Medicare payment changes draw fire

Neurologists rip lower test fees

By Chelsea Conaboy | BOSTON GLOBE

NOVEMBER 26, 2012

Neurologists in Boston and nationwide are objecting to a plan that would pay them less for certain diagnostic tests, a change meant to cut Medicare costs and direct more money to primary care physicians whose pay is widely seen as inadequate even before they take on more work under the national health care overhaul.

The neurologists are asking federal regulators to reconsider the plan and argue that the cuts, made under a provision of the Affordable Care Act, could undermine patient care and limit access to neurology services.

The debate highlights the short-term pain and pressure expected from changing the way health care is paid for, a process certain to produce winners and losers.

“This loss of revenue is devastating,” said Dr. Bruce Sigsbee, a neurologist in Rockport, Maine, and president of the American Academy of Neurology. The cuts cause harm not only to the subset of neurologists who perform the tests but to the specialty as a whole, he said.

The tests effectively subsidize other kinds of neurology care that provide less lucrative payments, and specialists said the change could prompt some neurologists and hospitals to see fewer Medicare patients.

But Jonathan Gruber, an MIT economist who was a consultant to the Obama administration during drafting of the Affordable Care Act, said there is little doubt that more money must be directed to primary care services.

“We have a system that everyone agrees is out of whack,” Gruber said. “Everyone agrees we spend too much on health care. The problem is, once we get to fixing it, that’s where the disagreements arise.”

The median pay for a neurologist in the United States last year was $254,836, according to the latest physician compensation survey by MGMA, previously called the Medical Group Management Association. That’s far lower than for doctors in the high-paying specialties of cardiology or dermatology but higher than for family physicians, whose median pay was $200,114.

Medicare is projected to pay about $1.6 billion for neurology services next year, 7 percent less than in 2012, according to payment rules issued by the Centers for Medicare & Medicaid Services.

Much of that reduction comes from a change in how Medicare will pay for tests used to understand nerve and muscle pain or weakness and to diagnose conditions such as carpal tunnel syndrome, ALS, and forms of muscular dystrophy.

Historically, neurologists have billed for each nerve they test — sometimes dozens in one patient. But the fee for each nerve includes costs such as the time a doctor spends greeting a patient, meaning those overhead costs are assessed multiple times.

Specialty groups that annually review the billing system in conjunction with the American Medical Association identified the neurology codes as “potentially misvalued,” leading to overpayment by the federal government. The Centers for Medicare & Medicaid Services agreed and issued a rule that includes new codes grouping nerves together and allowing lower charges overall for the tests.

The result is that while Medicare will pay slightly more for some tests, it will pay half as much as it did in 2012 for other tests, according to analyses from specialty medical groups.

“Medicare will still pay for the tests that a neurologist determines are necessary to diagnose a problem, but will only pay for the same practice expenses once,” Medicare chief Jonathan Blum said in an e-mailed statement.

Sigsbee’s group has asked members to contact lawmakers and is requesting that the agency phase in the change and is considering appealing the change.

“Medicare’s budget is under water, and they’re looking for ways to reduce payments,” said Dr. Lee Schwamm, vice chairman of the Department of Neurology at Massachusetts General Hospital. But the cuts could have “significant negative consequences,” he said.

Most major hospitals have centers to conduct the specialized testing, known as nerve conduction and electromyography. Several Boston neurologists said revenue from those tests offsets the poorer payments that come from office visits when doctors spend time with patients assessing complicated neurological disorders. They worried that, as often happens, private insurers would adopt similar cuts.

“There’s a feeling there of, where did this come from?” Schwamm said. “This seems rather abrupt.”

Schwamm said he expected Mass. General to continue using the tests for patients whose conditions warrant it, but he worried the cuts could limit patient access if some providers stop offering the tests or only serve people who are privately insured or can afford to pay more out of pocket.

Mass. General is among several hospitals in Massachusetts evolving into an accountable care organization. Under such a system, Medicare effectively sets a target for the cost of overall patient care, with hospitals sharing in savings or losses. With such arrangements, which emphasize preventive care, the neurology cuts could become irrelevant, Schwamm said, and doctors’ pay would be less contingent on fees from individual tests or treatments.

Similar changes are occurring in the private insurance market, but they won’t happen all at once. “The hardest time is the transition,” he said.

