Payers & Providers Midwest Edition – Issue of December 20, 2011

8/3/2019 Payers & Providers Midwest Edition Issue of December 20, 2011

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I like it.My rst reaction is caution.Its morally outrageous!Those are responses from three different

people to the healthcare bombshell droppedin Congress last Thursday by a pair of policywonks (or legislative provocateurs, dependingon your point of view) whoare trying to keep Medicare agoing concern withoutbankrupting the federalgovernment.

Democratic Sen. RonWyden of Oregon, alongtime deep-thinker onhealthcare, teamed up lastweek with Republican Rep.Paul Ryan of Wisconsin, the

House budget committeechairman, to unveil abipartisan approach toreforming Medicare thatcaught party faithful on bothsides of the aisle by surprise.

The concept behind theWyden-Ryan proposal is touse competitive bidding todepress cost growth. Seniorswould receive a voucher(sometimes referred to as premium support) tobuy the health plan of their choosing on the

open market. The voucher would be worth theprice of the second-least expensive plan in thelocal market. Premiums higher than thatwould be paid by the beneciaries

themselves. People would be allowed to stayin the present dened-benet Medicareprogram if they chose. The plan would limit

the growth of Medicare spending tonominal GDP growth +1%,although its not clear how this capwould be enforced.

Is Ron Wyden trying to electMitt Romney? asked a blogger forThe Nation magazine, a liberalpublication. A conservative bloggerwrote that Ryans timing and thenature of this plan will be viewedas a walk-back, one that weakens

the hands of Republicans goinginto the presidential (election).

All well and good in an electionyear, but what do Medicares actua

administrators think of theproposal? The three peoplequoted at the top of this article-- Gail R. Wilensky, DonBerwick, M.D., and Bruce C.Vladeck have each had aturn piloting the vast

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In Brief

Permits for 2 NewHospitals Denied byIllinois CON Panel

The Illinois Certicate of Need panel

denitively turned down two separatehospital projects in Chicagos farnorthwestern suburbs, citing a lack ofneed for either institution. Mercy Alliance, based in Janesville,Wis., was denied permission to build a70-bed hospital in Crystal Lake, at acost of $200 million. Centegra HealthSystem, based in nearby McHenry,was told it could not build a 128-bedhospital in Huntley, for $233 million.

The Illinois Health Facilities andServices Review Board had signaled in

June it would probably vote no onboth proposals. (Payers & Providers,

June 28 and July 12).The CON committees staff reported

an absence of need for the new beds,saying that six hospitals within lessthan an hours drive were operating atless than capacity for surgery, obstetric,and intensive-care services. Building anew hospital may result in an un-necessary duplication of service, thestaff report concluded.

Hospitals in the area, includingSherman Hospital in Elgin andAdvocate Good Shepherd inBarrington, had lobbied against thenew construction.

Iowa Medical Society

CEO Will Head OhioHospital Lobby

The Ohio Hospital Association hasreached across the Midwest to nd anew chief executive ofcer. MikeAbrams, executive vice president andCEO of the Iowa Medical Society, willtake ofce in the Buckeye State inFebruary.

Continued on Page 3

NEWS

Wyden-Ryan Plan (Continued from Page One)

entitlement program.Wilensky was administrator of what was

then called the Health Care Financing

Administration from 1990 to 1992, under theadministration of President George H.W.Bush. Vladeck ran the agency for President BillClinton, from 1993 to 1997. And Berwick juststepped aside on Dec. 2 as administrator ofthe renamed Centers for Medicare andMedicaid Services, having served for 17months as a recess appointment by PresidentBarack Obama.

Although they are, respectively, aRepublican and two Democrats, they offer aless politicized perspective, one rooted in adeep knowledge of the programs strengthsand deciencies, nancial and operational

challenges. Payers & Providers interviewed the three ofthem on Thursday and Friday, just after theWyden-Ryan plan had been released andbefore any of them had had an opportunity tostudy its details or think about it in any depth.

