Portland-area competitors try working together to cut costs for Oregon Health Plan

Published: Wednesday, April 04, 2012, 4:24 PM     Updated: Wednesday, April 04, 2012, 6:47 PM

By Nick Budnick, The Oregonian

A new push to reshape health care in greater Portland is reminiscent, its biggest booster says, of the race to land a man on the moon.

Erstwhile health care competitors hope to set aside their differences to care for the region’s 200,000 Oregon Health Plan members, says Legacy Health CEO George Brown. The task is happening in a timeline — Brown snaps his fingers — “that’s like that long. It’s a moon shot for sure. What we’re trying to do, to my knowledge, has not been attempted any place in the country.”

While the space analogy might seem a stretch, it’s no exaggeration to say Brown’s effort faces steep challenges. He leads a loose group of medical and mental health providers from Clackamas, Washington and Multnomah counties that earlier this week notified the state of plans to join efforts to better manage Medicaid spending.

The group aims to have a more detailed application in to the state by the end of the month. However, several members of the group, such as Tuality and Providence, have also sent their own letters to the state, saying they will set up their own care organizations if this group does not come together as planned. In all, 68 private companies and nonprofits have notified the state of their desire to qualify under Oregon’s reforms.

The obstacles are many. In Portland, the goal of operating by August is a tight one. Other care organizations formed under the state law won’t have as many competitors joining up. Federal funding has not materialized either locally or statewide. And the goal – to use new concepts to save money and improve health for low-income people in the region – has not been applied on so grand a scale.

One obstacle the new coordinated care organization won’t have to face is the U.S. Supreme Court. While headlines lately have focused on a challenge to the new federal law focused on Medicare and commercial insurance, Oregon’s law is different, pushing providers into better coordinated care for state Medicaid recipients.

The carrot? A cut of whatever savings the new Oregon health provider groups can find by moving away from traditional fee-for-service care. There’s possible federal funding as well as access to a potentially lucrative market in the future: public employees. Over time, Gov. John Kitzhaber envisions the new coordinated care organizations as serving teachers and state workers.

Though managed care groups already operate in Oregon, the new ones may be larger. The Portland area group calls itself the TriCounty Medicaid Collaborative and includes Providence Health & Services, Oregon Health & Science University, Tuality Healthcare, Kaiser Permanente, Adventist Health, federally funded community health clinics and health departments of Clackamas, Multnomah and Washington counties.

The region’s largest Medicaid provider group, CareOregon, hopes to join the new group, though it won’t cast a final vote until later this month. “It’s an unproven area, and it’s scary,” says CareOregon CEO Dave Ford. “But it’s exciting. It’s going to be an unfolding drama”

In contrast, a competing provider network of 1,500 doctors and nurse practitioners that has participated in discussions expects to go its own way. “The darn thing is so nebulous you really don’t know what they’re doing,” says Jeff Hetherington of FamilyCare.

The would-be collaborative expects to hear any day on a $34-million grant it requested in federal startup funds. The grant application promises focused efforts on those eligible for both Medicare and Medicaid, meaning they are not only poor but elderly or otherwise disabled, about 16,000 in all. The group will encourage healthy lifestyles among all Oregon Health Plan members, not just those most in need of care.

Other money could become available, too. Oregon hopes to hear by August whether it will receive $2.5 billion in federal funds to support its reforms.

Brown says the ongoing discussions, conducted in private, could lead to a federally sanctioned nonprofit.

The new group is dominated by health plans. In theory, their hospitals have the most to lose fiscally from a healthier population. Does it make sense to put them in charge of the new reforms?

“I know that cynical view,” Ford says. “This is more than rhetoric. These guys are activating their organizations in ways I haven’t seen before.”

Brown, for his part, says serving Medicaid patients is not a profit center for hospitals, moreover, participants are setting aside self-interest. “It just absolutely is surprising to me. The greater good has been held out as the right thing to do and the path to follow.”

Nick Budnick

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.”



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.



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.”



Rules For New Insurance Marketplaces Give Insurers Clout

By Julie Appleby

KHN Staff Writer

Mar 12, 2012

Insurers and other industry representatives will get to fill as many as half the seats on the governing boards for state health insurance exchanges, under final rules for the marketplaces issued today by the Department of Health and Human Services.  At least one seat must be reserved for a consumer representative.

