9 December 2010
California Edition
Calendar
January 12-15
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January 18-19
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January 20
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E-Mail
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the details of your event, or call
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DMHC Actions Plunge, But Fines Up
Tactical Shift in Enforcement Toward Larger Acts
The number of enforcement actions taken by
the California Department of Managed
Health Care this year has plummeted
compared to 2009 and is at its lowest level in
nearly a decade, but an agency ofcial said
the impact of its work in 2010 may be more
substantial than in the past.
As of this week, the DMHC has taken 95
actions against health plans and brokers, and
imposed nes totaling $2.25 million. That
compares to 367 enforcement actions taken in
2009, and nes totaling $3.525 million.
The number of enforcement actions taken
by the DMHC this year is the lowest since
2003, when the agency was just a few years
old and beginning to show its regulatory teeth.
DMHC spokesperson Lynne Randolph
noted that the agency typically makes about
100 or so enforcement actions per year,
levying nes of $2 million to $3 million.
“As far as the trend, it’s not completely
out of the realm,” she said.
Moreover the agency has yet to factor into
its 2010 tally nes of $4.85 million
announced last month against seven of the
state’s largest health plans for inaccuracies in
claims payments to physicians and hospitals.
The agreements between the agency and the
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plans have yet to be nalized and posted to
the DMHC website.
Assuming the nes are nalized before
the end of the calendar year, the DMHC
would have imposed more $7.1 million in
nes this year – double the 2009 total.
Randolph noted that the large increase in
monetary penalties is part of a shift in the
agency toward going after major acts of
malfeasance that can affect thousands of
enrollees.
She cited as an example the settlement
the DMHC reached in May with Victorville-
based hospital operator Prime Healthcare,
which had engaged in balance billing of
emergency room patients. Prime agreed to
settle the case for a $1.2 million charitable
donation, and to refund any claims collected
from patients with interest. Another example
was a $1.62 million ne recently levied
against Anthem Blue Cross of California for
failure to pay stop-loss claims to hospitals for
long inpatient stays.
“There may not be as many individual
actions, but these settlements may have much
more of an impact,” Randolph said.
Continued on Next Page
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In Brief
5 Million Have Lost
Coverage In Recession
A new study in the journal Health
Affairs concluded that 5 million
Americans lost health insurance
coverage between 2007 and 2009,
mostly as a result of the Great
Recession.
The Midwest and South were
hit hardest by the loss of coverage,
which boosted the number of
uninsured from 45 to 50 million, or
about 17% of the population. About
60% of those who lost coverage
were white.
Despite the grim increases, the
number of children who had
healthcare coverage increased by
600,000, partly because their
families’ loss of income made them
eligible for state children’s health
insurance programs.
Moreover, the study’s authors
concluded the Patient Protection
and Affordable Care Act would not
only obtain coverage for those who
lost it, but weaken the link between
health insurance and employment.
Kaiser Claims 136%
Return On Quality
Initiatives
Oakland-based Kaiser Permanente
is claiming that its quality
initiatives have saved $2.36 for
every dollar invested. The initiatives
include aligning hospitals by region
to reduce deaths from sepsis, and
other management initiatives.
“We focused on designing a
system wide performance
improvement approach that
cascades from national to regional
to facility levels," said Lisa
Schilling, vice president of Kaiser’s
care and service quality division.
"Our system demonstrates the value
of investing in developing
Continued on Page 3
NEWS
DMHC (Continued from Page One)
Some consumer advocates suggested
that some mundane enforcement may be
slipping through the cracks.
“I do not think that health plans are all of
a sudden 75% less likely to be breaking the
rules,” said Judy Dugan, research director for
Consumer Watchdog, a Santa Monica-based
group that regularly battles health plans.
However, Dugan did not conclude that the
quality of enforcement has been sacriced
with a lower volume of cases.
Randolph did note that the DMHC’s
Proposal Would Slash Healthcare
Schwarzenegger’s Stopgap is Coolly Received
In his waning days in ofce, Gov. Arnold
Schwarzenegger has declared a scal
emergency and asked for a special meeting of
the Legislature to close a new $6 billion
budget gap – a signicant portion of which he
proposed be extracted from healthcare
programs.
“I always said I would go and charge
through the nish line...why I would stop in
November or December makes no sense,”
Schwarzenegger said at a press conference
earlier this week.
By declaring a scal emergency and
calling a special session, the Legislature is
required to address the budget shortfall
within 45 days, or be barred from taking up
any new matters. However, Schwarzenegger,
a Republican, leaves ofce on Jan. 3.
Governor-Elect Jerry Brown, a Democrat, is
expected to have a more sympathetic rapport
with the Democratic-controlled Legislature.
Schwarzenegger proposed $9.9 billion in
cuts, which he noted would also prove
helpful for the 2011-2012 scal year.
