowland says.

All individuals, that is, with incomes under 133 percent of the federal poverty line. This year that’s $14,856. According to the Congressional Budget Office, that will add about 17 million new people — mostly adults without children — to Medicaid’s 60 million or so enrollees by the year 2016.

Currently, states share the cost of Medicaid with the federal government. Wealthier states pay half; poorer states pay a smaller share. But the federal government recognized that states are strapped for cash these days. So most of the new cost — all of it at first; 90 percent eventually — is being paid by the federal government.

But that’s not stopping states from claiming that this expansion amounts to unconstitutional arm-twisting. That’s because if they don’t follow through with the new changes, they have to pull out of Medicaid altogether — or so they claim.

Former Bush administration Solicitor General Paul Clement is representing the 26 states that are suing over the Medicaid provisions of the health law.

He says what the law means is that if states don’t agree to the expansions, “we’re going to take away all of your money, including all of the money that you’ve kind of gotten used to, all of the money that you’ve used for different groups of people. And that does seem a little more coercive.”

Medicaid is, in fact, a voluntary program. States don’t have to participate. But they all do. And Clement says so much money is at stake — more than $400 billion in 2010 — that dropping out is simply unrealistic.

“How any state at this point could say, ‘We’re just going to turn down Medicaid funding from the federal government’ — I don’t think any set of citizens would allow that to happen,” Clement says. “Because it’s all this money that’s being taken from the state taxpayers that would then be going to every state in the union but that state; it just wouldn’t work.”

But is this latest expansion of Medicaid really coercive? Sara Rosenbaum, a law professor and Medicaid expert at George Washington University, says it’s hardly different from many of the expansions that have come before.

“States already cover a lot of adults,” Rosenbaum says. “They cover parents; they cover adults with disabilities; they cover adults who are pregnant. And so all this expansion does is really to fill in the remaining gaps. And it’s something that many states have wanted to do over the years.”

While states are worried about how much they might ultimately have to pay for all those new adults, even if it’s only 10 percent of the cost, Rosenbaum says, over the long term, they might actually save money.

“There are studies that suggest by just 2019 alone, states will have saved about $100 billion in state funding for uncompensated care, especially for adults,” she says.

But the real reason people are watching the Medicaid arguments so closely has nothing to do with Medicaid. It’s the potential impact on the relationship between the federal government and the states. This is one of the few times the court has taken up what’s known as the “spending clause” of the Constitution.

“It’s long been established by the Supreme Court that Congress can attach conditions to federal funds that it gives the states,” says Elizabeth Wydra of the Constitutional Accountability Center, a liberal think tank. “States can follow the requirements … or they can opt out of receiving the funds altogether.”

But while earlier cases have suggested that there could be limits to those conditions, the court has never said what those limits are. And it’s not just Medicaid at stake.

“That places in jeopardy, in addition to the entire Medicaid program, a host of other very beneficial federal grant programs in the education context, child welfare and other programs,” Wydra says. In fact, it could affect virtually any program in which the federal government gives money to the states with conditions attached.

So far, no lower court has agreed that the Medicaid expansion coerces the states. But no one expected the Supreme Court to hear this part of the challenge against the health law, either.



Region’s hospitals, insurers keep close eye on impact of federal decision

9:21 PM, Mar. 26, 2012  |  

Written by

Laura Ungar for the Louisville Courier-Journal

It’s been cited as a driving force behind the proposed but thwarted merger involving University Hospital and a Catholic health care system.

It’s inspired new partnerships called “accountable care organizations,” including one being piloted by Norton Healthcare and Humana.

And it’s been hailed as providing extended coverage for more than 35,000 young adults in Kentucky.

The federal health reform law has already started making an impact locally — so area health advocates and officials are tuned in to this week’s Supreme Court proceedings.

“I think the entire health care sector and insurance sector are watching this closely because it has significant implications on both industries,” said Stephen Williams, chief executive officer of Norton. “This is very far-reaching.”

Jodi Mitchell, executive director of Kentucky Voices for Health, a coalition of health advocacy groups, said her organization takes no position on the arguments before the Supreme Court, instead concentrating on educating the public about health reform. But she added: “We expect the law will be upheld.”

One of the most well-known provisions of the Affordable Care Act, as the reform law is called, requires insurers that offer coverage to children on their parents’ plans to make that coverage available until the child is 26.

That portion of the law took effect in September 2010. According to the U.S. Department of Health & Human Services, 35,610 young Kentuckians already have gained coverage through that provision. In Indiana, 38,480 young adults gained coverage.

“This is helpful for college students going to school who can’t afford coverage,” Mitchell said. “And because they’re generally healthy, they’re advantageous on plans where you’re trying to spread out the risk.”

This week’s arguments before the Supreme Court won’t involve that provision, nor several others of the broad-ranging law, but instead will focus on a key and controversial provision — requiring nearly all Americans to have health insurance by 2014.