The long-awaited rules are likely to disappoint consumer advocates who would have preferred the governing boards “be dominated by consumers,” said Timothy Jost, who speaks as a consumer advocate before the National Association of Insurance Commissioners and is a professor at the Washington and Lee University School of Law.  But Jost said he is pleased the final rules require at least one consumer representative. “It at least gives a toe-hold,” he said.

But they may also frustrate insurers who had sought to prevent the governing boards from imposing requirements on plans beyond what is included in the 2010 health care law. HHS left that possibility in place, however, writing, “We continue to believe that states are best equipped to adapt the minimum exchange functions to their local markets and the unique needs of their residents.”

The exchanges are seen as a key element in the health law, offering one-stop shops for individuals and small businesses looking to purchase health insurance. They will also help determine applicants’ eligibility for programs such as Medicaid, and for federal subsidies to help them purchase insurance. An expected 21 million people will purchase coverage through the exchanges by 2017, according to Congressional Budget Office projections.

The Obama administration touted the 644-page rules as granting states great flexibility in how they design their exchanges, the types of organizations – nonprofit or public agency – that will oversee them and whether to partner with the federal government to operate parts of it. The rules were published as some states are working to set up exchanges and their governing boards – while others have balked at moving forward until after the Supreme Court rules on the constitutionality of the federal health law, which is expected in June.

Additionally, Monday’s announcement included some “interim” rules, meaning they could be tweaked following a 45-day public-comment period. Those interim rules cover issues such as how quickly states must determine if an applicant is eligible for Medicaid or the Children’s Health Insurance Program, and the role insurance brokers will play in helping low- and middle-income people apply for federal subsidies to buy coverage.

Administration officials said the new rules differ from preliminary regulations in several ways. Earlier guidance had proposed that each exchange be responsible for determining which applicants are eligible for insurance subsidies.  The final rule gives states the option to allow HHS to conduct eligibility review. To determine who is eligible for Medicaid or the Children’s Health Insurance Plan, states can choose their own Medicaid agencies.  It also says states cannot allow insurance agents to determine an applicant’s eligibility for subsidies or Medicaid, which remain government functions. But agents, including those who work for web-based private exchanges, can assist those applicants in sorting through their health plan options.

The rules appear to strike a balance between responding to thousands of comments about earlier proposals and providing more details “so states can move forward,” says Patti Boozang, managing director at Manatt Health Solutions, a law and consulting firm based in New York.

The rules do not explain how the federal government would set up exchanges in states that are unable or unwilling to develop their own marketplaces, with those details promised in future rules. In January, the Obama administration released a report saying about 28 states are “on their way” toward establishing exchanges.  “There’s no new information on how that would work, what the partnership model would look like or what states would have to pay – and that’s all information many states have anxiously awaited,” says Boozang.

Karen Ignagni, President and CEO of America’s Health Insurance Plans (AHIP), a trade group, said her organization would be reviewing the rule and offering feedback.

“Exchanges will work best if they are true marketplaces that maximize choice and competition so that individuals, families, and small businesses can purchase plans that are right for them,” she said in a prepared statement. “Consumers will be best served if a state exchange adopts an efficient, cost-effective approach that leverages existing health plan resources, utilizes federal resources or guidance where sensible, and relies on the exchange itself to administer key functions.”

The law says the exchanges will start taking applications in Oct. 1,  2013 – and policies purchased through them would take effect Jan. 1, 2014.  States that are allowed to operate their own exchanges must have approval or conditional approval from HHS by Jan 1, 2013, according to the rules.

In a nod to the fact that some states won’t be able to meet that deadline, the final rules say HHS can grant conditional approval to states that show they are likely to be fully operational by October 2013. Details on what it will take to prove that are expected in future rules.


Walgreens Launches Smoking Cessation Program for Passport Health Plan Members in Louisville

Pharmacists trained by Kentucky Cancer Program to provide education, support and follow-up to help smokers through cessation process

DEERFIELD, Ill., Feb 21, 2012 (BUSINESS WIRE) — Walgreens /quotes/zigman/245520/quotes/nls/wag WAG +0.43% /quotes/zigman/245520/quotes/nls/wag WAG +0.43% pharmacists at eight of the drugstore chain’s convenient Louisville locations are partnering with Passport Health Plan, a local Medicaid health plan, on a new smoking cessation program which launched in early January 2012. The program is free to Walgreens customers and Passport members and aims to improve the community’s health by giving smokers the tools, resources and ongoing clinical pharmacist counseling to help achieve their cessation goals.