The concept behind the Wyden-Ryanproposal is to use competitive bidding todepress cost growth. Seniors would receive avoucher (sometimes referred to as premiumsupport) to buy the health plan of theirchoosing on the open market. The voucherwould be worth the price of the second-leastexpensive plan in the local market. Premiums

higher than that would be paid by thebeneciaries themselves. People would beallowed to stay in the present dened-benetMedicare program if they chose. The planwould limit the growth of Medicare spendingto nominal GDP growth +1%. Its not clearhow this cap would be enforced.

The new proposal marks an about-face byRyan, whose original Medicare reform planfrom last year has become a whipping post forpoliticians of both parties. Ryan proposedreplacing the Medicare entitlement with avoucher for seniors to buy their own plan, butat a limited amount that put them at greater

nancial risk.The Democrats planned to use it to

campaign against the Republicans, andpresidential candidate Newt Gingrich called itright-wing social engineering.

Wilensky thinks the new proposal deectsthe use of Medicare as a political whippingblock. The best part of it is, bipartisanshipisnt necessarily dead, she said. It recognizeswe need more choices, we need to take careof the people who are already in existingMedicare. Its terric that the two of themwere willing in this most partisan time, to say,there are ways to get this done. I like it.

In some ways, Wilensky may be theintellectual godmother of the Wyden-Ryanplan. The proposal bears a resemblance to

some suggestions she outlined in the May 192011, issue of the New England Journal ofMedicine: Reforming MedicareToward aModied Ryan Plan. Her three suggestions modifying Ryans original privatization pro-posal allow a greater rate of cost increase,up to 1%; make the subsidy rich enough topurchase at least one health plan in eachregion; and let seniors continue to chooseraditional Medicare all appear as hallmarkpieces of the new bipartisan plan.

Berwick, however, was deeply cautiousabout the implications of the new proposal.There are so many ways to shift costs back

beneciaries, including people who are notable to bear those costs, he said. You havebe very careful with that dynamic.

His second concern is how insurancecompanies will behave. Wyden and Ryanbasically put the private sector insurancecompanies and Medicare in directcompetition through this exchangemechanism. Does this reopen the opportunfor selective enrollment and gaming theprivate market insurance side? There are allkinds of ways for the insurance companies tcover only the people who will be low cost.

The Department of Health and Human

Services right now is struggling how to denthe medical loss ratio for purposes of the ACInsurers of large groups must spend at least85% of premium revenue on medical care,and insurers of small groups and individualsmust hit 80% under the new law. Insurancecompanies are pushing for a lower rate, ormore liberal denitions of what may beconsidered medical costs, while consumergroups are lobbying for a higher MLR.

By that measure Medicare is an extremly efcient system, Berwick pointed out. TMLR would be well over 90%, whereas theinsurance companies have trouble swallowi

80%. Under a consumer choice approach tMedicare, Youd incur marketing and othercosts that would raise the MLR for Medicare

For Vladeck, the analysis is very simpleIf the goal is to cap the federal liability for thMedicare program, there are two ways to doit: You can keep the nancial risk with thefederal government, where it now is, whichmeans government has to gure out how torun the program with a budget constraint.

Or you can shift the risk to beneciaries.To me thats outrageous. Its morally

outrageous and practically stupid, Vladecksaid.


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Page 3Payers & Providers

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NEWS

In Brief

Outgoing president and CEO JimCastle is retiring Dec. 31 after 23years leading the organization.

The OHA represents 167 hospitals,19 health systems, and more than350,000 employees.

At a time when alignment withphysicians and hospitals is critical, the

OHA Board of Trustees is excited tobring in a new CEO whosebackground and reputation will helpOhio hospitals work even moreeffectively with physicians to improvecare to the communities they serve,said Mina Ubbing, president and CEOofFaireld Medical Center, Lancaster,and chair of both the OHA Board andthe search committee for a new CEO.

Abrams, 50, has been CEO of theIowa Medical Society since 1996. Heand his wife, a physician, are nativesof Ohio.

Illinois Hospitals Hire

Firm to Fight on TaxExemptions

The Illinois Hospital Association,facing aggressive moves by stateofcials to examine hospitals taxexemptions, has hired a publicrelations rm to help preserve theirtax-exempt status and lobby forMedicaid funding.