Public health plans such as Medi-Cal and
Healthy Families, the state’s children health
insurance program, would endure some of
the biggest cuts. Many would come in the
form of cost-shifting. Schwarzenegger’s
proposal includes:
• Cutting $983.5 million from Medi-Cal
between now and 2012. It would include
limiting total prescriptions to six per month,
with an exemption for life-saving
medicines. Payments for over-the-counter
drugs such as cold medicine would be
eliminated entirely. Physician visits would
!!!"#$#!%&!'(&)*+!,!'*-./0)*+!'1%2/+3/456!778
Page 2
resources have been stretched thin, given
recent budget cuts have required regular
furloughs of staff, including its team of 12
attorneys that litigate and nalize enforcement
actions.
Ironically, resources have also been
devoted to ghting a lawsuit Consumer
Watchdog led last year against the DMHC
regarding how it regulates plan benets for
autistic children. Randolph said hearings on
the case would begin within the next few
weeks in Los Angeles Superior Court.
be limited to 10 per year. Annual maximum
caps for such products as durable medical
equipment, hearing aids and wound care
would be imposed. A $50 co-payment for
emergency room visits and a $200
maximum co-payment for hospital stays
would also be imposed. Benets for adult
day care and coverage for most legal
immigrants would also be eliminated.
• Cutting $26.6 million from the Healthy
Families program. This would include
increasing monthly premiums among
households with income between 150%
and 250% of the federal poverty level by
$14 to $18 per child per month. That would
boost premiums from a minimum of $30 per
month for one child to $126 per month for a
household with three or more children. The
current scale is $16 to $72 per month.
Vision coverage for children would be
eliminated entirely, while co-payments for
emergency room visits would increase from
$15 to $50. Hospital stays would have a
$100 daily co-payment, capped at $200 per
stay.
• Shifting the mental health services from a
state to a county responsibility.
The governor’s proposals have been coolly
received. Legislative leaders, although
compelled to meet, have all but rejected it out
of hand.
“We will work and will work hard this
month but I err on the side of actually
Continued on Next Page
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In Brief
capability to improve capacity in
operations, supporting its
application in the delivery setting
and its impact on overall medical
center performance. These
elements can be adapted to smaller
systems and single hospitals.”
The results of the Kaiser
initiatives are being published in
several parts in the Joint
Commission Journal on Quality
and Safety.
Half Of State’s New
Nursing Grads Not In
Profession
More than 40% of California’s
recent nursing school graduates
have been unable to find a job in
their profession, according to a
new survey by the California
Institute for Nursing & Health
Care.
The survey, conducted by
CINHC in conjunction with the
California Board of Nursing, the
Association of California Nurse
Leaders and other nurse-oriented
organizations, polled 973 recent
graduates and newly licensed
nurses.
Of those graduates, 57%
were working in the nursing
profession. Of those who had been
unable to find employment, 20%
said they had been looking for jobs
longer than one year.
“The unexpected difficulty of
new RNs finding employment is
now California’s most pressing
workforce issue,” the report said.
Of those responded, 61% had
two-year nursing degrees. Thirty-
five percent were told that a
bachelor’s degree was required for
them to be hired.
The report suggested that
unpaid internships be used to keep
the skills of newly minted nurses
sharp until the economy picks up
enough to create more job
openings.
NEWS
Budget (Continued from Page Two)
completing the work once once Governor-
elect Brown takes ofce," said Senate Leader
Darrell Steinberg, D-Sacramento.
Schwarzenegger’s proposal has also been
blasted by some advocacy groups, who claim
that it unfairly burdens the poor.
“At a time when millions are looking for
relief, the governor has proposed cuts that
will deny medically necessary care, place
greater nancial strain on families, and turn
back hundreds of millions of dollars in
federal matching funds for our economy,”
S.F. Initiative Focuses On Diabetics
SFHP Uses Medical Homes To Boost Screenings
San Francisco’s Medi-Cal managed care and
universal access plans showed signicant
success in using medical homes to better
screen risk factors for its diabetic enrollees,
suggesting such a structure could prove a
durable pathway for disease management.
Twenty-four community clinics
designated as “medical homes” for enrollees
in the San Francisco Health Plan and
Healthy San Francisco began in 2009 to
improve the blood pressure and cholesterol
screenings for diabetic patients. Such
diagnostic tools lead to more consistent
treatment of the disease, which if left
unchecked can lead to blindness, lost limbs
and heart attacks.
“Half of the people with diabetes in this
country do not get the preventive care they
should receive,” said Kelly Pfeifer, M.D.,
medical director of San Francisco Health
Plan, the Medi-Cal managed care insurer.
Those patients who underwent an
annual cholesterol test increased 4.7%, to
74.4%. Patients who underwent a
hemoglobin A1c test – a benchmark test for
controlling blood sugar levels – went up
6.3%, to 85.1%. In some of the clinics,
baseline improvements were up 20% or
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Page 3
said Anthony Wright, executive director of
Health Access, a Sacramento-based advocacy
