Payers & Providers Midwest Edition - March 1, 2011

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1 March 2011

Midwest Edition

Calendar Illinois Blues, Hospitals in Quality Pact


Insurer Pledges $4 Million to Reduce Readmissions

March 15 If hospital readmissions are any indication of Commonwealth Fund released Medicare data
quality of care, Illinois is trending toward the for 2009, showing Illinois’ 30-day readmission
bottom of the deck. The state ranks 44th in the rate increased to 20.3% from 19.6% in 2007.
J3/-!:-+>/;(2!@++-A/(;/-4!R-.)*4(4A)! nation in the rate of Medicare 30-day Nationally, the median is 17.5% and the
J*/)4;(;/-4S readmissions, and is getting worse. average for the top ve states is 13.8%.
T1/20/45!;3)!E-140(;/-4!H-*!LHH)A;/.)! The Illinois Hospital Association and “That is not where this state should be,
:-+>/;(2!U*1+;))+3/>C!L=%(++&!<1/;)+6!
O1%2/4C!P$Q# Blue Cross and Blue Shield of Illinois have based on the caliber of health care being
teamed up to reduce the rate of delivered.” Wurth observed. “Our
82/AD!:)*)!E-*!F-*)!G4H-*=(;/-4 unnecessary readmissions. So far board of trustees said, we need to
201 Illinois hospitals have step up our leadership role, give
pledged to raise the state’s them additional assistance. Then
performance from the bottom we said to membership, We are
March 15-16 quartile in the nation to the top better than this. We need to raise
half by 2014. Blue Cross will the bar.”
invest $1 million a year to support Hospitals will receive
91*(2!:)(2;3!<&=>-+/1= the initiative for the next four assistance through four
?(4+(+!:-+>/;(2!@++-A/(;/-46 years. established programs that have
B/A3/;(C “Not only is it the right thing proven successful in reducing
to do for patient care, it’s the right readmissions:
82/AD!:)*)!E-*!F-*)!G4H-*=(;/-4
thing to do for bending the cost * Project BOOST, sponsored by
curve,” said Maryjane A. the Society of Hospital
Wurth, IHA president. Medicine;
IHA’s PREP program, Maryjane A. Wurth * The Illinois Transitional
Preventing Readmissions Care Consortium’s Bridge
April 6-8 through Effective Partnerships, intends to apply program, which uses social workers to help
ve key initiatives: patients go from hospital to home;
* Northwestern Memorial Hospital’s training
* Redesigning hospital discharge processes; program on palliative care; and
BIJKL!"#$$!@441(2!8-4.)4;/-4!
B/+A-4+/4!J*5(4/M(;/-4! * Improving care transitions; * AHRQ’s Project RED: Re-Engineered
-H!K1*+)!LN)A1;/.)+ * Developing palliative care programs; Discharge.
?(2(3(*/!9)+-*;6 * Reducing readmissions from infections; and Each of these has a slightly different take
B/+A-4+/4!O)22+C!PQ#IP"Q#C * Standardizing metrics for measuring on reducing readmissions. Project RED, for
reductions in readmissions. example, concentrates on communications
82/AD!:)*)!E-*!F-*)!G4H-*=(;/-4
* among caregivers and patients, said Jeffrey
Charles Schutz, M.D., a medical director at Brady, M.D., the patient safety research
Blue Cross, said the joint project was like “an portfolio lead at the Agency for Healthcare
alignment of the stars at a very opportune Research and Quality in Washington.
moment.” Preventing readmissions has been RED underscores the importance of the
E-Mail on the radar for some time. “We’ve been pharmacist in the discharge process. “In many
info@payersandproviders.com with looking for partners to help address this. It’s hospitalizations, the goal is to achieve the
the details of your event, or call not something you can effectively address as right balance of medications,” Brady said.
(877) 248-2360, ext. 3. It will be an insurance company doing routine “The patient doesn’t always understand that.”
published in the Calendar section, utilization-management type things,” he said.
space permitting. The hospital association approached the
Blues about three months ago, after the Continued on Next Page