The IHA has engaged PR rmKathy Schaeffer & Associates, ofChicago, to organize a campaigndefending the tax exemptions ofIllinois hospitals. Its clients includeSherman Health System, which justprevailed in an effort to derail twonew hospitals in McHenry County(see rst item, above).

In August the Illinois Departmentof Revenue took away the taxexemptions of three hospitals becausethey spent so little on charity care(Payers & Providers, Aug. 23). Itannounced it would review thetaxation status of another 15 hospitals.

Gov. Pat Quinn has put thatexamination on hold pendingnegotiations between the hospitalsand state authorities, which should beconcluded by March 1.

The federal government has decided to puntthe question of the basic benet packageunder the Affordable Care Act to the states.

Last week Health and Human ServicesSecretary Kathleen Sebelius announced thather agency would allow states wide leeway insetting the terms of the basic benet. Contraryto expectation, HHS will not set one nationalstandard for what health insurance companiesmust cover under health reform. (Payers &Providers, Dec. 13).

Each state may choose an existing healthplan to use as a benchmark for coverage. Thebenchmark can be the HMO with the largest

market share, or one of three biggest plansthat covers small employers, state workers, ofederal employes in that state. This will allowstate regulators maximum leeway in guringout what the local market desires.

Coverage that works in Florida may notwork in Nebraska, Sebelius said.

Starting in 2014, the ACA requires allsmall-group and individual insurance plans cover a set group of services, known as anessential benets package.

HHS said there will be limits on stateexibility to set benet packages, and it willaddress those issues in the next few months.

Hospital groups in Michigan and Ohio arepartnering with major insurers to explorealternative reimbursement strategies that shouldin theory provide better care at lower cost. St. John Providence Health System insoutheast Michigan has joined with thePhysician Alliance to form Partners in Care, aphysician-centered system created to managedthe health of populations. The group has 2,300physician members in southeast Michigan.

Together these entities are working with BlueCross Blue Shield of Michigan to establish apay-for-performance protocol intended toeventually replace fee-for-service.

This is the rst outcomes-basedreimbursement arrangement between BlueCross and a major Michigan hospital system,said Susan Barkell, senior vice president forhealthcare value at Blue Cross. We recognizethe leadership and foresight of St. JohnProvidence for partnering with Blue Cross onit.

The Blues will help pay for infrastructureupgrades that will integrate care servicesbetween the Physician Alliance and the vehospitals controlled by St. John Providence,which is a division ofAscension Health, thecountrys largest Roman Catholic health system.

In 2013 the hospital group will include aperformance-based reimbursement model in itsnext contract with Blue Cross.

Meanwhile, in Ohio, Aetna Inc., thecountrys third-largest for-prot health insurer,has announced results of a prototype

accountable care plan partnership withCentral Ohio Primary Care Physicians.

Since 2009 when the collaborative begaCOPC achieved a 97% rate of preventive anfollow-up visits for 3,200 Aetna MedicareAdvantage members. The Aetna cohortexperienced 30% fewer inpatient hospitaldays than the average traditional OhioMedicare population, and 22% fewer hospitreadmissions.

Aetnas model allows for a nurse casemanager to be embedded in the COPCpractice who coordinates care for the AetnaMA members. Research conducted by TheCommonwealth Fund into this prototypefound that this program decreased duplicateunnecessary services and improved outcomeIn 2010, Aetnas MA enrollees in this prograrequired 43% less acute hospital care,compared to unmanaged Medicarebeneciaries.

By working more effectively andefciently with outstanding health careproviders like COPC, we have demonstratedthat we can help improve the coordinationand quality of care and reduce health carecosts, said Randall Krakauer, M.D., Aetnasnational Medicare medical director. Aetna

believes patient-centered collaboratives canserve as one stepping stone to the creation oaccountable care organizations.

Aetna plans to expand the program acrothe country for its Medicare Advantagepatients.