group. “Nothing has a worse economic impact
than cutting health and human services, which
leads to lost federal funds and ripple effects in
our health system and economy, since you
can't outsource healthcare. We hope Gov.
Brown address this budget crisis as he said he
would, by putting everything on the table,
including cuts and revenues, and seeking to
maximize federal funds for our state and our
economic recovery."
more.
“We’re thrilled with these numbers,” said
Tammy Fisher, SFHP’s director of quality and
performance, noting that they’re inching close
to the national Medicaid benchmarks for
diabetes control.
The diabetes initiative is part of Strength
in Numbers, a disease management and
quality improvement program launched
between SFHP and Healthy San Francisco, the
city’s intermediary for providing universal
healthcare access to all residents. There are
about 55,000 Healthy San Francisco enrollees
altogether.
Fisher noted that SFHP provided incentive
payments of $10,000 or more to the clinics,
primarily to hire extra staff to monitor its
diabetic patients.
Although not all of the clinics have
electronic health records, they have access to
an electronic patient registry, the contents of
which Fisher said was leveraged to better
focus on those who are diabetic.
Strength in Numbers will be expanded in
2011 to focus on other preventative measures,
such as vaccinations for hepatitis b, colorectal
screenings and management of chronic pain,
Fisher said.
Payers & Providers
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OPINION Page 4
Thinking Outside The Inpatient Box
The Future of Hospitals is Found Beyond Its Four Walls
One of few “knowns” in the otherwise administrators, hospitals and community. It is
unknown world of what health reform will designed to help local residents connect with
bring is the fact that all hospitals will need a wide range of health resources in the
to do a better job of truly concerning community
themselves with the health of their !!!!!!Healthy Pasadena also provides a
communities beyond the hospital walls. calendar of community events, as well as
In the 20th century, our industry news and statistics regarding the social,
focused the majority of its attention on how educational and economic elements of the
to better care for people from the time they community.! Visitors can compare the San
were admitted into the hospital until they Gabriel Valley’s health status to that of Los
were discharged.! But truth be told, it is a Angeles County and the State of California
fairly infrequent event that people and learn best practices and protocols for
encounter a hospital at all.! So here in the addressing heath related issues.! They can
21st century, it is now time to start focusing also identify local resources for health and
on where people spend the social services throughout the area.!
majority of their lives – not from !!!!!!There is also information
admission to discharge but from about air quality, cancer rates, and
discharge to admission.!We as a crime, plus more than 100
society, and particularly as “indicators” that address topics
responsible healthcare providers, including public safety,
must have a new commitment to transportation, voter turn-out and
maintaining and improving health more.! Healthy Pasadena even
rather than merely treating provides a page where visitors can
episodic illnesses. take content information from the
!!!!!!The emergence of site and fill in fields to create their
Accountable Care Organizations own personal report – ideal for
will help this shift occur because it By Jane school or business.
forces hospitals to think value, not Haderlein !!!!!!HCI has developed a network of
just volume.! As one of the similar sites throughout the country,
government-prescribed remedies but whom better than the local
aimed at improving quality of care while community hospital to be a partner in this
reducing overall health care costs, ACOs effort?! After all, it is the hospital that is there
call upon hospitals to reflect on the for the community 24 hours a day and whose
community as a whole and morph from a very mission is centered on being the local
traditional health center concerned with “expert” in health and healthcare.
admissions to a new charter dedicated to !!!!!!Nonprofit hospitals have always
keeping people healthy and out of the recognized that we have a unique obligation
hospital whenever possible.! to be concerned with our community’s overall
!!!!!!Toward this end, Huntington health wherever that may take us.! But the
Memorial Hospital recently became the first confluence of healthcare reform, community
hospital in the country to partner with demand and the power of the internet now
Healthy Communities Institute (HCI) in make this commitment more possible than
offering a one-stop, online source of data ever for all of us. ! The upshot of healthcare
about community health. The website, reform may still be cloudy, but I like to think
known as Healthy Pasadena of it as cloudy with a chance of greatness. !
(www.healthypasadena.org), is designed to
help community members and policy Jane Haderlein is senior vice president of
makers learn about health related issues so external affairs for Huntington Memoria
individuals can make informed, healthy Hospital in Pasadena.
lifestyle choices for themselves and their
families.!
Op-ed submissions of up to 600 words are
!!!!!!The new website creates a welcomed. Please e-mail proposals to
repository for information and data that editor@payersandproviders.com,
assists public health departments, local
!!!"#$#!%&!'(&)*+!,!'*-./0)*+!'1%2/+3/456!778
Payers & Providers MARKETPLACE/EMPLOYMENT Page 5