Sigsbee said the cuts could push some neurologists not employed by a major hospital out of business or make it harder to recruit young doctors to the speciality.

Medicare payments for family physicians next year are expected to increase 7 percent, to $5.9 billion, according to the physician fee schedule. (The increase will hold only if Congress — as it has for several years — overrides a provision to limit Medicare spending.)

Changes like the neurology cuts could help to push providers into newer models of care, such as accountable care organizations, Gruber said. But lessening the blow in the short term is tricky as the government corrects such “cross subsidies,” when what may be seen as overpayment for one test or treatment helps to cover the cost of other worthwhile services. “I’m stuck on that,” he said.



Administration unveils health care regulations

By Kelly Kennedy, USA TODAY

Starting in January, insurers will be unable to charge consumers more based on such factors as health status and occupation — but smoking may cost you.


Rules would give employers breaks for encouraging wellness programs

Insurers can charge more for people who smoke

Insurers will be unable to charge more based on claims history and other factors

11:45PM EST November 20. 2012 – WASHINGTON — The Obama administration released new health care regulations Tuesday that preclude insurers from adjusting premiums based on pre-existing or chronic health conditions, tell states what benefits must be included in health exchange plans, and allow employers to reward employees who work to remain healthy.

“The Affordable Care Act is building a health insurance market that works for consumers,” said Health and Human Services Secretary Kathleen Sebelius. “Thanks to the health care law, no one will be discriminated against because of a pre-existing condition.”

The rules released so far aim to:

— Stop insurers, starting in January, from charging more for insurance or refusing service to people who have pre-existing or chronic health conditions. Insurers may not charge seniors more than three times the amount they charge young people. Now, insurers in 42 states charge seniors five or more times the amount they charge young adults.

— Allow insurers to charge smokers more, as well as adjust premiums based on family size and geography.

— Prohibit insurers from using claims history, health status, gender and occupation to increase premiums.

— Require states to have 10 essential benefits, such as prescription drug coverage or hospital care, provided in the new health care exchanges — websites set up so consumers can quickly and easily see what plans are available in their states. The benefits are meant to make it easier for consumers to see a comparison in prices and coverage. However, the new rules allow the states to determine how those benefits are set up.

— Allow employers to use wellness programs to promote health and try to control health care costs. Employers may reward people for annual exams or regular work outs, but they may not punish people who don’t engage in those activities.

— Propose implementing and expanding employment-based wellness programs to promote health and help control health care spending, while ensuring that individuals are protected from unfair underwriting practices that could otherwise reduce benefits based on health status.

None of the regulations is unexpected: They provide guidance for implementing provisions within the 2010 health care law. They are also not final. There is a 90-day comment period during which the government and participants can negotiate to adjust the regulations.

Some industry representatives have complained that the rules were released too slowly or delayed until after the election for political reasons.

“We thought we needed to have the regulations – all of them – by 2012,” said Alissa Fox, senior vice president of policy for the Blue Cross and Blue Shield Association. “Everything is so interconnected you really need to see the whole picture.”

Without the rules, she said, states will make avoidable mistakes as they create their exchanges.

Essential health benefits, Fox said, should not be so comprehensive that plans become too expensive. The government, she said, should focus on keeping plans simple to help states meet their deadlines.

“While additional flexibility on essential health benefits is a positive step, we remain concerned that many families and small businesses will be required to purchase coverage that is more costly than they have today,” said America’s Health Insurance Plans’ CEO Karen Ignagni.

Others have argued for stronger requirements.

“This flexibility should not become a reason to allow for benefit restrictions and limitations on people with certain medical conditions like cancer,” said Stephen Finan, policy director at the American Cancer Society Cancer Action Network. “We hope the country will move toward a uniform definition of coverage in the next few years that provides patients with an evidence-based continuum of care, regardless of their geographic location.”

Insurers and employers have already started cooperating to implement ideas in the proposed rules, Fox said, such as offering lower premiums to people who undergo wellness checks. In some cases, a wellness check that catches a heart condition early through a blood test could save an employer several thousand dollars.

“The Affordable Care Act recognizes that well-run, equitable workplace wellness programs allow workers to access services that can help them and their families lead healthier lives,” said Secretary of Labor Hilda Solis. “Employers, too, can benefit from reduced costs associated with a healthier workforce.”



