Payers & Providers Midwest Edition – Issue of December 6, 2011

8/3/2019 Payers & Providers Midwest Edition – Issue of December 6, 2011

http://slidepdf.com/reader/full/payers-providers-midwest-edition-issue-of-december-6-2011 1/6



!"#"$%"&!'(!)*++!,!)*++!%- !./-"&0!1!.&2345"&0!.6%740849:(!;;<

Payers & Providers Page 2

Top Placement...Bottomless Potential

Advertise Here

(877) 248-2360, ext. 2

In Brief

HHS Issues Final Rulefor Calculation of

Medical Loss Ratios

The Department of Health and

Human Services declined to acceptcertain recommendations of the healthinsurance industry when it set the nalregulation last week setting standardsfor calculation of minimum medicalloss ratios.

The Affordable Care Act requireslarge-group health plans to spend atleast 85% of premium revenues onactually medical care for insureds,known as the medical loss ratio, orMLR. The required MLR for smallgroups and individuals is 80%. Im-provements to medical quality mayalso be included in the MLR.

In comments on the preliminaryrule issued last December, the health

insurance industry requested thatantifraud programs and all codingcosts be included within the accepteddenition of the MLR.

The agency agreed to allow some of the costs related to ICD-10 codingimplementation. AHIP, the health insurance lobby inWashington, said HHS had followed“a thorough and balanced process incrafting this nal regulation.” It said itwould continue to work with HHS onthe fraud issue, and expressedsatisfaction that some of the claimsupgrading expenses “are appropriatelyrecognized as activities that improvehealthcare quality.”

Journalism Group AsksSupreme Court to

Broadcast Arguments

The Association of Health CareJournalists has asked the U.S. SupremeCourt to allow live video and audiocoverage of the oral arguments on the

Continued on Page 3

NEWS

Health insurance Predictions (Continued from Page One)

the critical inection point of 25 million lives,Mango said.

* Despite the merger mania and desire to

get big in anticipation of the full rollout of health reform, hospitals might want to thinktwice about acquiring too many physicianspractices. “I am hearing some buyers remorsefrom hospital system CEOs who boughtphysicians practices,” Mango told thegathering.

AHIP President KarenIgnagni, who moderated thediscussion, asked the three tocomment on where unit costsare headed.

Transparency andaccountability are going to

depress unit cost growth,Mango suggested, becauseinformed consumers can walkaway from expensive providers.Consumers now realize theycan consider various options.

Boorady was skeptical thatthis would really work toconsumers’ advantage. “Insome markets you don’t havechoices,” he said. “The U.S. islargely a rural country. Paul’s thesis only worksin urban areas.” You have to gain leverage overthe supply chain to really affect unit costs, and

hospitals have built a brick wall around theircost structures, he said.

Baker said that low-cost providers havenever had the opportunity to talk about what agreat job they do. “Transparency and data willallow them to crow about it,” and that mightdrive some volume their way.

The industry must treat a careful course soas not to repeat the errors of the 1990s, whenpeople were forced into HMOs they didn’tlike by their employers, Baker said. This time itwould be preferable to let people nd the low-cost providers and plans on their own, via thenew products that make them responsible for

choosing their providers.Baker, who was CEO of the Harvard

Vanguard physicians organization and laterhead of the Harvard Pilgrim health plan afterit emerged from state supervision, gave a fairlydownbeat assessment of the prospects facingthe industry and the country in general, wherehealth spending is concerned. He expressed adistrust toward the public sector and its habitsof mind, and warned the crowd that “thepublic sector will be inclined to regulatemore. They won’t necessarily regulate well.”

Don’t expect good behavior from the publsector, he advised.

The health reform in Massachusetts, wh

served as a model for many of the innovatin the Affordable Care Act, has been a mixbag, he said.

A key battleground is determining whatshould be in or out of the basic essentialbenet plan. Public entities push up the o

on the minimum benets planwhich drives up the cost. InMassachusetts, this had direconsequences for the small grmarket, which saw its premiuskyrocket, but it also created aattractive individual market wnone had existed before. Sma

businesses ended up with fewchoices of plan.Baker said he “wouldn’t be

the farm” on the huge expansof Medicaid as a solution to tuninsured problem. States andthe federal government don’thave enough money to live upthe promises made in the ACAExpect governments to cut thepayment rates to providers

“because they can’t do real reform,” he saiTo Ignagni’s question whether health p

should build or buy their new products,

Boorady said plans are destroying enormoamounts of value by building things theycould purchase from vendors.

Take Weight Watchers, for example. Arecent article in The Lancet demonstrated people generally lose much more weight ithis program than in the conventional heaplan wellness program. “Yet no health planare offering Weight Watchers as a diseasemanagement option” and making it free toemployees,” he said.

