26 April 2011
Midwest Edition
Calendar
May 11-13
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June 15-17
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E-Mail
info@payersandproviders.com with
the details of your event, or call
(877) 248-2360, ext. 3. It will be
published in the Calendar section,
space permitting.
New Ohio Governor Trims Medicaid
Reshapes Program to Improve Care, Save Cash
Facing a potential budget decit of $7.7
billion in the next two years, the newly
elected Republican governor of Ohio has
proposed a sweeping reform of Medicaid that
he hopes will improve quality of care and
patient satisfaction while saving large sums
for taxpayers.
In so doing Gov. John Kasich has alienated
some interest groups but also attracted
attention from national observers for an
approach characterized as more
comprehensive and nuanced than what’s
happening in many statehouses.
Kasich created the Governor’s Ofce of
Health Transformation as soon as he took
ofce in January. It coordinates policy for all
six state agencies that have a hand in
Medicaid.
The Medicaid reforms are arrayed around
ve basic goals:
* Improve care coordination.
* Integrate behavioral and physical health
care.
* Rebalance long-term care.
* Modernize reimbursement.
* Balance the budget.
The last item is driving all the rest. The
budget proposal that Kasich prepared in
March shaves $1.4 billion off the trendline for
Medicaid, according to Eric Poklar,
www.lakesidecommunityhealthcare.com
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transformation ofce spokesman. It does so
by insisting that Ohio’s 2.2 million Medicaid
beneciaries have a medical home that
coordinates their care, and by asking that
providers assure more value for each dollar
spent. It also addresses “hot spots” of high
medical resource consumption, such as
nursing home care and chronic disease care.
That’s where the money is: Just 4% of
Medicaid recipients cost 52% of Medicaid
spending, the transformation ofce says.
“I like what they’re doing in Ohio,” said
Tricia Brooks, a senior fellow at the
Georgetown University Center for Children
and Families. “It is refreshing to nd a
conservative administration choosing not to
have ideology guide their action but really
take a hard look at how the state is delivering
healthcare. They are looking at where cost
and quality can be improved, together,
without relying on cutting coverage as a
mechanism to get the budget under control.”
This week the governor’s proposed budget
will go through its rst hurdle in the
legislature, as the House takes up the bill on
April 28. “Everything we have proposed will
be modied a little bit,” Poklar said in a
telephone interview.
Continued on Next Page
 Payers & Providers
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In Brief
UnitedHealth Group
Shares Rebound After
Strong Earnings Report
UnitedHealth Group Inc. shares
jumped on April 21 after the company
said net income rose to $1.35 billion
in the rst quarter, up from $1.19
billion a year ago. Earnings per share
hit $1.22 a share, compared with
$1.03 a share in the rst quarter 2009.
UnitedHealth’s earnings beat
estimates by 33 cents a share,
propelling the stock 8% higher by the
day’s close, to $47.81. Revenues
reached $25.4 billion, up from $23.3
billion last year.
The Minnetonka, Minn.-based
insurer, the largest in the country by
sales, is the rst of the major managed-
care companies to report earnings this
season. It raised its estimate for full-
year prots at the same time, from
$3.70 per share to $4.05.
The solid results lifted the entire
group of health insurance stocks.
WellPoint Inc. rose 4.2%, Aetna Inc.
went up 5.5%, and Cigna Corp.
increased 3.2%, signaling optimism
among investors about their quarterly
results. A full year after passage of the
Affordable Care Act, the insurance
companies appear to be adapting
better than many observers had
expected.
WellPoint is scheduled to report on
April 27, Aetna on April 28, and Cigna
on May 5.
U Wisconsin Group
Won’t Take Money
from Pharmacos
A small policy group at the University
of Wisconsin School of Medicine and
Public Health has decided to stop
accepting donations from the
pharmaceutical industry, after criticism
that it advocated for narcotic
painkillers.
Continued on Page 3
NEWS
Ohio Medicaid (Continued from Page One)
Over the past two years, Medicaid
expenses in Ohio rose by 16%. The Kasich
budget would trim that by $1.4 billion in the
next two years, mainly by addressing the
needs of the chronically ill and changing the
way nursing home care is provided.