According to the U.S. Census Bureau, an average of 15.5 percent of Kentuckians — or 663,000 people — lacked health insurance from 2008-2010, as did 12.8 percent of Hoosiers, or 813,000 people. Nationally, 15.8 percent of Americans lacked health insurance during that period.

Health care experts say the reform law eventually would bring the rate of uninsured Americans down by about 60 percent.

Louisville-based Humana Inc., one of the nation’s largest health insurers, said it has long supported universal health coverage for all Americans.

And the company said that other parts of the reform law, such as requiring insurers to cover all applicants regardless of their health condition, cannot work without the “individual mandate” provision. Otherwise, healthy people could pass up insurance while sicker people would get it, raising premiums for all.

Officials at local hospital systems, which provide charity care for many uninsured patients and have unpaid bills from others, have said projections of how many people would gain coverage under the reform law are encouraging.

But they add a caveat — saying it’s unclear if projected gains in patients who would get insurance under health reform would be offset by funding reductions in a state and federal program for hospitals that treat large numbers of low-income people.

Officials at University Hospital, which cares for large numbers of uninsured patients, talked about this uncertainty during the debate involving the proposed merger with Jewish Hospital & St. Mary’s HealthCare and Lexington-based St. Joseph Health System, which is part of Catholic Health Initiatives of Denver. Gov. Steve Beshear ultimately rejected the proposed three-way merger, and Jewish and St. Joseph merged without University to create KentuckyOne Health.

Officials at those health care organizations — as well as others such as Norton and Baptist Hospital East — have said the reform law encourages them to partner with others to become more efficient, improve care and reduce costs.

Norton and UK leaders said the law is one of the main reasons behind their partnership, announced in June. That partnership includes a statewide stroke collaboration and a cancer program that would share resources.

Norton and Humana are also piloting an “accountable care organization” for commercially insured patients, a program that establishes financial incentives for health care providers to improve quality, eliminate waste and control costs. Louisville is one of four national sites in the ACO Pilot Project of The Engelberg Center for Health Care Reform at the Brookings Institution and The Dartmouth Institute for Health Policy and Clinical Practice. Officials said the program brings a emphasis on wellness and preventive care for patients.

Last October, the U.S. Centers for Medicare & Medicaid Services finalized new rules under the health reform law to help doctors and hospitals better coordinate care for Medicare patients through ACOs. The Medicare program is designed to reward ACOs that lower the growth of health care costs while still providing quality care.

Williams said Norton will still go forward with the ACO and partnerships no matter what happens with the health reform law.

“Even if major parts of it get repealed, I believe what we are doing and what other providers are doing we will continue to do,” he said. With health care expenditures making up 18 percent of the Gross Domestic Product in the United States, “we have to bend the cost curve or we are going to cripple the economy.”



Some Insurers Paying Patients Who Agree To Get Cheaper Care

By Michelle Andrews

Mar 26, 2012

In recent years, insurers have tried to cajole consumers into using less-expensive health-care providers by promising lower co-payments and other cost-sharing breaks for members who select those doctors and hospitals.

Lately, they’re trying an even more direct approach: cash rewards.

Some Anthem Blue Cross and Blue Shield members in New Hampshire, Connecticut and Indiana can receive $50 to $200 if they get a diagnostic test or elective procedure at a less expensive facility than the one their doctor recommended. The offer covers nearly 40 services, from standard radiology tests such as mammograms and MRIs to such surgical procedures as hip and knee replacements, hernia repair, bariatric surgery and tonsillectomies.

“We identified a subset of highly utilized services with cost variances that we thought would have a big impact,” says Denise McDonough, regional vice president of sales for Anthem BCBS of New Hampshire. “We want to provide information to members to drive health-care costs down.”

It seems to be working. The city of Manchester, N.H., the first employer to pilot Anthem’s Compass SmartShopper program in January 2010, has saved more than $250,000 in health-care costs in two years, even after factoring in the cash rewards paid to the 476 members who have participated.

The differences in costs can be eye-popping. According to Anthem data, in Manchester a hernia repair ranges in price from $4,026 on the low end to $7,498 on the high end. A colonoscopy could cost $1,450 to $2,973.

“It was a huge eye-opener for us,” says Jane Gile, human resources director for the city government.

It, of course, can also save money for employees who haven’t met their plan’s deductible.

Here’s how the SmartShopper program works. At least 24 hours before a member has a scheduled service, he or she calls a toll-free number or logs on to a Web site to get a list of lower-cost local providers.

If a doctor has referred someone to a location that’s not on the list of cheaper providers, the member can request that the doctor change the referral. If the physician is performing the procedure, the member can ask that the doctor do it at a cheaper location.