Mango pointed out that in times of greadisruption, enormous wealth accrues but nto incumbent organizations. “Plans need to

think like an attacker,” he advised.Mango thinks high-deductible health p

will continue to grow as a market segmentThe so-called Cadillac tax on rich healthbenets will move employers to adoptHDHPs, he said.

In Massachusetts, because of its high cobasis and high-income population, almosteverybody in large employer groups will btouched by the Cadillac tax, Baker said,further encouraging movement toward thehigh deductible plans.

Charles BooradyCredit Suisse

Investment Research



!"#"$%"&!'(!)*++!,!)*++!%- !./-"&0!1!.&2345"&0!.6%740849:(!;;<

Page 3Payers & Providers

Longer ALOS!*

Advertise Here

(877) 248-2360, ext. 2

*For our ads, not your hospital

NEWS

In Brief

Affordable Care Act, scheduled to beheard in March 2012.

In a letter to Chief Justice John G.Roberts, association president CharlesOrnstein said that such a historic casewith a profound impact on the lives of ordinary Americans deserves morethan the traditional renditions by print

reporters in the court room. Recently,the court began to allow delayedaudio recordings of oral arguments.

“The case before the court hasramications for these and manyother aspects of healthcare inAmerica, however it is decided,” theletter said.

Given the importance of the issue,the court has expanded its usual onehour of oral argument to ve hours,and has appointed two specialcounsel to advise it on aspects of thelaw.

Republican attorneys general in 26states challenged the constitutionalityof the so-called individual mandate,

and are hoping that the court willinvalidate the law.

Henry Ford SystemWins Malcolm Baldrige

Award for Quality

Detroit’s Henry Ford Health Systemwas awarded the prestigious MalcolmBaldrige National Quality award inNovember, one of four organizationsin the country to be so honored.

“We are extremely proud andhumbled to have been selected,” saidNancy Schlichting, the system’s CEO.

“Our team members ... are nationalrole models for performanceexcellence who demonstrate prideand passion in what they do.”

Congress created the Baldrigeaward in 1987 to acknowledgemanufacturing and service quality inU.S. industry. Healthcare as acategory was added in 1999. Sincethen only 15 organizations have wonfor excellence in healthcare. Bob Riney, Henry Ford’s presidentand COO, said the award validatesthe system’s business acumen and its“energized and focused organizationalculture.”

States may receive as much as $220 million innew grants to help them set up healthinsurance exchanges, the Obama

administration announced last week.Thirteen states, including Iowa ($7.7

million), Nebraska ($5.4 million), andMichigan ($9.8 million), won grant awardsfrom the Department of Health and HumanServices based on the steps they have takentoward establishing the new internetmarketplaces, which are intended to simplifyshopping for health insurance on the part of consumers and small employers. TheAffordable Care Act of 2010 created theexchanges as one mechanism to expand theease of obtaining health insurance.

Acting in response to requests from state

insurance commissioners to allow more timeto set up the exchanges, HHS delayed by sixmonths a deadline for ling grant applications.Where previously they had to apply by Dec.31, now states have until June 29, 2011, to gettheir applications in. HHS also signaled a newexibility in helping states gure out how toproceed. Susan Voss, Iowa’s insurance commissionerand the president of the National Associationof Insurance Commissioners, said in a letter toHHS Secretary Kathleen Sebelius that thelaw’s inexibility “in allowing the states to

select which elements of the ve corefunctions they would like to perform mayprevent some states from participating in the

partnership.”In Kansas, where Insurance Commissione

Sandy Praeger is still hoping to get a state-based exchange operating, the deadlineextension is giving some breathing room indeciding how to proceed. Praeger’sdepartment had earlier won a $31.5 millionplanning grant, but it was turned back by theadministration of Gov. Sam Brownback, likePraeger a Republican, who didn’t want thestate to participate in any part of implementthe ACA.

Lt. Gov. Jeff Colyer said the delay in theapplication deadline af rms the state’s wisdo

in holding off making any large investment ithe exchange. The delay also means the U.SSupreme Court will have heard and probabruled on the legality of the act before theapplications are due.

Kansas is one of the 26 states that havesued to invalidate the law. Implementing anexchange prior to a ruling would be animprudent use of taxpayer dollars,” Colyersaid last week.

Michigan will use the money to to analyzthe exchange and establish contracts withvendors.