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Payers & Providers NEWS Page 2

Top Placement... Reducing Readmissions in Illinois (Continued from Page One)


Bottomless Potential RED aligns resources so that patients the nancial driver facilitating ignoring this
understand why they’re being admitted and problem.”
Advertise Here how their care plan is changing. Some community hospitals have
Project BOOST, by contrast, has an readmission rates of 25% to 30%, he added.
(877) 248-2360, ext. 2
emphasis on mentoring individual hospitals at “If you dropped to 10% those hospitals would
their specic level of competency and go bankrupt.” The country can’t afford this any
resources. “It’s targeted and exible,” said longer, and the changes in federal law will
In Brief Mark Williams, M.D., chief of the division of
hospitalist medicine at Northwestern
force everybody to pay more attention,
Williams said.
Memorial Hospital in Chicago. He is the Schutz said the initiative is in large part
principal investigator for Project BOOST driven by provisions in the Accountable Care
nationally. Act that levy penalties on hospitals that don’t
“We got input from every component control their readmissions rate. “That is
Humana Enters Deal
that’s involved in the hospital discharge motivating hospitals all over the country to get
to Create Incentive process,” he said. on the ball,” he said.
Wellness Program Readmissions have long been recognized Those nancial penalties would be
as a quality problem in U.S. hospitals, but the signicant for Illinois hospitals, Wurth said.
Humana Inc., the fifth largest U.S. industry has never focused on it, for a number Based on an IHA analysis of the new law,
for-profit health insurer, has entered
of reasons. Recently a news article Illinois hospitals would forfeit $680 million
a joint venture with Discovery
Holdings, a South African financial highlighted a handful of hospitals that had over 10 years if the state stayed in the bottom
services provider, to create a new successfully reduced their readmissions, but quartile, compared to what they would save if
joint-venture corporate wellness that were forced to end their programs they moved into the top quartile. “It hasn’t
program. because it was costing them too much created the need to change, but it’s providing
The new entity,
HumanaVitality LLC, will give money. acceleration and emphasis” she said.
Humana customers tools and “They were losing the revenue from
support mechanisms to lead readmissions,” Williams said. “That has been
healthier lives. It will be based in
Chicago.

