Ohio judge stops state Medicaid contract process

 

By Ann Sanner on June 27, 2012

COLUMBUS, Ohio (AP) — In a dispute over the scoring of contract applications, a central Ohio judge on Tuesday blocked the state from moving forward with tentative Medicaid contracts it awarded to five health plans.

Franklin County Common Pleas Judge Richard Sheward ordered the contract process halted for now, at the request of Aetna Inc.’s Better Health of Ohio.

Aetna is suing the Ohio Department of Job and Family Services because state officials had selected the company for a contract in April and then revoked the decision earlier this month. Aetna claims the state retroactively changed the definition of certain requirements in its request for contract applications, and the company wants its contract reinstated.

The contract awards are preliminary. The health plans, or managed care organizations, must first pass a state assessment, in which they must prove that they will be ready and able to provide care when Medicaid enrollment under the plans begins in January.

The state had expected to complete its readiness review by the end of August and fully award the contracts. But it’s unclear how the judge’s ruling on Tuesday will affect that timeline.

A spokesman for Job and Family Services says the agency won’t comment on pending litigation.

Sheward has set another hearing for July 23 to decide whether the order should be extended.

The eventual contract winners will provide health care services to more than 1.6 million poor and disabled people, or roughly two-thirds of the state’s Medicaid population. The contracts provide billions in government work to the companies.

The health plans chosen were said to be the highest-scoring applicants in the state’s Medicaid contract process. But five of six companies that lost bids for the contracts had filed formal protests with Ohio officials in April, claiming flawed and inaccurate scoring.

A state review of the contract applications changed how points were scored. And on June 7, state officials said Aetna Better Health of Ohio and Meridian Health Plan of Ohio would no longer get the contracts.

Instead, Molina Healthcare of Ohio Inc., a subsidiary of Molina Healthcare Inc., and Buckeye Community Health Plan, a subsidiary of Centene Corp., were picked.

Ohio has also selected CareSource, Paramount Advantage and United Healthcare Community Plan of Ohio.

The health plans were judged on certain components, including experience, care management and clinical performance. The provider network was also a factor but not as heavily weighted.

The state’s review found that Meridian should have been disqualified because it didn’t have a necessary health-insuring corporation license or an application pending for one at the time of its bid. And Aetna lost many points for experience because the state said it did not provide evidence of full liability for certain plans with other states.

Jan Stallmeyer, a senior vice president for Aetna Medicaid, said Tuesday the state should take time to further re-examine the questions raised about the manner in which the contracts were awarded and re-awarded.

“Given the size of this contract and the importance of these healthcare services to hundreds of thousands of Ohio citizens, many of whom are in the most vulnerable segments of society, it is in everyone’s best interest to have a thorough and transparent review,” Stallmeyer said in a statement.

About $5.1 billion in state and federal money was paid to all the managed care plans in the fiscal year that ended June 30, 2011, according to Job and Family Services.

Senator Paul Introduces Access to Physicians in Medicare Act

Published on 26 June 2012 by admin in Press Releases

Protects seniors from losing access to quality health care

WASHINGTON, D.C. – Sen. Rand Paul today introduced the Access to Physicians in Medicare Act, which aims to reform the current physician reimbursement formula for Medicare patients and replace it with a formula that is similar to the one used to calculate cost-of-living increases for Social Security benefits.

 “As an eye surgeon, many of my patients are seniors, and many of those seniors are Medicare recipients,” Sen. Paul said. “Medicare, in its constant quest to save money, cuts physician reimbursement and in turn puts America’s seniors at risk of losing their access to quality health care. I know the value of quality care and I want to ensure our nation’s seniors continue to get it.”

 

BACKGROUND:

The Access to Physicians in Medicare Act aims to repeal the current reimbursement formula known as the Sustainable Growth Rate (SGR) and replace it with the same formula used to calculate cost-of-living increases for Social Security benefits with a cap set at 3 percent so that physicians will be able to practice medicine without the threat of massive pay cuts each year. This legislation is paid for by repealing the expansion of Medicaid and subsidy payments under Obamacare with any remaining savings going toward deficit reduction.

The legislation:

• Repeals SGR formula used to calculate physician reimbursement under Medicare and replaces it with a formula based on the U.S. Consumer Price Index for Urban Wage Earners and Clerical Workers (CPI-W).
• Prevents a harmful 30 percent cut to physician reimbursement currently set to enact on Jan. 1, 2013, which will jeopardize seniors’ access to quality health care.
• Provides for an annual increase of not more than 3 percent to physician reimbursement each year beginning in 2013.
• Paid for by repealing Medicaid expansion and subsidies payments under Obamacare.

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Taxpayers paying twice for veterans’ health care plans

 

By Gregg Zoroya, USA TODAY

Updated 4h 30m ago

Reprints & Permissions

The Department of Veterans Affairs spent an estimated $13 billion to care for veterans whose health coverage was already paid for by Medicare — a case of the taxpayer paying twice, according to research published Tuesday.

“They pay once to Medicare Advantage plan to deliver all Medicare-covered service and they pay again to the VA to deliver comprehensive care to the same veterans,” said Amal Trivedi, a doctor with the VA and on the faculty with Brown University in Providence.

But Medicare says the $13 billion projection identified in the study, published in the Journal of the American Medical Association, is far too high.

Spokesman Brian Cook said Medicare attempts to reduce managed-care payments to private insurance companies if veterans enrolled in those programs use them less frequently, for example, because they seek treatment from the VA.

Federal law prohibits the VA from recouping expenditures from Medicare-funded health programs. The VA issued a statement Tuesday saying that even if the law were changed, allowing reimbursement would only add administrative complexity that would impede care.