After Divorce, Many Women Lose Health Insurance

IDEAS MARKET REVIEW- The Wall Street Journal

November 14, 2012, 11:40 AM

By Daniel Akst

Shedding light on the issues of divorce and health care, a new University of Michigan study estimates that 65,000 American women become uninsured each year as a result of marital dissolution.

Indeed, among married women who had health insurance and then divorced, 17 percent were uninsured six months later. There was also a big shift among divorced women from private insurance to public insurance, such as Medicaid. After divorce an estimated 115,000 women each year lose private coverage, the study reported, but many are bailed out by government programs.

The loss of insurance was especially prevalent among divorced women who’d been covered as dependents on their husband’s health insurance. In this group, 23 percent were uninsured six months after divorce. Another risk-factor for ending up without coverage: being too affluent for government insurance programs but not affluent enough to afford costly private coverage.

By way of perspective, last year about 48.6 million people were uninsured, the Census Bureau has reported.


Remaking Health Care: Change the Way Providers Are Paid

November 19, 2012

Mark T. Bertolini, Chairman, President and CEO, Aetna Inc. ?Larry J. Merlo, President and CEO, CVS Caremark Corp. ?Brent L. Saunders, President and CEO, Bausch & Lomb Inc.

Subject Expert

Mark D. Smith, M.D., President and CEO, California HealthCare Foundation

In the debate over the nation’s finances, health care is one of the biggest items on the agenda. How do we bring down soaring costs as more people get coverage and more baby boomers head into retirement?

The Wall Street Journal’s Laura Landro moderated the task-force discussion on remaking health care. Here are edited excerpts of their presentation of priorities to the CEO Council.

Eliminate Waste

LAURA LANDRO: Mark Smith, chief executive of the California Health Care Foundation, gave us some initial proposals. We ended up with some very provocative ideas about national standards for quality and price transparency, even looking at the agricultural subsidies that might contribute to bad habits like smoking and consumption of high-fructose corn syrup. A lot of people are also very concerned about the limited time that we have to get state insurance exchanges. How are we going to get insurance to our employees? Should we be taxing people for health benefits above a certain amount? For our top priorities, I’m going to turn over the first two to Mark Bertolini.

MARK BERTOLINI: The Institutes of Medicine last year published a report that said we have $750 billion a year of waste in the health-care system. If we solve that problem, over the next 10 years we solve half of the nation’s deficit. And if we just get 20% of it, which is a 6% change in health-care costs, we pay for the Affordable Care Act.

What happens in our system is if you get paid by a unit of service, you do more units of service. Our notion was to shift to population management. You assess the disease burden, the demography and the trends in the community and build a system and budget around that. You reward the system for improving the productivity and health of the population they serve.

If we were to say, “Here’s the budget you have to take care of all these people. It is yours. You manage it effectively,” then the system should organize itself appropriately and look for opportunities to make it better. Seventy-five percent of the next $10 trillion in the nation’s debt is Medicare and Medicaid. If we can stem the increase, we can work on the deficit.

The second notion is transparency. We need to have a true market where people understand what the prices are for health care. Today, that’s concealed.

Imagine a supermarket where you go in with your cart and pull items off the shelf with no prices on them. You take it up to the counter. It’s scanned. The clerk swipes your card and says, “In 30 days you’ll get your credit-card bill, and you’ll know how much your groceries cost.” Would you shop there? But that’s how the health-care system works. We need to create transparency in the system so people can understand how much health care costs.

The Role of Care Givers

LARRY MERLO: The third one that we talked about is new delivery models, focusing on the role of licensed health-care professionals such as nurses and pharmacists. This is responding to a shortage of primary-care physicians that exists today and is expected to continue to grow.

What we can do is to harmonize the licenses of health-care professionals to a scope of practice that is based on their education, training and experience versus just the regulations within the state where they practice. At the same time, this would allow for the cross-licensure of these professionals across states. Only 16 states have standardized scope-of-practice regulations to allow nurse practitioners to practice independently and really complement primary-care physicians. At the same time, you look at the ability to expand pharmacist-administered immunizations. It’s inconsistent across the states.

The goal is to increase access to care, reduce costs and improve the quality of care. Tied to this is health-care information-technology connectivity. This would enable health-care providers at all points of care to engage patients, to see if they’re adhering to prescriptions and having preventative checkups.