MEDICARE COMPLIANCE ADVISOR - ensures that L.A. Care and its subcontracted provider network is compliant with all Centers
for Medicare &!Medicaid federal regulatory requirements. This is achieved by participating in the annual PPG and quarterly audits,
working with internal and external staff to correct performance deciencies, identifying internal areas for improvement, serving as
the compliance contact with Plan Partners for member grievance oversight, provider services oversight, and interpreting CMS/SNP
Program requirements for L.A. Care. ! Additionally, this individual is a resource to internal staff on compliance matters relating to
CMS/SNP standards, including, but not limited to, marketing materials, grievances and appeals, member rights issues, and claims
adjudication.! Responsible for performing internal audits, monitoring for implementation of corrective measures, and interpretation
of CMS requirements. !Working knowledge of federal and state requirements is required, as well as highly developed analytical skills
and excellent verbal and written communication skills.!

For complete job description, qualications/requirements, visit our website: www.lacare.org

To apply, email resume with salary history and requirement to: recruiter@lacare.org referencing “Payers & Providers Ad”

ASSOCIATE MEDICAL DIRECTOR FOR CLINICAL INTEGRATED SOLUTIONS

(Los Angeles, CA)
The Associate Medical Director for COPE Health Solutions’ Clinical Integration Solutions service line will serve as the
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Provider Practice Redesign (PPR) is one component of Clinical Integration Solutions, designed to expand access to specialty
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Camino de Salud “Healthy Road” Network is a public-private partnership between LAC+USC Healthcare Network, four
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• M.D. with a non-restricted license and board certication
• Minimum 2 years of full-time experience in practice (not including residency training) in one or more of the following:
private physician practice, hospital-based practice and inpatient care.)
• Master’s degree is strongly preferred
• Procient in Microsoft Ofce Programs (Outlook, Word, Excel, Access and PowerPoint) and experience with Internet
research.

To apply and learn more visit: www.copehealthsolutions.org/careers

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Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

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