21 Charged in Detroit Fraud Cases


Discovery Vitality serves 1.9
million people world wide and
describes itself as “the world’s
largest incentive-based health-
enhancement program.” Medicare Bilked of $23 Million, Investigators Say
Its U.S. subsidiary, The Vitality
Group, offers consumers “a Federal prosecutors in Detroit charged 21 Erroll Sherman, 63, a podiatrist in Oak Park,
sophisticated health-behavior individuals with Medicare fraud on Feb. 17 as Mich., was charged with submitting $700,000
chnage model supported by an part of a “nationwide takedown” of illicit
actuarially sound incentive
in false claims.
health care providers. The defendants include Surya Nallani, 43, a physician in Troy, Mich.,
program,” the companies said in a
statement.
owners and operators of companies, was charged with billing $8.5 million for
Discovery says that incentives physicians, physical and occupational excessive home visits.
are essential to changing consumer therapists, ofce employees, and patient Joann McGhee, 45, of Southeld, Mich., was
behavior. In 2010 it awarded its recruiters, according to the Ofce of the U.S. charged with participating in a $6.1 million
members 500,000 flights, almost Attorney for the Eastern District of Michigan. scheme to submit false claims for psychotherapy
20,000 hotel stays, and 3.5 million “We want health care providers to know services. She was also charged in Tennessee
movie tickets to people who met that we are paying attention to billing records, with billing $1.1 million for services not
goals for changing their lifestyles. and that abuses will be aggressively
Discovery will hold 25% of
delivered.
prosecuted,” said U.S. Attorney Barbara L. Other defendants include: Tariq Mahmud,
shares in HumanaVitality, and
Humana will gain a 25% stake in
McQuade. The cases include: 53, of Canton, Mich.; Fatima Hassan, 43, of
The Vitality Group. * U.S. v Hernandez et al. Ten 10 people, Dearborn; Victor Jayasundera, 57, of Southeld;
including a physician, six clinic owners or Carol Gant, 65, of Berkley, Mich.; Vanessa
managers, two employees and one patient Dowell, 49, of Oak Park; Karina Hernandez, 26,
Michigan Blues Agree recruiter were charged with submitting false of Doral, Fla.; Marieva Briceno, 45, of Doral;
to Roll Back Individual claims for nerve conduction studies in Livonia, Dora Binimelis, 57, of Miami; Jonathan
Rate Increases Mich. Agbebiyi, 61, of Rochester Hills, Mich.;
* U.S. v. Mahmud et al. Five people were Santiago Villa-Restrepo, 33, of Doral; Juan Villa,
Blue Cross Blue Shield of Michigan accused of submitting false claims for physical 28, of Doral; Isaac Carr, 28, of Belleville, Mich.;
reached an agreement with the and occupational therapy at a location in Diana Brown, 50, of Farmington Hills, Mich.;
state attorney general to hold rate Dearborn, Mich. Jasmine Oliver, 32, of Oak Park; Henry Briceno,
* U.S. v Javidan et al. Three people, including 57, of Miami; Mehran Javidan, 48, of West
two physical therapists, were charged with Bloomeld; Vishnu Pradeep Meda, 30, of Troy;
Continued on Page 3 sending in false claims for home health and Ram Naresh Rajalupati, 31, of Canton.
services and physical therapy.

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Payers & Providers NEWS Page 3

Longer ALOS!* Illinois Blues Pay $25M to State, Feds


Advertise Here Civil Settlement Covers Medicaid Allegations
(877) 248-2360, ext. 2
Blue Cross and Blue Shield of Illinois last week The investigation was started by the ofce of
*For our ads, not your hospital agreed to pay $25 million to settle allegations Lisa Madigan, the state attorney general, who
that it denied coverage to sick children under alleged that children whose care should have
policies that it should have honored. been covered by the insurance company under