The fourth one is primary care, and it picks up on the theme of today’s shortage of primary-care physicians. We talked about incentives to improve the balance between specialty and primary-care physicians, like education and emphasizing reimbursement rates. At the same time, there’s forgiving medical-school loans. Some of these same principles would also apply to the nursing profession.

The Top Four Recommendations

1. Population Health Management Explicitly gear our system around population health. Create public-private partnerships to encourage healthy behavior, and identify specialty populations with unique needs, such as the seriously mentally ill. Reshape financial incentives to meet the goal of population health, and build capacity and reimbursement systems to support it. Have the administration clarify how to deal with the huge shift into insurance exchanges.

2. Transparent Standards The Center for Medicare and Medicaid Services should develop, and require all public-health programs to adopt, uniform standards for health-care service quality, performance and price transparency so consumers can make value choices. And it should encourage states to follow suit.

3. New Delivery Models Use the full continuum of care givers, such as nurses and other professionals. Create uniform standards for licensing care givers across the country, and encourage more care in retail clinics, pharmacies and other sites. Require patients’ medical data to be available electronically.

4. Primary Care Provide incentives to correct the imbalance of specialists to primary-care doctors by changing reimbursement rates, increasing funding for undergraduate and graduate medical education for primary care, and forgiving medical-school loans. Increase focus on advanced nurses and nurse practitioners as care providers.

Copyright 2012 Dow Jones & Company, Inc. All Rights Reserved


Kentucky’s diabetes rate jumps by 158 percent in 15 years


Published: November 16, 2012 Updated 4 hours ago

 It’s the second biggest increase in nation

By Mike Stobbe — Associated Press

NEW YORK — The nation’s diabetes problem is getting worse, and Kentucky showed the second biggest jump in cases in the nation over 15 years, trailing only Oklahoma, according to a new report from the Centers for Disease Control and Prevention, issued Thursday.

The CDC study, appearing in the Morbidity and Mortality Weekly Report, found that Oklahoma’s diabetes rate increased 226 percent. Next was Kentucky at 158 percent; Georgia, 145 percent; and Alabama, 140 percent.

The South’s growing weight problem is the main explanation, said Linda Geiss, lead author.

“The rise in diabetes has really gone hand in hand with the rise in obesity,” she said.

Bolstering the numbers is the fact that more people with diabetes are living longer because better treatments are available.

The disease exploded in the United States in the last 50 years, with the vast majority from obesity-related Type 2 diabetes. In 1958, fewer than 1 in 100 Americans had been diagnosed with diabetes. In 2010, it was about 1 in 14.

Most of the increase has happened since 1990.

Diabetes is a disease in which the body has trouble processing sugar; it’s the nation’s seventh leading cause of death. Complications include poor circulation, heart and kidney problems and nerve damage.

The new study is the CDC’s first in more than a decade to look at how the nationwide boom has played out in different states.

It’s based on telephone surveys of at least 1,000 adults in each state in 1995 and 2010. Participants were asked if a doctor had ever told them they have diabetes.

Not surprisingly, Mississippi — the state with the largest proportion of residents who are obese — has the highest diabetes rate. Nearly 12 percent of Mississippians say they have diabetes, compared to the national average of 7 percent.

But the most dramatic increases in diabetes occurred largely elsewhere in the South and in the Southwest. Oklahoma’s rate rose to about 10 percent, Kentucky went to more than 9 percent, Georgia to 10 percent and Alabama surpassed 11 percent.

An official with Oklahoma State Department of Health said the solution is healthier eating, more exercise and no smoking.

“And that’s it in a nutshell,” said Rita Reeves, diabetes prevention coordinator.

Several Northern states saw rates more than double, too, including Washington, Idaho, Montana, Wyoming, South Dakota, Minnesota, Missouri, Ohio and Maine.


Study points to problems in Medicaid managed care


Written by
Mike Wynn
The Courier-Journal

FRANKFORT, KY. — A new study funded by the Foundation for a Healthy Kentucky says the state’s Medicaid managed-care program has led to gaps in health care services and appears to lack case management efforts needed to improve care.