Blue Cross Blue Shield of Michigan will bepermitted to invest in an out-of-state for-protMedicaid managed-care plan after MichiganAttorney General Bill Schuette negotiated a ratefreeze for the state’s 200,000 Medigap policyholders.The Michigan Blues, together withIndependence Blue Cross in Philadelphia, arepurchasing the AmeriHealth Mercy Family of Companies, which operates Medicaid plans ina number of states, but not in Michigan.The Michigan Blues have invested about $132into the AmeriHealth Mercy purchase, whileIndependence Blue Cross has paid about $170million. The two partners want to expand thebusiness nationally, and Blue Cross would liketo increase its Medicaid business in Michigan.Medicaid is expected to cover millions of

newly insured Americans under the Affordab

Care Act.Acquiring the plan lets the Blues partner “wthe best Medicaid managed care plan in thewhole country,” said Andrew Hetzel, aMichigan Blues executive. The deal will givethe company expertise to serve Medicaidconsumers in Michigan that it didn’t have, hsaid.The Blues needed the permission of the stateattorney general to swing the deal. Schuetteextracted from them a moratorium onincreasing premiums on Medigap customersin the state until July 31, 2016. In JuneMichigan allowed the premium to rise 9%,bringing the average monthly charge for theMedigap Plan C to $121 a month.

Michigan Blues Win Medicaid DealState Requires Medigap Price Freeze for Seniors

HHS Relaxes Deadline on ExchangeNew Rules Allow Applications Until June 29, 2012



!"#"$%"&!'(!)*++!,!)*++!%- !./-"&0!1!.&2345"&0!.6%740849:(!;;<

Payers & Providers Page

Perhaps no state in the country has done asmuch for holistic medicine as California. Butit’s time to apply the concept of holistic—dealing with entire systems as a whole, notindividual parts—to healthcare managementas well as medicine.

California’s healthcare systems are facingthe same tidal wave of pressures found inother states -- a conuence of new regula-tions,oversight, cost and quality requirements --that is about to get even more complex. Theimpending changes in reimbursement,regulations, and closer scrutiny of patientoutcomes are just the tip of the iceberg.

Healthcare systems areincreasingly coping withcontinually soaring costs(which have led to staff layoffswhen hospitals nd no otherway to meet budgets),shortages of personnel andsupplies, increased waitingtime and changingrelationships betweenproviders and payers. Giventhat California’s inpatienthospital costs are alreadyamong the highest in the

nation, it’s clear that thepressures to control costs,manage effectively, and improve patient outcomes areonly going to get moreprevalent.

Talk to the CEO of anyhospital system and odds are thathe or she will be able to citepockets of success in their organization. Butask about the overall impact on the patientsand the bottom line, and most would admitfalling short.

And that is the problem in a nutshell:

Healthcare system improvement is beingattacked in isolated pockets instead of lookingat the whole. The CFO focuses on cost. TheCMO looks at quality of care. The CIO is surethat IT will be the solution to most of theproblems. The CEO is thinking about whetherto join a new provider network or negotiatepartnerships with other providers or payers.

Department heads innately focus onensuring that their people are working mosteffectively and ef ciently…often at the

expense of other treatment units. A radiologyinstitute’s streamlined procedures may throw monkey wrench into cardiology’s processingrecords and patients. No wonder there is oftennegative synergy created, where improvemenone area cause worse performance in another

To navigate through the increasing complelandscape of healthcare, organizations need tstart looking at themselves more holistically, sthat improvements can be synchronizedhorizontally—not just vertically. In some waysthis is similar to the trend towards patient-centered care, where practitioners work moreclosely to coordinate all the treatment a patie

receives—and to make sure all the components are wortogether and not in conictwith each other. If you thinthe “patient” as the health-csystem, the metaphor is aperfect t.

Holistic, patient-centerecare applies in another wayhere as well. The one thing can align all the componena healthcare system is makisure that everyone is lookinthe system from the patient’

perspective. Getting “macroaround how you give care tpatient and how the patientreceives that care is not easbut developing that per-spective in your organizatio

can help you decide where ahow to deploy unied and co-ordinated improvement efforts.

Taking this holistic view of your organization,shaped by the patient’s perspective, is the rstcomponent of developing a high-performancehealthcare culture that can address the myriad

challenges ahead.

Leadership at all levels must think and acmore holistically as well as ecumenically tosynchronize performance improvement inorder to make change effective and see atangible difference in patient and institutionasuccess.

OPINION

Embracing Holistic ManagementSystems Are Too Complicated to Envision Piecemea

Ron Wince is chief executive officer of Guid

Performance Solutions, a hospital and healt

system consulting firm in Mesa, Ariz.

=276$"!+(!>006"!?*./-"&0!1!.&2345"&0!40!

@6%7408"5!"3"&- !A6"05/- !%- !./-"&0!1!.&2345"&0!.6%740849:(!;;<B! C9!/996/7!49543456/7!06%0#&4@D429!40!EFF!/! -"/&!GE+?F!49!%67H!6@!D2!+*!