After the provider submits the claim and Anthem pays it, the insurer compares the records of online and telephone inquiries made by the member to the SmartShopper program. If the member chose to get care at a low-cost provider identified by the program, he gets a check in the mail within 60 days. (The amount is usually about $100, but it varies with the size of the amount saved.) An employee who has not yet met his annual deductible would also save directly on the cost of the treatment.

If the member wants to stick with his doctor’s initial plan and forgo the cash bonus, no problem. The program is entirely voluntary.

Last year, Harvard Pilgrim Health Care launched SaveOn, a similar program that covers a limited number of services in New Hampshire and that recently expanded into Massachusetts.

Physician groups have some concerns. “It appears as though the decision is being made by the health plan, and tiering of providers is being made simply on an economic basis,” says Scott Colby, executive vice president of the New Hampshire Medical Society.  “We have concerns about giving economic incentives without giving weight and credence to quality measures.”

It’s a fair criticism, insurers concede. Listed providers are licensed and credentialed, but quality indicators such as complication rates aren’t factored in. “It’s a first-generation set of data,” says Eric Schultz, president and chief executive of Harvard Pilgrim Health Care. “We all have a long way to go on performance data.”

Likewise, the Compass SmartShopper FAQ page says, “It is up to you to talk to your doctor or research online at anthem.com to determine your quality requirements.”

For simple diagnostic lab and radiology procedures, choosing providers based primarily on cost is probably fine, says Ha Tu, a senior researcher at the Center for Studying Health System Change, a Washington-based think tank. “But when you start talking about surgery, it’s hard to argue that quality doesn’t vary quite a bit, and people shouldn’t be making these decisions purely on cost.”

Physicians are also concerned that programs such as SaveOn and SmartShopper may hinder care coordination among providers at a time when such coordination is considered key to managing patients’ health and controlling health-care costs.

When the SmartShopper program was introduced, some Manchester city employees were skeptical, says Gile. But many have come around.

Gile herself has used the program three times: twice for screening mammograms and once for a colonoscopy. She had a good experience each time. By choosing a lower-cost provider for the tests, she qualified for cash rewards of a few hundred dollars altogether, she says.



Periodontal Care Linked to Diabetes Management

‘Striking’ Data Links Periodontal Care to Lower Diabetes Costs

John Commins, for HealthLeaders Media , March 27, 2012

An insurance industry study, touted as the largest of its kind, shows that medical costs can be reduced by more than $1,800 a year for each diabetic patient who receives periodontal care.

The study examined medical records from more than 1.6 million people who were covered by both United Concordia Dental and Highmark Inc. and identified about 90,000 Type 2 diabetics.  About 25% of those diabetics elected to receive periodontal treatment in 2007 and the study compared their medical costs over the next three years with the 75% of diabetics in the group who declined the oral care.   

“The data is striking. In 2007 you had fewer than half the inpatient admissions if the patients had periodontal surgery when compared with the patients who did not,” says Marjorie Jeffcoat, DMD, with the University of Pennsylvania, the lead author of the study.

“I also found it striking that this result was carried through for three years,” Jeffcoat told reporters at a Monday teleconference. “If you look at the mean number of visits they paid to a physician, again in 2007 they saw half the number of physician visits and this statistically significant result was carried through again for three years.”

“If we look at mean medical costs we have a reduction in all three years and if you look at it the mean medical savings was $1,814 per patient per year. That is a striking number. This affect is apparent two years after the periodontal treatment,” Jeffcoat says.

The study’s release coincided with United Concordia launch of a diabetes-specific program that provides 100% coverage for surgical procedures, other treatments, and maintenance for patients with gum disease.

“This is the most statistically conclusive study proving the relationship between oral health and medical cost savings. The savings are just the start of what is to come,” United Concordia COO/President F.G. “Chip” Merkel told reporters. “We believe that employers will realize reduced medical costs when their employees with diabetes receive appropriate periodontal care.”

James Bramson, DDS, chief dental officer for United Concordia, noted that about 25.8 million Americans have diabetes, a number that has doubled since 1999. He says the sheer size and scope of Jeffcoat’s study shows “that the results here are not a fluke.”

“We did some modeling to look at the ability to take care of these kinds of patients and the cost of doing that and what kinds of savings you’d have on the medical side,” Bramson says. “In a group of about 200 members, even as small as that, it would only take about 3% of the diabetics to actually return the savings on the medical side equal to what it would cost to provide these additional treatments. Beyond that all the rest is healthcare savings.”

While the study examined diabetics, Bramson says other studies have provided linkage between oral health and coronary artery disease, cerebral vascular disease, and even premature and low-weight infants. “We believe other chronic diseases will show some association, some economic savings medically if those people had periodontal treatment,” he says. “So when we know more about the breadth and depth of the accuracy of that savings across those other diseases our hope here is to broaden the coverage we are now starting with diabetes.”