Participating Walgreens pharmacists and technicians have undergone specialized training provided by the Kentucky Cancer Program at the University of Louisville’s James Graham Brown Cancer Center. The program provides further education on tobacco treatment, and helped in the development of Walgreens formal, 12-month process for helping those interested in tobacco cessation.

“The harmful effects of tobacco use are well-documented, and by working closely with our community pharmacists who people know and trust, we hope to encourage more smokers under Passport Health Plan to improve their health through this free program to help them quit,” said Greg Baker, Walgreens pharmacy supervisor for Louisville. “The cessation process can be very challenging. We believe the ongoing dialogue with pharmacists, who are among the most accessible health care professionals in the community, can be an effective tool in working with and supporting people to overcome those challenges.”

“Smoking and tobacco use are complex problems that require different approaches to adequately address,” said Stephen Houghland, M.D., chief medical officer for Passport Health Plan. “We believe that addressing this critical driver of negative health outcomes in as many areas where our members are, and with people they trust, is a great opportunity to truly make a difference in their health and quality of life.”

Passport Health Plan members identified as tobacco users can enroll by visiting one of the eight participating Walgreens pharmacy locations. Upon enrollment, pharmacists will work with patients through a multi-step process that includes:

— Information and education on smoking cessation

— Cessation options and tools, products and therapies

— Regularly-scheduled patient follow up for the next 12 months

The program is now offered at the following Louisville Walgreens stores:

— 3421 W. Broadway

— 3980 Dixie Highway

— 1475 Dixie Highway

— 700 Algonquin Parkway

— 200 E. Broadway

— 1008 N. Mulberry St.

— 1602 N. Dixie Highway

— 550 W. Dixie Highway

Walgreens will be sharing program results with Passport Health Plan on a monthly basis and will also be measuring the program’s effectiveness for individuals enrolled over a six- and 12-month period.

“We applaud Walgreens for stepping up to help patients in two districts of Kentucky and Southern Indiana end tobacco use, in this pilot initiative,” said Celeste T. Worth, Professional Education and Training Manager at the Kentucky Cancer Program. “We are pleased to work with Walgreens pharmacies in their efforts to help customers get the medications and counseling they need to successfully overcome nicotine addiction.”

About Walgreens

Walgreens ( http://www.walgreens.com ) is the nation’s largest drugstore chain with fiscal 2011 sales of $72 billion. The company operates 7,830 drugstores in all 50 states, the District of Columbia and Puerto Rico. Each day, Walgreens provides nearly 6 million customers the most convenient, multichannel access to consumer goods and services and trusted, cost-effective pharmacy, health and wellness services and advice in communities across America. Walgreens scope of pharmacy service includes retail, specialty, infusion, medical facility and mail service, along with respiratory services. These services improve health outcomes and lower costs for payers including employers, managed care organizations, health systems, pharmacy benefit managers and the public sector. Take Care Health Systems is a Walgreens subsidiary that is the largest and most comprehensive manager of worksite health and wellness centers and in-store convenient care clinics, with more than 700 locations throughout the country.

About Passport Health Plan

Passport Health Plan is a unique public-private partnership with the Commonwealth of Kentucky and a provider-sponsored, Medicaid health plan serving more than 170,000 members in 16 Kentucky counties. The Plan has operated successfully over the past 14 years. The counties of service include Breckinridge, Bullitt, Carroll, Grayson, Hardin, Henry, Jefferson, Larue, Marion, Meade, Nelson, Oldham, Shelby, Spencer, Trimble and Washington. Passport Health Plan is sponsored by the University of Louisville Medical School Practice Association, University of Louisville Hospital, Jewish and St. Mary’s Healthcare, Norton Healthcare, and the Louisville/Jefferson County Primary Care Association, which includes the Metro Louisville Department for Health and Wellness and Louisville’s two federally qualified health centers, Family Health Centers and Park DuValle. For additional information, please visit http://www.passporthealthplan.com .

About the Kentucky Cancer Program (KCP)

Their mission is to promote education, research and service programs to reduce the heavy burden of cancer in our state. KCP is recognized nationally as a unique program that is state-funded, university-affiliated, and community-based. KCP is the state-mandated cancer control program, jointly administered by the University of Louisville and the University of Kentucky. For more information, contact (502) 852-6318 or visit the Kentucky Cancer Program online at http://www.kycancerprogram.org .