In Brief
The civil settlement, among Blue Cross Blue existing policies were instead shifted to the
Shield, the state of Illinois, and the federal Home and Community Based Services
government, arises from complaints of parents Medicaid program, run by the Illinois Division
of medically fragile children who are of Specialized Care for Children. Parents who
dependent on technological devices to stay asked for a claims review after being denied
increases on individual policies to alive and healthy. They said that Blue Cross had coverage were “fraudulently told” that their
between 7% and 9.3%. wrongly terminated insurance coverage for children weren’t covered for private-duty
The insurer had originally private-duty, skilled nursing care, so that it nursing, the government said.
sought increases of 7.8% to 15% could shift the patients to a Medicaid program Linda Wawzenski, deputy chief of the civil
for about 195,000 policyholders designed to provide home care for children at division in the U.S. attorney’s ofce in Chicago,
younger than 65. risk of being institutionalized. said that patients were already receiving the
Blue Cross said it is taking In a statement, the Blues said that the
losses on these products. Under
nursing care. “Then Blue Cross told them, ‘No,
settlement “resolves a longstanding dispute this is no longer covered, this benet will no
the agreement, the not-for-profit
company will raise rates for 62,000
concerning certain claims involving private- longer be provided to you.’” Blue Cross denied
policyholders by 7%, and the other duty nursing benets. We disagree with the patient claims based on “internal undisclosed
133,000 individual policyholders allegations and deny any inappropriate conduct guidelines that were more restrictive than the
will see an increase of 9.3%. The at any time.” language provided to beneciaries in plan
new rates may become effective as Under the agreement, Blue Cross Blue policy materials,” the government said.
soon as May 1. Shield will pay $14.25 million to the state and Blue Cross, in its statement, said that in
$9.5 million to the federal government. The cooperation with the state attorney general, it
Medtronic Trims Jobs company will pay a further $1.25 million to the had expanded the explanation of benets to
state for allegations under the consumer fraud explicitly describe the nursing benets under its
as Sales Decline law. plans.
Blue Cross did not admit liability and Wawzenski said it was an unusual case for
Medtronic, the Minnesota based agreed to the settlement “to avoid the delay,
medical device maker, said last
her ofce, which usually prosecutes Medicare
uncertainty, and expense of protracted and Medicaid fraud by providers.
week it will reduce its work force
by 4% to 5%, or roughly 1,500 to
litigation,” according to a statement issued by “We settled it before we actually had to le
2,000 positions. I the ofce of Patrick Fitzgerald, U.S. attorney for a complaint,” she said. The U.S. attorney’s ofce
The company employs 8,000 Northern Illinois. The period covered by the is obligated to notify a defendant any time it
in Minnesota. It wasn’t clear how settlement is 2000 to 2010. thinks there might be a serious case developing.
many of the layoffs would be in The Illinois Blues are the largest insurer in “Ninety-nine percent of the time, people are
that state. Illinois. Their parent company, Health Care interested in having a conversation with us,” she
Medtronic, the largest medical Services Corp., also based in Chicago, is the said. In this instance, Blue Cross was willing to
device company, with 24,200 U.S. largest mutually owned Blues organization in
workers and 41,000 globally, is
discuss a settlement with the government
the country. It also controls Blues plans in agencies before a civil case was led.
based outside Minneapolis.
Its cardiac rhythm disease
Texas, Oklahoma, and New Mexico.
management division is losing
market share in key segments, and
saw its sales sales decline 2% to
$1.22 billion in the most recent
HEALTHCARE’S BEST ADVERTISING VALUE
quarter. ]

A recent article in the Journal


of the American Medical PAYERS & PROVIDERS reaches 5,000 hospital, health plan and non-
Association said that about 22%
of patients who received prot executives statewide. There is no better venue for marketing
implantable cardiac defibrillators
probably didn’t need them. your organization or conference, or recruiting new staff.
The market for cardiac rhythm
management devices and
pacemakers is slowing in the U.S.,
analysts say, although it is growing
LEARN MORE HERE
in emerging markets.
Phil Nalbone, an analyst with
Wedbush Securities, said that OR CALL (877) 248-2360, ext. 2
Medtronic is “starving for growth.”
Hospitals, physicians, and payers
have been taking a more critical
look at pricing and overuse of
medical devices.

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Payers & Providers OPINION Page 4