“As an example, VA would have to comply with Medicare rules and policies for Veterans, which would leave VA administering two systems of care: Medicare’s and VA’s,” the statement says.

But without that reimbursement “the government has made two payments for the same services,” the medical study concludes.

Researchers examined records for 1.3 million veterans who were enrolled simultaneously with the VA program and the Medicare Advantage managed-care program between 2004 and 2009.

They found that the number of veterans enrolled in both programs increased during that time frame from 486,000 to 925,000.

In addition, the amount of VA medical care provided to those patients grew from $1.3 billion to $3.2 billion.

Kenneth Kizer, a co-author of the study and director of the Institute for Population Health Improvement at University of California-Davis Health System, said he first became aware of the issue when he was VA undersecretary for health in the 1990s. But Kizer said the study shows the problem has worsened.

Researchers found that veterans remained enrolled in both Medicare Advantage and with the VA for about three years on average. Veterans who are entitled to VA care are also entitled to Medicare after age 65.

Contributing: Kelly Kennedy

The truth behind the marketing … Louisville hospitals not as safe as Appalachia

Insider Louisville Guest blogger Dr. Peter Hasselbacher:

By Guest Bloggers |

 

Hospital grades across Kentucky. (Click to enlarge.)

(Editor’s note: This post originally appeared on the Kentucky Health Policy Institute blog.)

By Dr. Peter Hasselbacher, Kentucky Health Policy Institute

One of the themes presented on my Kentucky Health Policy Institute blog during the last year is that consumers should be careful about uncritical acceptance of unsupported promotional claims of quality by hospitals and other medical providers.

After all, how can every hospital be “the best?” As in Lake Woebegone, at least some hospitals have to be average, and unfortunately, some even less than average when compared to their peers.

The Leapfrog Group is one of the most respected organizations currently measuring and publicizing the safety and quality of care in hospitals. They use publicly available data and information provided voluntary by the hospitals themselves.

Earlier this week, that organization made available their Hospital Safety Score derived from 26 different elements. I have not personally seen a more comprehensive panel of items rigorously assessed for this purpose.

It includes – but is broader than – the “Hospital Compare” scoring system published by Medicare. I would certainly have more confidence in these Hospital Safety Scores than any claims about quality or safety made by the hospitals themselves.

In Leapfrog’s words, “The Hospital Safety Score is an A, B, C, D, or F letter grade reflecting how safe hospitals are for patients.”

I was frankly surprised by the results. You can review the final Safety Scores here, sorted by score and Hospital. However, you should also take a look at the Hospital Safety Score website yourself because it lists all the underlying data for the 49 hospitals studied.

Select Kentucky as the state without any other qualifier. Click the “agree to terms of use” and you will see all the scores and a map. Unfortunately for us, the small federally-designated Critical Access Hospitals, of which there are some 29 in Kentucky, are not required to report publicly their safety statistics. [Who is being served by this rule?]

Here are some of the facts that jumped out at me.

Louisville not so good!

Based on the extensive panel of items measured, the 49 Kentucky Hospitals received scores as follows: ‘A’s- 10, ‘B’s- 11, and ‘C’s- 26.

Both state University Hospitals received an initial score of either a D or an F.

All the (other) hospitals in Louisville received a score of only C.

Compare the hospitals of Louisville to the hospitals of deep Appalachia which earned 4 ‘A’s, 3 ‘B’s, and one ‘C’. To my eye, it seemed that the larger the hospital and the larger the city, the worse the safety score. These rankings seem to fly in the face of accepted, or at least self-proclaimed wisdom.

There is a tremendous amount of additional information underlying these safety scores that might help us better understand their robustness and usefulness to us consumers. I was allowed to reprint the Kentucky scores and map with the permission of the Leapfrog group. I intend to dig into the supporting data more deeply to more fully understand the process and to try to explain the results. In the meantime, I suggest the following.

Conclusions:

1. Start informing yourself. The items measured and discussed by the Safety Scores are becoming the standard panel and vocabulary of hospital quality and safety. We will be presented with these concepts in the future much more often. That is a good thing! We deserve more than just financial transparency and accountability from our healthcare system. It is our job collectively to demand that our hospitals do a better job, or at least explain why they disagree with those who are doing the analysis. We are also obligated to make sure such ratings are reliable.

2. I will begin here myself. All of you hospitals in Louisville that I might have to use personally had only average or worse safety scores. Why is that? Do you disagree? What are you doing about it? Show me how you are getting better. Please do not make any more claims about the excellence of the care that you provide until you can explain why presumably impartial judges rated the safety of your institutions as less even than good.

3. To the University of Louisville I can only repeat my earlier requests. The quality and safety of the medical care you provide as measured here and by others is poor at best. This is unacceptable. How many more outside examinations do you need before you get the message? The most important priority of your School of Medicine and your other health professional schools is to provide the highest quality medical care to the patients you serve.

You cannot even begin to provide high quality medical education unless you succeed in fulfilling this most important responsibility first. Sponsoring research is a luxury to be enjoyed only when you get medicine and education right.

Putting major efforts into your commercial research enterprise while running a hospital that your own faculty refuses to use in my mind constitutes abandonment of your duty to the Commonwealth. I am holding you responsible.

Our community and governmental leaders should too.

About Dr. Peter Hasselbacher: Peter Hasselbacher MD is Emeritus Professor of Medicine at the University of Louisville.  He has been a medical educator, clinician, scientist, and health care executive for 35 years. Currently, he is president of KHPI.

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