SOURCE: Walgreens

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Physician praises Passport

By Special to The Sun
Tuesday, February 14, 2012 at 2:31 pm

When I started practicing medicine in Bardstown almost 35 years ago, I was optimistic about my opportunity to make sick children well and to watch healthy children grow into strong adults.

Even though I started out with a slightly naïve view, I’m very proud to say I’ve had a hand in caring for thousands of Kentucky’s children. I made a commitment to serve Medicaid patients at the very beginning of my career, but I was not enthusiastic when managed care arrived in 1997.

Both my staff and the staff at Passport Health Plan will attest to my reservations during the start up. On one hand, I was right to be cautious; there were administrative and technology issues that created burdens on my practice.

On the other hand, Passport worked hard to fix what wasn’t working so doctors could focus on providing patient care. But, the gap between where we were with Medicaid managed care then and where we are now is enormous. Several recent articles point out that the state’s attempt to save money by introducing three other Medicaid managed care plans outside the Passport region isn’t going well. Maybe it was too much too soon.

My practice, Physicians to Children and Adolescents, serves over 4,700 patients on Medicaid.  Because of our locations in Bardstown and Springfield, some are covered by Passport, some by the other plans.

I’m not a managed care expert, but my staff and I see and experience the differences daily.
I suspect part of the difference is that Passport is a nonprofit and therefore never has to put the expectations of shareholders before the needs of members.

I’ve been impressed enough with Passport’s commitment to the Commonwealth to accept an offer to join their Board of directors.  From this vantage point, I’ve been able to confirm what I have long suspected: Passport Health Plan has a strong and engaged provider network, and an intense focus on delivering services at a cost that doesn’t diminish quality. In fact, engaging with providers is one of the hallmarks of Passport’s remarkable success.

I feel that Passport’s effectiveness, including their impressive clinical outcomes, are directly due to physicians and other health professionals (from throughout the service area) sitting  at the table making key decisions and sharing sacrifices for the good of the plan and the members.

The National Committee on Quality Assurance recently ranked Passport as the 13th best Medicaid plan in America, which could not have been accomplished without an invested provider network and a top-notch staff. As a member of the board of directors, I want to say Passport stands willing and ready to help the state get Medicaid back on track.

In addition to Jefferson, the plan has been successfully serving 15 rural counties for 14 years and respects and understands their unique needs.  Claims are paid on time, and members have access to the doctors, pharmacies, hospitals and specialists.

Passport is a strong and cost effective Medicaid plan that could be easily replicated throughout the Commonwealth.


Dr. James Hedrick, MD, practices pediatrics in Bardstown and received his medical degree from the University of Chicago, Pritzker School of Medicine in Chicago, Ill.


To view this article by Dr. James Hedrick, MD for The Springfield Sun please visit http://www.thespringfieldsun.com/content/physician-praises-passport

Officials: Care disrupted Medicaid changes causing ‘nightmare’

Health officials who spoke said they have no such complaints about Passport Health Plan.

Deborah Yetter – Louisville Courier-Journal
FRANKFORT, KY.— Health care officials from throughout Kentucky described massive problems Wednesday with the state’s new Medicaid managed- care system — resulting in outcomes they say range from outrageous to absurd.

“This bureaucratic nightmare needs to change,” said Dr. Shawn Jones, a Paducah physician and president of the Kentucky Medical Association, speaking at a meeting of the Senate Health and Welfare Committee.

Jones was one of several officials who testified that it appears any cost savings from managed care will come at the expense of patients.

“It appears to me the only place the savings can come from is the delay and denying of care,” Jones said. “Patient care is being delayed and, in some cases, simply prevented.”

The problems date to Nov. 1 — the day the state hired three companies to handle most Medicaid services outside the Jefferson County region — and include chronically late payments, bungled claims processing and constant battles over new rules that require services once routinely covered by Medicaid to be “pre-authorized” to guarantee payment.

Patients spend hours in physicians’ waiting rooms — or get sent home and told to return after procedures are authorized, Jones said. Pharmacists spend hours on the telephone trying to get prescriptions authorized, said Robert McFalls, executive director of the Kentucky Pharmacists’ Association.