Gov. Steve Beshear implemented the managed-care system in November 2011 with the goal of saving millions of dollars and improving health care for roughly 560,000 low-income and disabled beneficiaries outside the Jefferson County region.

The study — presented to the joint Health and Welfare Committee on Friday — evaluated the first eight months of the program, raising questions over the adequacy of provider networks, new administrative requirements and quality care for patients.

Among the key findings, the study reported that:

• Advocates are concerned about gaps in behavioral health care while providers said patients have experienced breaks in medication for chronic conditions.

• Provider networks continue to fluctuate, and case studies indicate that many providers do not contract with all the managed-care companies in the program.

• Providers and advocates said they have not seen “substantial evidence” of new case management programs.

• Auto-assignment of beneficiaries into health plans caused patients to switch plans at a high rate during the start-up phase.

• Managed-care companies are dissatisfied with capitation rates and question the ability to provide quality services at those rates.

• Health care providers report problems working with the managed-care companies, including delays in prior authorizations for services, claim denials and difficulties getting information and understanding company coding systems.

Friday’s study represents the initial findings of a three-year evaluation that the foundation is funding to review implementation of managed-care in Kentucky. But advocates, health-care providers and lawmakers have been decrying most of the issues for months.

Senate Health and Welfare Chairwoman Julie Denton, R-Louisville, said the report didn’t shed much light on the issues but helped reiterate some important points.

“I was right over a year ago when I said this is going to be a disaster,” she said.

Sen. David Givens, R-Greensburg, called the report a “little soft” in its discussion of the issues, but said the Beshear administration should weigh those concerns when considering the benefits and costs of expanding Medicaid.

The state originally contracted with three managed-care companies — CoventryCares of Kentucky, Kentucky Spirit Health Plan and WellCare of Kentucky — under a three-year deal to administer the $6 billion federal and state program.

The Jefferson County region, which comprises around 170,000 patients, was managed under an exclusive contract with Passport Health Plan for the past 15 years. But the federal government required Kentucky to establish more competition in the region this year.

In response, the state has contracted with four companies — Passport, Wellcare, Coventry Cares and Humana — to serve the region, and Passport has since filed a protest against the state’s bidding process.

Denton, in a charged criticism of the health cabinet Friday, said the move will drive up operation costs and bring problems from across the state into the Jefferson County region.

Cabinet Deputy Secretary Eric Friedlander countered that many states have faced the same issues “but that is no reason not to move forward and try to make the system better, which is what we will try to do and have been trying to do.”


States try to innovate with health exchanges

Kelly Kennedy, USA TODAY

1:01AM EST November 10. 2012 – States should use their creation of health insurance exchanges required by the 2010 health care law to create prevention programs aimed at promoting long-term savings, expert say, but state officials argue that those “wish lists” might have to wait so states can meet their deadlines.

“To do something different, I sure wish we had an extra year,” said Howard “Rocky” King, executive director of Cover Oregon, Oregon’s health insurance exchange. “Our first priority is to come up with something that works.”

That means states such as Oregon hope to build the foundation of their exchangesfirst and then add the extras over the next few years.

“States could play a huge, important role in prevention and care coordination,” said Ken Thorpe, head of Emory University’s health policy department. “But if we’re looking at yesterday’s benefits, we’ll get yesterday’s problems. We need to pull costs out of the system.”

Otherwise, more people will be covered through the 2010 health care law, also known as the Affordable Care Act, but premiums will continue to go up, Thorpe said.

Rather than focusing purely on making insurance available, states could build evidence-based prevention and lifestyle-change options into the plans. Theycould insist that their insurers pay teams of hospitals, primary-care physicians, home health care professionals and hospice providers a set price to care for a consumer, rather than pay by the injection, scan or visit.

Without such changes, Thorpe said, health care costs will keep rising.

So far, Thorpe said, California has done the most to promote innovation in itshealth care exchange.

Health exchanges are state- or federally run websites that allow consumers to choose a health plan, as well as to compare benefits and costs of each plan. Some states will allow all insurers to participate; others have asked insurers to bid to participate; and some states are creating a list of requirements insurers must meet to participate.

Peter Lee, California Health Benefit Exchange’s executive director, said that insurance has “been a game of avoiding sick people” to keep insurers’ costs low. Now insurers must take everyone, and that means keeping chronically ill people stable and trying to prevent people from becoming sick in the first place.