The federal health reform law of 2010 will
have a dramatic impact on the states and
their budgets, Poklar pointed out. The
Affordable Care Act will add 970,000 new
Medicaid eligibles in Ohio and contribute
$34 billion in costs from 2014, when it goes
into effect, to 2019, when the federal
subsidies to the states diminish.
In 2011 the state and federal governments
together will pay $18 billion to support
Medicaid in Ohio. By 2017 the state expects
to spend 30% more to cover half again as
many eligibles. State ofcials are worried
that the requirements of the ACA are going
to completely bust the budget.
“If federal health reform does stand, in
2014 we need to be prepared for these new
people coming in,” Poklar said. While the
governor doesn’t like the reform law, the
transformation ofce “has not been shy
about adopting the best-practices aspect” of
the law for Ohio. Those include the medical
homes and incentives to achieve better
outcomes.
“What’s impressive about it is it’s a broad
range of interventions, not just one thing,”
said Alan Weil, executive director of the
National Academy for State Health Policy in
Washington. Many states are trying to gure
out how to rein in Medicaid spending.
Ohio’s approach, focusing on how care is
delivered instead of on provider payment
rates, is distinctive, Weil said.
Kasich served in Congress as chair of the
House Budget Committee in the late 1990s
when Newt Gingrich was speaker. He spent
10 years in private industry, then ran for
governor last year. He is regarded as “one of
the most aggressive reformers among the
new crop of Republican governors,”
according to Washington Post blogger
Jennifer Rubin.
Well before he was elected, however,
Kasich had convened a small group of policy
experts starting three years ago to begin to
research overhauling the state’s Medicaid
policies. After the election, that group,
!!!"#$$!%&!'(&)*+!,!'*-./0)*+!'1%2/+3/456!778
Page 2
chaired by Greg Moody, an experienced
Medicaid policy expert, went into high gear.
They put the entire Medicaid package
together in 50 days.
Part of the problem is specic to Ohio.
The state ranks 42nd in health outcomes for
health systems overall, and it is 37th most
affordable. That means “37 other states have
an advantage over Ohio when it comes to
workforce productivity,” Poklar said.
The transformation team is using the “hot
spots” approach discussed by Atul Gawande,
M.D. in a New Yorker article in January. The
essay documented how dogged physicians
are trying to control health spending on
people with multiple illnesses who have no
medical home and rely on emergency
departments and frequent hospitalizations for
care.
“Some of those people are expensive
because the system is not well set up to deal
with them,” Poklar said. You end up with
“bad outcomes for people and high cost to
the system and the taxpayer.” The patients are
seeing multiple doctors, who don’t talk to
each other, and there is often an underlying
mental health diagnosis. The Ohio team will
require such frequent yers to have a medical
home, with a care coordinator to see to it that
their chronic conditions are managed as well
as possible.
Another area of proposed savings is
nursing home care, where Ohio spends 52%
more than the national average. The reform
plan will reallocate resources to allow elderly
patients to stay in their own homes as long as
possible. The budget proposal raises funding
for home and community-based services for
the elderly by $31.6 million over two years,
allowing 7,248 more people to be served this
way.
The nursing home lobby is the only
advocacy group that has heavily opposed the
reform package. “Gov. John Kasich’s budget
proposal has the potential to devastate Ohio’s
skilled nursing facility community, cutting
rates more than 7% for a total $472 million,”
says the Ohio Health Care Association on its
website.
The Ohio Hospital Association has largely
supported the reforms, agreeing to extend a
franchise fee that taxes hospital revenues
because it draws down federal funds.
Payers & Providers
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In Brief
The UW Pain & Policy Studies
Group had taken about $2.5 million
over 10 years from companies that
manufacture opioids. During this
period, the group supported
prescribing narcotic painkillers for
non-cancer chronic pain and
published papers in scientic journals
advocating use of the opioids. Those
drugs, such as OcyContin, are highly
addictive and have led to an epidemic
of abuse, sometimes leading to death
through overdose.
The Food and Drug Administration
recently unveiled a new program to
control prescription abuse by
educating physicians about pain
management and patient selection.