06%0#&4%"&0IB!>D !40!5"743"&"5!%- !"J$/47!/0!/!.!K!/DD/#8$"9D(!2&!/0!/9!"7"#D&294#!9"L07"DD"&B C77!/53"&D4049:(!06%0#&4%"&!/95!

"54D2&4/7!49M64&4"0NGOPPI!)?OJ)Q'*

49R2S@/-"&0/95@&2345"&0B#2$

T/4749:!/55&"00NO+O!UB!V277-L225! W/-(!X64D"!YY6&%/9H(!<C !F+Z*Z

W"%04D"

LLLB@/-"&0/95@&2345"&0B#2$

K/#"%22H

LLLBR/#"%22HB#2$[@/-"&0@&2345"&0

AL4DD"&

LLLBDL4DD"&B#2$[@/-"&0@&2345"&0

\54D2&4/7!Y2/&5 W4774/$!TB!!L-"&V"/7D8#/&"!XD&/D":40D ]/90/0!<4D-(!T2B ^/- ! W/&5"9

X"942&! =4#"!.&"045"9D A8"! W4774/$!!L-"&</$5"9!

_&26@

`200! CB!X72DD"9(!TB!B]7"49!X72DD"9!1!K&"9#8

<84#/:2

T4#8/"7!;B!T477"9029.&"045"9D

V"/7D8!a6/74D- ! C53402&0!;;<V4:87/95!./&H(!>77B

.6%7408"&`29!X849H$/9

@6%7408"&S@/-"&0/95@&2345"&0B#2$

\54D2&

!69#/9!T22&"5$22&"S@/-"&0/95@&2345"&0B#2$

>R! -26!52!92D !&"#"43"! -26&!4006"!2R!./-"&0!1!.&2345"&0!%- !+!.BTB!29!

A6"05/-(!@7"/0"!#/77!GOPPI)?OJ)Q'*B

By Ron Wince



!"#"$%"&!'(!)*++!,!)*++!%- !./-"&0!1!.&2345"&0!.6%740849:(!;;<

MARKETPLACE/EMPLOYMENTPayers & Providers Page 5

CHIEF EXECUTIVE OFFICER

Governed by a ve-member board, Girard Medical Center is a district, critical access hospital (CAH) licensed for 25 acute care

beds with a 10 bed DPU, providing comprehensive health care for its patients .! The hospital has 15 physicians on staff with another

32 courtesy physicians.! Girard Medical Center offers health care services for children, adolescents, adults, and geriatric patients

The hospital services the town of Girard, KS (population 2,800) and Crawford County (population 44,000) with net revenues of

$17.5M and an ADC of 20.! They have a Senior Behavioral Health Unit and 5 clinics.

The hospital website is www.girardmedicalcenter.com

ABOUT THE OPPORTUNITY

The Chief Executive Of cer is responsible for all day-to-day operations of the Hospital. This position is accountable for planning,

organizing, and directing the hospital to ensure that quality patient care is provided and that the nancial integrity of the hospital is

maintained. The CEO ensures compliance with applicable laws and regulations as well as all policies and procedures set forth by the

Governing Board and Medical Staff, and those required by Medicare Survey Standards.!!The CEO is responsible for creating an environment and culture that enables the hospital to fulll its mission by meeting or

exceeding its goals, conveying the hospital mission to all staff, holding staff accountable for their performance, motivating staff to

improve performance and being responsible for the measurement, assessment and continuous improvement of the hospital's

performance.

POSITION REQUIREMENTS

• MHA or MBA Preferred.

• 5 plus years progressive experience in hospital operations as hospital CEO or equivalent.

• Previous Critical Access Hospital (CAH) experience preferred.

• Strong physician relations and understanding of physician practice management.

• Managed care experience, experience and knowledge in quality initiatives.

BENEFITS AND COMPENSATION

• Salary is commensurate with experience.

• To attract!and retain the best professionals, we offer a comprehensive and competitive benets package that includes

medical, dental, vision, 401(k), employee assistance program, and much more.

Contact: Mary Ann Holloway, Director, Human Resources(620) 724-5142

[email protected]



Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

SEEKING A NEW POSITION?

CAN HELP.We publish advertisements for those seeking

new careeropportunities for just $1.25 a word.

If you prefer discretion, we’ll handle all

responses to your ad.Call (877) 248-2360, ext. 2, or e-mail

[email protected].

It costs up to $27,000 to fill a healthcare job*

will do it for a lot less.

Employment listings begin at just $1.65 a word

Call (877) 248-2360, ext. 2Or e-mail: [email protected]

Or visit: www.payersandproviders.com

*New England Journal of Medicine, 2004.

Documents

Payers & Providers Midwest Edition – Issue of December 6, 2011