9-21:)!$6!;++1)!<!
It’s Time to March Like An Egyptian
'(&)*+!,!'*-./0)*+!/+!
=1%2/+3)0!).)*&!>31*+0(&!%&! Uninsured Should Take to the Streets to Save Reform
'(&)*+!,!'*-./0)*+!'1%2/+3/456!
778?!@4!(441(2!/40/./01(2!
+1%+A*/=B/-4!/+!CDD!(!&)(*! Maybe the uninsured could learn something lobbying against repeal to the big insurance
EC$FD!/4!%12G!1=!B-!$#! from Egyptians and the Arab streets. At a companies such as Aetna, Humana,
+1%+A*/%)*+H?!;B!/+!0)2/.)*)0!%&! time when the health reform granting most UnitedHealth Group and WellPoint
)I:(/2!(+!(!'JK!(BB(A3:)4B6! of the uninsured access to medical care is Worse, while the Institute of Medicine
-*!(+!(4!)2)AB*-4/A!4)L+2)BB)*?
being threatened, protests by the uninsured characterizes the consequences of a lack of
@22!(0.)*B/+/456!+1%+A*/%)*!(40! themselves are nowhere to be seen. access to care as “needless illness, suffering,
)0/B-*/(2!/4M1/*/)+N In 2009, a staggering 51 million and even death,” it is Republican physicians in
EOPPH!"FOI"<Q#
Americans had no health Congress brazenly lead the
/4R-S=(&)*+(40=*-./0)*+?A-: insurance. The Urban Institute effort to repeal care coverage.
estimates that 400 of them die By coincidence, there are
T(/2/45!(00*)++N each week due to lack of about the same number of
O$O!U?!V-22&L--0!W(&6!X1/B)!Y access to care. However, elderly on Medicare as there are
Y1*%(4G6!8@!D$Z#Z instead of pouring into the uninsured. Egyptians
streets to protest, the uninsured understand the power of an
W)%+/B) leave the loudest push-back to aroused populace. Do the
LLL?=(&)*+(40=*-./0)*+?A-: (well-insured) political uninsured? In red states and
K(A)%--G partisans. blue states in 2012, there will
LLL?R(A)%--G?A-:[=(&)*+=*-./0)*+ One in six Americans is be congressional districts and
>L/BB)* now uninsured. Where are senatorial races up for grabs
LLL?BL/BB)*?A-:[=(&)*+=*-./0)*+ they? Their faces and voices and a contest for the presidency
and names are missed. At a featuring a man who made a
\0/B-*/(2!Y-(*0 hearing led by Sen. Tom historic effort on their behalf.
Coburn, an Oklahoma By Michael Millenson Republicans have never put
Y*/(4!]?!X/2.)*+B)/46!T?J? Republican, a sobbing, forth a serious proposal to
X)4/-*!9/A)!'*)+/0)4B middle-aged woman provide access to care for all.
>3)!8(:0)4!^*-1= confessed she couldn’t afford care for her Will they suffer any consequences?
_-++!@?!X2-BB)46!T?J? brain-injured husband. Coburn, a physician, If anyone understands the power of
`2)/4!X2-BB)4!,!K*)4A3 glibly responded that “the idea that individuals coming together to make demands
83/A(5- government is the solution to our on their own behalf, it is a black man who
problems…is very inaccurate.” The partisan started his career as a community organizer
T/A3()2!7?!T/22)4+-4 Republican crowd applauded. on Chicago’s South Side. Yet rather than rally
'*)+/0)4B
V)(2B3!a1(2/B&!@0./+-*+!778 An estimated 690,000 Oklahomans have the uninsured, President Obama has allowed
V/532(40!'(*G6!;22? no health insurance. Why were so few in Republicans to frame the issue as a debate
the room? Why did hundreds of them not over the commerce clause of the Constitution.
\0/B-* jam into Coburn’s ofce the next day? Why The ght to retain actual funding for the
J14A(4!T--*) do they not continue to tell their stories? expanded coverage in the Affordable Care Act
Like the ruling elite in Egypt or Bahrain, is just beginning. It is a battle that Democrats
0:--*)S=(&)*+(40=*-./0)*+?A-:
who genuinely don’t comprehend the can win only if Americans understand that the
'1%2/+3)* problems of the average family, Republicans health and lives of their friends, neighbors and
are more likely than Democrats to believe relatives is at stake. For that to happen, those
_-4!X3/4G:(4 that the uninsured really don’t have any whose lives are most intimately affected must
trouble nding care. rst stand up for themselves.
=1%2/+3)*S=(&)*+(40=*-./0)*+?A-: The political and legal peril in which
health reform nds itself is attributable to Michael Millenson is president of Health
;R!&-1!0-!4-B!*)A)/.)!&-1*!/++1)!-R! the failure of the uninsured to visibly Quality Advisors in Highland Park, Ill.
'(&)*+!,!'*-./0)*+!%&!$$!@?T?!-4! advocate on their own behalf. Those without
>1)+0(&6!=2)(+)!A(22!EOPPH"FOI"<Q#? health insurance have allowed the issue to Op-ed submissions of up to 600 words are
become a referendum on Big Government. welcomed. Please e-mail proposals to
And they have left the heavy work of dmoore@payersandproviders.com,