And in one recent case, a woman arrived in labor at the hospital, and the managed-care company insisted that her care be pre-authorized, said Joe Grossman, chief financial officer of Appalachian Regional HealthCare, which operates eight hospitals in Eastern Kentucky.

“Fourteen days later, mom and baby are home and we still have no pre-authorization,” Grossman said.

The managed-care plan, which covers about 560,000 Medicaid members outside the Jefferson County region, is the linchpin of Gov. Steve Beshear’s administration’s plan to achieve savings in the $6 billion-a-year federal-state health plan for the poor and disabled.

Several officials who spoke Wednesday said they believe the companies — CoventryCares of Kentucky, Kentucky Spirit Health Plan and WellCare of Kentucky, all affiliated with out-of-state national chains — may be deliberately stalling payments.

“I feel like I’ve become a bank to these out-of-state insurance companies,” said Grossman, who added that his hospital chain is owed about $8 million. “I’ve lent them money.”

Nancy Galvani, with the Kentucky Hospital Association, said hospitals across the state are owed millions of dollars in unpaid claims since managed care took effect three months ago. Meanwhile, the managed- care companies are getting large payments up front to run Medicaid.

The companies have been paid about $135 million since Nov. 1, according to state Auditor Adam Edelen, who last week opened an inquiry into their claims payments in response to complaints to his office.

No one from the managed-care companies spoke Wednesday. Sen. Julie Denton, a Louisville Republican and committee chairwoman, said she has invited their representatives to speak at next week’s meeting.

The companies issued a statement after Wednesday’s meeting.

“If there are complaints about WellCare, we want to address them and work with our providers to make the program a success,” said WellCare spokeswoman Denise Malecki.

Coventry spokesman Matthew Eyles said the company is willing to address the issues. “With any major new program, some problems will arise that need to be fixed, and we are committed to doing just that and won’t rest until those problems are resolved,” he said.

And Kentucky Spirit spokesman John Lee said the company continues to work “directly with our providers on specific, case-by-case issues.”

Health officials who spoke said they have no such complaints about Passport Health Plan, a nonprofit Medicaid managed care entity that provides service to about 170,000 Medicaid patients in Jefferson and 15 surrounding counties.

Neville Wise, the state’s acting Medicaid commissioner, spoke briefly, saying state officials are continuing to work with the health care providers and the managed-care companies to try to iron out problems. Many are being addressed, he said — such as the requirement that childbirth be pre-authorized. That has been corrected, he said.

Denton told Wise to keep trying to solve problems. “How many more ludicrous scenarios can there be?” she asked.

Health care officials who testified said that, while some problems have been corrected, others continue.

Janice Richardson, chief executive for Rivendell Behavioral Health Services, a children’s psychiatric hospital in Bowling Green, said the managed- care companies’ rules are disrupting care and in the long run are costing more.

For example, the companies limit the stay of children — even in cases where Rivendell doctors believe they need more care. So the children get discharged, get worse outside the hospital and are readmitted, Richardson said.

Managed-care officials have argued with Rivendell about the severity of children’s diagnoses and in one case accused hospital officials of “monkeying around” with a child’s treatment to prolong it, she said. “We are seeing kids over and over and over.”

Further, Richardson said, children who may be severely emotionally disturbed and suicidal are not getting the care they need.

“Somebody’s going to get hurt, and its going to be bad when it happens,” she said.

Steve Shannon, who represents the state’s 14 community mental health centers, said in an effort to head off such problems the centers began meeting with the managed-care companies before the Nov. 1 start-up date and have continued regular meetings and conference calls.

Still, claims processing and late payments are causing major hardships for the nonprofit community mental health centers. And the managed-care companies insist on prior authorization for many services and medications — yet don’t respond within the two days required by the state contracts and regulations.

Some authorizations take days or weeks, he said. Though the companies are supposed to fax the authorizations, one was mailing them, Shannon said.

“They were folding it, putting it in an envelope, licking it and putting a stamp on it,” Shannon said. “There is this thing called the Internet.”

Shannon said that all three of the new managed- care companies have extensive experience in other states and he is surprised they didn’t get off to a smoother start in Kentucky.

“They should know how to do this,” he said.

Shannon was among witnesses who said he wonders whether the delays and denials of care are deliberate on the part of the companies to keep money they get from the state to manage Medicaid.

“Is it really that hard to approve services and pay claims?” he asked.