In part, California can push for change because there are so many players: 33 health plans submitted bids to be part of the health exchange.

“The exchange has asked the plans not just for the lowest cost on Day One, but the lowest costs over the long term,” Lee said. “Our board said one of our values is to be a catalyst for change.”

California officials wanted health plans to show how they pay for and reward primary care, provide better care for the chronically ill and build in preventive services, Lee said.

Not every state is moving this direction. C.J. Bawden, spokesman for the SilverState (Nevada) Health Insurance Exchange, said their main goal is to take as little money from the federal government as possible by outsourcing much of the technology of their exchange to Xerox, rather than building from the ground up.

“A lot of states want to build it from the ground up and keep it in-house,” Bawden said. “We came out with a good business plan.”

Everyone with plans that meet federal and state requirements may participate in whatBawden called a “free-market” approach. “We’re trying to facilitate without doing a lot of market disruption,” he said.

Washington, D.C., exchange officials are waiting to hear what the plans will come up with, but they included preventive services, health club memberships and coordinated care included in the plans on their wish list.

Mohammad Akhter, the chairman of the exchange, said Washington’s main innovation wasthat exchange board members are experts in medicine and education and not politicians.

“We expect more innovations because of that,” he said. Negotiating possibilities with insurers is difficult until everyone knows just how manypeople are enrolled in the exchanges, Oregon’s King said.

Oregon officials have asked that each carrier offer several plans, so that they’ll end up with 10 or so carriers with five or six possibilities each for the smallgroup market. That way, someone who knows she probably won’t need a lot of time with the doctor can choose a high-deductible plan.

In the meantime, the state is testing out new care models in their Medicaid and state health programs to see what works to keep costs down, King said. These things include preventive-care programs, as well as making sure doctors arepaid to keep people healthy, rather than through a fee-for- service program.

In Rhode Island, only four carriers exist, but officials still hope to set up different products than were available before. They’ll be negotiating with the insurers over the next month.

Christine Ferguson, Rhode Island’s director of the health benefit exchange, said the plans will be able to do more with a higher concentration of people.

The state hopes to build the exchange, collect data about what works and what doesn’t, and then re-evaluate. For example, do cancer screenings and immunizations affect the number of days people go to work or children go toschool?

“So we’re looking at improvement,” she said. “The exchange is a catalyst to move the debate to reform.”


Statewide Insurance Services Selects COMS Interactive as Preferred Partner

Enhancing Care to Residents by Reducing Avoidable Hospital Re-admissions

By COMS Interactive, LLC

Published: Tuesday, Nov. 13, 2012 – 5:32 am

LOUISVILLE, Ky., Nov. 13, 2012 — /PRNewswire/ — Statewide Insurance Services (SIS), a subsidiary of the Kentucky Association of Health Care Facilities (KAHCF), has signed a Preferred Partner Agreement with COMS Interactive, LLC (COMS).  Given SIS’s objective of helping KAHCF members enhance the quality of resident care by reducing unnecessary re-hospitalizations, the partnership with COMS is a natural extension of the association’s membership services.  The three-year agreement focuses on improving clinical and financial outcomes for each member facility.

The COMS flagship Disease Management software, Daylight IQ™, is used in leading nursing homes, assisted living facilities and home care organizations nationwide.  The Software as a Service (SaaS) product features a series of integrated, disease-based library of clinical protocols that significantly empower the entire care team including physicians, therapists, nurses, and nurse aides, and facilitates enhanced communication between all parties.  The initial Daylight IQ™ training can be completed in less than two hours, immediately improving clinical results and providing positive tangible financial outcomes.

“With almost 60 years representing long-term care providers in Kentucky, it is incumbent upon us to offer products and services to KAHCF members which facilitate the continued improvement of clinical and financial outcomes,” noted Ruby Jo Lubarsky, President, SIS and KAHCF.  “In light of various Centers for Medicare & Medicaid Services (CMS) mandates, it is critical that our member organizations identify ways to reduce unnecessary re-hospitalizations, and the Daylight IQ™ bedside technology will help our member organizations achieve this goal.”

Daylight IQ™ empowers clinical teams with information and technology at the point of care.  This results in caregivers providing better care for residents.  A key component of Daylight IQ™ is the reduction in unnecessary hospital re-admissions by as much as 50%, a related decrease in premature mortality rates, and an increase in successful discharges.