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Payers & Providers MARKETPLACE/EMPLOYMENT Page 5

DIRECTOR OF PHARMACY

(Urbana, IL)
Health Alliance Medical Plans seeks Pharmacy top-level individual responsible for drug formulary design and development,
implementation, contract negotiation, and risk management. Quality, utilization management, customer service, and cost
containment are key performance metrics. Responsible for dealing with the wide variety of clinical, administrative, nancial
and regulatory challenges involved in the management of pharmacy cost and utilization. Responsible for the supervision and
management of the Pharmacy Network, Pharmacy Staff, and pharmacy related contracting.

JOB REQUIREMENTS

Education, training, experience:

Education: Doctor of Pharmacy preferred.

Licensure: Current unrestricted license from the State Board of Pharmacy, State of Illinois by examination.

Experience: Five years industry experience and two years experience in managed care organization. Must include experience
in third party reimbursement, formulary and clinical programs. Government program experience (Part D and Medicaid) is
desirable. Previous experience in pharmaceutical rebates/discount contracting negotiation with pharmaceutical
manufacturers. Previous experience and understanding of retail pharmacy, hospital pharmacy, LTCF operation, billing, and
drug purchasing. Extensive experience with word processor and spreadsheet applications. Personnel management experience.

Other Knowledge/Skills: Ability to organize, interpret and distill large volumes of data formats and accurately communicate
issues to physicians, pharmacists, employers, administration, and Health Alliance staff. Ability to create and utilize cost
benet analysis (pharmacoeconomics) of therapeutic selection and available alternatives. Must be able to anticipate and take
corrective action in response to changes in pharmacy regulations, prescribing patterns, new therapeutic technologies, etc.
Ability to maintain a credible professional image with physicians and drug manufacturers. Must be adept at persuasion and
direct confrontation. Working knowledge of claims systems, pharmacy operations, and managed care required. Ability to
positively address issues from dissatised enrollees and pharmacists.

Contact:
Lesley Schacht
Professional Recruiter
Human Resource Services
Carle and Health Alliance Medical Plans
lesley.schacht@carle.com
http://www.carlecareers.com

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Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

DIRECTOR OF OPERATIONS – MEDICARE


!! (Health Plan in Midwest)
• Perform duties as senior liaison between the Medicare business unit and Corporate department.
• Partner with multiple stakeholders and business unit leadership to establish operational objectives and procedures.
• Support due diligence and integration for business unit expansions.
• Facilitate operational oversight for Medicare business units and identify opportunities for maintaining effective
operations.
• Ensure cost effective programs are developed and maintained throughout the business unit.
• Identify operational efciencies and develop “best practice” policies and procedures.
• Contribute to the development of new products and markets.
• Utilize corporate and industry standard management tools and techniques to effectively oversee projects; negotiate
with project stakeholders to identify resources, resolve issues, and mitigate risks.
• Coordinate cross-functional meetings with various functional areas to meet overall stakeholder expectations and
business unit objectives.
• Provide functional and technical expertise across multiple business and technical areas.
• Coordinate cross-functional meetings with various functional areas to meet overall stakeholder expectations and
business unit objectives.

Bachelor's degree in Business Administration, Finance, Accountancy or equivalent. Six-plus years of experience in Medicare
managed care operations with emphasis on nance and information technology preferred. Project management, administration
or operations in the Healthcare industry preferred. Master’s degree preferred.

Contact:
ES&P SEARCH!!!!
Sonia Varian at (818) 707-7118, or espsonia@pacbell.net

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-)!B)&%!3;#-!)-%!;)5&:!/#77!4)-!M;+-AB#-!#3!VWWE<XVE<YZ=I!%F3:!>I!)&!%EB#+7!;+B!#3!%,+3)&[2#$%&'#-,2&)*+,%&':9)B:!
! !

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Payers & Providers MARKETPLACE/EMPLOYMENT Page 7

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*New England Journal of Medicine, 2004.

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