“The thought is you don’t need to cover everybody in the population,” he says. “The better thing to do is cover those targeted populations where we can show savings and where we know an intervention program of information and assistance will help them get in and get the treatment they need.”

Bramson says dentistry accounts for about 4% healthcare spending in the United States, while hospital care, physician and clinical services, and drugs account for 63% of all spending. “If we can improve the spending in the dental that is going to affect the three other largest segments of the healthcare spending, so we believe you will have some savings well beyond the $1,814,” he says.

The study did not specifically examine the cause-and-effect relationship between periodontal disease and diabetes, but Jeffcoat says earlier studies have explained the linkage.

“Any sort of infection you have, be it pneumonia, a kidney infection, it makes your diabetes worse,” she says. “Periodontal disease is an infection. If we can get that infection under control we tend to get the hemoglobin A1C, the measure of three months of diabetes, under control. It has to do with inflammation and infection and getting it under control.”

John Commins is an editor with HealthLeaders Media. He can be reached at jcommins@healthleadersmedia.com.

Passport, Leadership host Chamber breakfast

by Brittany Wise – Grayson County News Gazette
03.25.12 – 12:00 pm

Representatives from Passport Health Plan, along with Leadership Grayson County hosted Thursday’s Chamber of Commerce breakfast at the Centre on Main, where a new local Passport board member was announced, along with the 2012 Leadership class and the new Executive Director of the Grayson County Chamber of Commerce.

Passport’s Chief Executive Officer, Mark B. Carter, spoke to the group about the non-profit organization’s service in central Kentucky. The group serves 16 counties, including Grayson, and provides health care for around 5,000 Grayson County residents – about 20 percent of the county’s population.

Carter explained that through the group’s partnerships with hospitals, primary care providers and a large number of specialty physicians, they are able to provide excellent quality healthcare to residents who would otherwise not have healthcare.

Carter boasted of the group’s #13 ranking among similar agencies country-wide, adding that all but two of the top 100 ranked companies were located in either New England or the West Coast, which makes Passport’s excellent slot an even more powerful accomplishment.

It was also announced that local business-owner Steven Elder has joined the Passport Health Plan Board.

Elder said of the group, “Passport Health Plan truly brings the community together. Their committee and board structures allow concerned citizens like myself to bring perspectives to the table and work collaboratively to find innovative solutions that work for everyone.”

Another exciting announcement for the Elder family was the reveal of the new Executive Director of the Grayson County Chamber of Commerce, his wife, Tara Elder.

Tara will be stepping into the shoes of former Director Caryn Lewis, who is leaving the position to work for the Grayson County School System.

Before Caryn’s departure, however, she had the opportunity to announce this year’s Leadership Grayson County class, which includes: April Bowman, with Wilson & Muir; LaShawn Cole-Hack, with Head Start; Tara Elder, with Grayson County Chamber of Commerce; Kindra Ewing-Jones, with Grayson County Extension Office; Valerie Farris, with Elder Wealth management; Alicia Harrell, with City of Leitchfield; Lisa Jones, with Grayson County Public Library; Amanda Joyce; Jessica Kelley, with Carter Harrell State Farm; Ellis Kiper, with Rocky-K Log Homes; Harold Miller, with WRECC; Trish Niles, with Mid-Park, Inc.; Carrie Petrocelli, with Twin Lakes Home Health; Natalie Taul, with Grayson County Extension Office; and Christopher Wilborn, with United Way of Central Kentucky.



Passport employee’s award to benefit OVEC’s Head Start

By The Staff
Friday, March 23, 2012 at 3:00 am       (Updated: March 23, 3:06 am)

Marcelline Coots, one of the first individuals to be hired at Passport Health Plan in 1997, has been named the 2012 Making A Difference award winner by the Association for Community Affiliated Plans (ACAP), and that’s going to benefit the Ohio Valley Educational Cooperative’s Head Start program.

She was selected from a pool of candidates submitted by the national organization’s 57 affiliated health plans located throughout 27 states. ACAP serves more than 10 million Medicaid and CHIP members across the country.

In her honor, ACAP is presenting a $500 donation to her charity of choice, OVEC, in a ceremony Wednesday at the cooperative’s office on Alpine Drive in Shelbyville.

Coots, whose daughter attends  Christian Academy of Louisville, serves on the advisory council and community board of the OVEC.

She is the main member outreach event planner for Passport Health Plan and has participated in or planned numerous special events.

“Marcelline embodies the mission of Passport Health Plan – to improve the health and quality of life of our members,” Passport Health Plan CEO Mark B. Carter said in a press release announcing her award. “She’s done things like learn to drive a truck for some of Passport’s large outreach events. That’s the kind of commitment that Marcelline has demonstrated every day during the length of her service here, and I’m delighted that she is being recognized in this manner.”