“As the eighth State Association partnering with COMS, we commend SIS and KAHCF management for their thought leadership and strong advocacy for implementing progressive clinical solutions,” noted Edward J. Tromczynski, Chief Executive Officer, COMS Interactive.  “KAHCF plays a key role in supporting member facilities’ clinical excellence, and we look forward to working with the KAHCF team and association membership.”

Industry data shows that the average skilled nursing facility resident has a complicated disease profile, with one primary disease and up to eight secondary diseases or afflictions.  Over 70% of re-hospitalizations are due to the progression of secondary diseases or the onset of a new disease.  By providing early detection of changes in condition, Daylight IQ™ highlights potential problems and offers caregivers the opportunity to respond, preventing further advancement of the illness.

About Statewide Insurance Services, Incand Kentucky Association of Health Care Facilities

Founded in 1954, the Kentucky Association of Health Care Facilities (KAHCF) represents proprietary and nonproprietary nursing facilities and personal care homes across the Commonwealth.  An affiliate of the American Health Care Association, KAHCF provides a wide variety of services to member facilities including legislative and regulatory activities, professional development, statewide recognition programs, publications, media relations, research and advocacy relations.  In order to meet the growing needs of the membership, Statewide Insurance Services (SIS) was incorporated in 1992 as a subsidiary of KAHCF. SIS provides association members with an array of insurance services as well as providing financial support to KAHCF through various Preferred Partners.  For additional information, visit the KAHCF website or by calling #502.425.5000.

About COMS Interactive, LLC

COMS Interactive, LLC deploys processes and systems that stabilize and improve resident health while improving financial outcomes for skilled nursing facilities. The Daylight IQ™ Software as a Service (SaaS) product combines business administration, disease management and long-term healthcare knowledge to empower the nursing team, reduce medical errors, more efficiently address resident healthcare needs and increase facility revenues.  This combination of clinical and technical processes can save millions of dollars a year in preventable hospital re-admissions. Additional information regarding COMS Interactive and Daylight IQ™ is available or by contacting COMS at #330.650.9900.

SOURCE COMS Interactive, LLC

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Passport Files Formal Complaint over Louisville Medicaid Contracts

Kentucky officials are once again facing the prospect of lawsuits over efforts to expand managed health care within  Medicaid. 

This time, it’s Passport Health Plan that is threatening to sue, based on what they call broken rules and promises made to them. 

Passport is a group of doctors and other medical personnel that has operated as a managed care operator for decades in Louisville’s Medicaid region. Passport is facing competition for the first time next year, thanks to the state awarding contracts to Coventry Cares, WellCare and Humana for that region. 

Passport CEO Mark Carter claims that his group was promised 41 percent of the Louisville Medicaid membership, based on their ability to have contracts with nearly every doctor and hospital in the region. 

But the state actually assigned Passport only 27 percent of the members. Coventry and WellCare each received 25 percent and Humana received 23 percent.  That’s a 73 percent reduction in the membership Passport currently manages.

Because of that, Passport has formally asked for the state to stop the process of implementing the new Louisville region contracts until the issue is resolved. And if the state refuses, Passport has threatened to sue. 

But Passport Vice President Jill Bell says she hopes it doesn’t get to lawsuits.

“Actually we’re committed to working with the state to find a reasonable solution and I’m pleased to let you know that we have been in contact with them, so we hope to reach a resolution very soon,” she said.

Passport claims it should receive its potential maximum allotment of 41 percent because it has the best network of agreements with doctors and hospitals, while Humana has to build theirs from the beginning. WellCare also has to build a Louisville network, but operators statewide. Coventry Cares also operates statewide, but has few contracts after their broke many of them. Coventry currently does not have contracts with Kentucky One Health or Norton Hospitals, two main hospital networks in the region. 

Regardless of outcome, Bell said Passport will aggressively market itself to Medicaid to sign up with them during open enrollment. 

Medicaid Meltdown update: Passport files formal complaint against state over Medicaid contracts

By Staff | Published: November 2, 2012

Mark Carter, Passport CEO.

Another salvo has been fired in the widening war over the Beshear Administration’s Medicaid reforms.