According to an investigative
report in the Milwaukee Journal-
Sentinel, the UW Pain Group received
a total of $1.6 million over 10 years
from Purdue Pharma, maker of
OxyContin. The company and three
of its executives pleaded guilty to
various charges and paid nes and
restitution of $635 million.
Physicians who Wrote
Excuses for Wisconsin
Protesters are Probed
Wisconsin officials are
investigating eight physicians who
wrote medical excuses so that
protesters at the state Capitol could
explain why they were not at work.
Many protesters were teachers
who had been warned by their
school districts not to be absent
from class, unless they could show
a doctor’s note or prior permission.
The investigations are under the
auspices of the Wisconsin Dept. of
Regulation and Licensing and the
Medical Examining Board. One
physician from the University of
Wisconsin Medical School offered
to help out protesters with doctor’s
notes.
The demonstrators were
protesting the bill pushed by Gov.
Scott Walker, a Republican, to cut
back collective bargaining rights
for public employees in Wisconsin,
which subsequently passed.
NEWS
Healthcare Cost Inflation Is Slowing
Spending Growth on Branded Drugs Declines
Two independent indices released last week
indicate that the rate of health care ination
may be slowing, albeit slightly.
The Standard & Poor’s Healthcare Economic
Composite Index rose 6.19% over the 12
months ending February 2011, a drop from a
rate of 6.31% as of January.
Spending on prescription drugs increased by
0.6% in 2010 on a real per capita basis,
compared to 3.1% in 2009. Nominal spending
increased 2.3%, reaching $307 billion last year,
according to a study by IMS Health. Nominal
spending went up 5.1% in 2009.
Even with the decline in the rate of cost
growth, health care spending still rose by three
times the rate of the consumer price index,
which was 2.1%. In May 2010 the S&P health
care index showed 8.74% growth.
Costs paid by commercial insurance plans
went up 7.97%, while Medicare claim costs
rose 3.22%, the lowest rate of growth in six
years. Physician wages rose by an annualized
5.4% as of February, almost twice their rate of a
1099 Repeal Contains Hidden Tax
Low-income Subsidies Might Have to be Paid Back
The rollback of one of the most unpopular
provisions of the 2010 Affordable Care Act
also contained a modication that may cause
taxpayers some grief after the law goes fully
into effect.
Two weeks ago President Obama signed
into law a bill repealing the 1099 reporting
requirement, which obligated any employer
doing more than $600 a year in business with
a vendor to ll out an IRS form 1099. The
additional $22 billion in revenues gleaned
from this clause in the health reform act were
to cover some of the costs of the expansion in
insurance coverage.
The business community complained that
the additional paper work was burdensome
and not worth the effort, so Congress, in a rare
instance of bipartisan unity, got rid of it.
But to make up for the lost revenues,
Congress decided to make low-income
families covered by the subsidized insurance
pay back the subsidy if their income exceeds
their estimate for the year.
!!!"#$$!%&!'(&)*+!,!'*-./0)*+!'1%2/+3/456!778
Page 3
year earlier.
IMS Health said the historically low growth
rate in pharmaceutical spending was caused
by a variety of factors, including fewer patient
visits to physicians ofces, patent expirations,
increasing reliance on generics, and less
spending on new drugs.
The average prescription copayment
declined by 1.8%, from $10.93 in 2009 to
$10.73 in 2010.
Payers and physicians are becoming
increasingly adept at encouraging the switch
to generic medications once branded drugs
fall off patent. Within six months of patent
loss, patients got the generic form of the drug
80% of the time last year. The value of the
branded products that went off patent and
faced generic competition in 2010 was $12.6
billion, compared to $19.5 billion the year
before.
Generics accounted for 78% of total
prescription market share, up from 63% in
2006.
Timothy Jost, a professor at Washington
and Lee University in Virginia, explained at a
healthcare journalists conference in
Philadelphia last week that to qualify for the
reduced-cost insurance coverage, families
must project their income for the year.
But, he pointed out, income is often
unstable and unpredictable, especially among
the self-employed or those engaged in the
trades. If, at tax ling time, a family’s income
has exceeded their estimate and takes them
over the prescribed limit, or if the status of a
dependent child has changed, the family
could be liable to pay back the value of the
subsidy, up to $2,500.
“What they thought was a grant turns out
to be a loan,” Jost said. “Repayment demands
may be substantial and cause serious
hardships.”
Taxpayers, as a result, are likely to be angry
when they get the bill, which may over time
erode support for the expanded insurance
coverage, Jost said.
Payers & Providers
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OPINION Page 4
EHR Won’t Be Happening Soon
The Economics of Digitizing Are Still Punishing Offices
This is a big year many physicians, including our hospital electronically, what’s the point of
myself. There are big nancial incentives to going electronic? The above-mentioned vendor’s
invest in an electronic health record (EHR) system, as well as a whole host of others out
today, not tomorrow. If we digitize this year, there, is not compatible with our hospital and it’s
we can qualify for an $18,000 payment under not likely to be for some time. All systems would
the American Recovery and Reinvestment Act have to be compatible eventually, the vendor
(ARRA) passed as part of the economic stimulus said. In the meantime, our system would be pretty
package of 2009. And we may be eligible for useless, at least when it came to sharing
up to $44,000 over the next ve years if we can information with our hospital network.
prove that our EHR improves and streamlines The system our hospital is in the process of
patient care. If we wait till 2013, implementing is expensive. Initially,
the payment will be less; and it we were told that it would cost
will disappear after 2016. $7,000 per physician per year. In
So why am I not more excited? our practice, that would be a
Converting from paper to whopping $21,000, which can’t be
digital isn’t as easy as it sounds. recovered through patient charges.
There are lots of obstacles, not After protests by many physicians,
least, fear of change. After 27 the price has come down a little
years of practice, I’ve developed a bit, but it’s still too expensive.
charting system that works for me; I have the suspicion that quality
switching to something new seems of care is not the primary motive
daunting. for going electronic; rather, money
Moreover, our charting—which is. Frankly, no one trusts us any more.
must respond to demands from By Ross A. In the eyes of the federal government
malpractice lawyers, insurers and Slotten, M.D. and insurers, doctors are a bunch of
government regulators, who are crooks who must be scrutinized at
always searching for errors and deceit—is every step. I say this because the nature of the
already a pain in the neck. Digitizing requires a medical chart has changed over the last few
whole new set of hand-eye coordination decades. Instead of being a simple record of an
techniques. interaction between patient and doctor, it now
In principle, I agree with the need for must comply with a variety of cumbersome
digitizing. Most important, the record would be standards. Every encounter has a code based on
legible. Doctors’ handwriting is horrible. I still level of service; every diagnosis must match
can’t read the notes of one of my partners. The what’s in the record. And now easily tracked by
problem is, he can’t type. When asked how this the powers-that-be. Once again, it’s a good idea
was possible, he said his sister typed his papers in principle, but a mineeld if any errors are
when he was in college! We always knew he made.
was spoiled. For him, a signicant obstacle is Finally, will the electronic medical record
an inability to type. No matter how many reduce costs? I doubt it. At least not for the
templates you have in the EHR—and there doctors and hospitals that are being compelled to
could be a huge number for a primary care acquire it. Medicine is one of the few areas in
physician—you still have to write a narrative of which innovation leads to greater expense, not
your encounter with a patient. less.
One vendor assured us that there are now
good voice recognition programs available to Ross A. Slotten, M.D., practices family
get around this. But that same vendor told us medicine in Chicago. He is
that we could also scan our written notes into a member of the Payers & Providers editorial
the computer. So we’d be faux digital, yet still board.
able to demonstrate “meaningful use” of an
electronic medical record system and get our
$18,000. This is absurd, and one more reason
we won’t be buying this vendor’s system.
Another obstacle is compatibility with our
hospital system. If we can’t communicate with
!!!"#$$!%&!'(&)*+!,!'*-./0)*+!'1%2/+3/456!778
Payers & Providers MARKETPLACE/EMPLOYMENT Page 5

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Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

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Call (877) 248-2360, ext. 2, or e-mail
advertise@payersandproviders.com.

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