Passport Health Plan, the Louisville-based non-profit Medicaid managed care organization, filed a formal protest yesterday opposing how patients are being divvied up its area, Region 3, after state officials brought other MCOs into the region.

Region 3, which includes Louisville and 15 surrounding counties, covers about 180,000 Medicaid members.

Passport executives filed the protest after “discussing concerns around the assignment of members to health plans with officials from the Cabinet for Health and Family Services’ Department for Medicaid Services,” according to a news release.

Kentucky officials announced in May they would issue a request for proposal to add other MCOs in Region 3 despite the fact that the National Committee for Quality Assurance.and even state officials rated Passport the state’s most efficient and problem-free Medicaid managed care provider.

The move added Humana, WellCare Health Plans and Coventry Health Care to Region 3, potentially cutting Passport’s business by 75 percent.

Now, Passport executives are saying the patient assignment plan is flawed.

From the release:

The assignment of members was arbitrary and will cause unnecessary and harmful disruption of patient’s continuity of care and, moreover, inappropriately increase the cost of providing Medicaid services to the Commonwealth and ultimately the taxpayers. “Passport exists for one reason and that is to help Kentuckians lead healthier lives, which is embodied in our mission statement of improving the health and quality of life of our members.” said Mark B. Carter, Chief Executive Officer. “Our organization doesn’t exist to generate a return for shareholders. We exist as forceful advocates for some of the least fortunate people in our community. I am convinced that patients will be harmed if the arbitrary assignment process is utilized. I am also concerned that the cost of providing care in Region 3 will be materially increased to the detriment of Kentucky tax-payers.” continued Carter. “We shared this information with the Commonwealth and the DMS went forward with the assignment process. We felt compelled to take this action.”

What this all means is unclear. CHFS officials were not in their offices when Passport executives announced the complaint Thursday evening.

This is the latest skirmish after the Beshear Administration implemented a new Medicaid managed care system one year ago, replacing a fees-for-services system.

Medicaid managed care contracts were awarded in July, 2011 to three bidders – St. Louis-based Centene Corp., Tampa-based WellCare Health Plan and Bethesda, Md.-based Coventry Health Care – in the other seven Medicaid regions in Kentucky outside Region 3.

The result has been that outside Passport’s area, doctors and other providers have gone unpaid and physicians groups and clinics have been ejected from insurer networks in the poorest parts of Kentucky as the insurers struggled to deal with huge and mounting losses.

There have been suits and counter-suits. Late last month, Centene, which operates in Kentucky as Kentucky Spirit, announced it was terminating its Kentucky contract and suing the state after $120 million in losses.

In the suit filed in Franklin Circuit Court, Centene executives charged state cabinet officials misled Centene officials about the overall health of Kentucky’s Medicaid members during the period leading up to the awarding of $6 billion in  contracts back in November 2011.

The Centene suit also claims Kentucky officials submitted incorrect data to the insurer after rushing to stand up a Medicaid managed care system.

More as we know more.

The back story on Kentucky’s Medicaid Managed Care Meltdown:

In April 2011, state officials asked health insurers to submit managed-care proposals for the $6 billion worth of care 800,000 poor and elderly Kentuckians receive annually under the federal/state Medicaid program. At the time, Gov. Steve Beshear touted the switch to managed care from fee-for-services as saving the state $375 million over the life of the initial three-year contracts. Insiders said officials in other states such as Georgia took as long as 18 months to make the change while Kentucky tried to do it in less than six months.

The three companies receiving MCO contracts were Centene, WellCare and Coventry Cares, all publicly traded companies. (Passport Health Plan, a Louisville-based non-profit controlled by providers, is the managed care insurer for Jefferson County and 17 surrounding counties.)

Each bid for the Kentucky MCO business was based on per-member, per-month health care costs projections. Low-bidder Centene bid $330 per member, per month, according to documents submitted to Insider Louisville. WellCare bid was based on $400 per member per month, and Coventry bid $436 per member per month.

The algorithm state officials used to choose the winners favored the low-cost plans, obviously, because therein lies the savings.

The state methodology initially assigned members to a plan, with the two lowest cost plans getting more members than the highest.

If Centene’s manged care system actually got each member to spend less than $330 per month, they’d make a profit. But crucial to getting costs that low would mean cutting reimbursements to health care providers such as doctors and pharmacies, which meant losing some.