Joint Efforts Paying Off in Ohio, Mich.Aetna, Michigan Blues Develop ACO Prototypes

Basic Benefit Gets Tossed to StatesHHS Decides Against Setting One National Standar


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Payers & Providers Page

Employers could avoid a lot of frustration,disappointment, and unnecessary costs if theymore effectively set expectations andperformance guarantees with their healthcarevendors (i.e. health plans, providers, pharmacybenet managers). Warren Buffett once noted,price is what you pay, value is what you get.While he may not have been talkingspecically about purchasing healthcarebenets, I think he would agree that employersneed to focus not only on price, but onperformance and value.

All too often, employers dontset expectations for levels of

services, reports, and metrics earlyin their request-for-proposalprocess and overlook the need tooutline specic performanceguarantees in their vendornegotiations and contracts. Theyare often left with theperformance deemed appropriateby the vendor, which may notmeet their level of satisfaction oremployee needs.

Employers are wasting millionsof dollars on wellness andprevention programs that get little

participation or may not evenwork. Many have no idea howmany employees are engagedin their programs. To ensurevalue for every dollar spent,they must rst set clear expectations andmeasurable deliverables.

While larger employers have been doingthis for some time, small- to mid-sizeemployers are moving toward hosting vendorsummits, meetings where all of an employerspartners can learn how the employer wants thevendors to work together and set theexpectations for their relationship. This can

reduce overlapping services and help thevendors understand the employers biggerpicture. Many employers are interested inhaving a more integrated understanding ofwhat their data sources are telling them alltogether. Collaboration among vendors iscritical.

Before this can be accomplished, however,they need to ensure they have the necessarydata to make smart decisions, set expectations,and measure results. One initiative currentlyhelping employers understand their data is the

Midwest Health Strategy Project. As a result othis effort, employers will be able to introducecomplementary array of employee health offeand incentives that better align health promotand prevention strategies with their medical apharmaceutical plans, and other benets suchdisability and workers compensation.

Another way to bring about positive changfor purchasers to work together to have acommon ask and collaborate on what is mostimportant to move the market. An example ofis the BlueCross BlueShield User Group, led b

the Midwest Business Group onHealth, which brings together

employers of different sizes anindustries who share a commohealth plan. The user group allothem to not only share informaand experiences, but tocommunicate as a collective gto the plan on areas of concernimprovement.

A second instance of aninitiative that fosters requiredcollaboration is eValue8, anannual survey and evaluation uby healthcare purchasers to assand manage the quality and

efciency of health plans.EValue8 involves

collaboration among theNational Business CoalitioHealth, the organization th

developed it, the regional coalitions that manit, the employers that use it and the health plathat accept the challenge of accountability anmotivation within their networks of doctors anhospitals.. The health plan-customer dialogueleads to improvements in the plans structure,process, and outcomes, and helps to answer tcritical question: What are plans doing to impquality and value?

Its no longer about asking a vendor Whayou do for me? Its about going to a vendor atelling them what you need as an employer. Uwant your vendors to be partners. To do this,employers must rst understand their populatand then communicate their needs to ensure are receiving value, and ultimately healthieremployees, for their healthcare dollar.

OPINION

Getting Value for Healthcare DollarsEmployers Need a Rigorous Approach with Vendor

Larry Boress is president and CEO of the

Midwest Business Group on Health.

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MARKETPLACE/EMPLOYMENTPayers & Providers Page 5

Senior Vice President, Health System Planning and Performance

If your career has driven you to the forefront of strategic healthcare thought and planning, here is theopportunity to play a lead role in shaping the future of one of the worlds largest providers. Alberta HealthServices was created as the result of Canadas largest ever merger. With its 90,000 employees andannual budget of $12 billion, AHS serves a population of nearly four million people. In three years, it hastaken great strides in realizing an ambitious goal of accessible, integrated, and sustainable healthcare forall. The next crucial steps will depend upon the visionary leadership and co-operative example ofaccomplished transformative leaders like you.

As AHS designs and builds a healthcare model of the future, you will contribute your insights andexperience to the mission. A key decisionmaker in the Strategy and Performance portfolio, you will call onyourexperience to provide the leadership, systems thinking and structuresthat will promote continuousimprovement in system performance andoutcomes. You will:

Provide linkages to policy development, performance reporting and overall joint integrated systemplanning processes.

Act as a pivotal interface with operational planning and performance reporting in the zones.

Develop integrated planning and budgeting processes.

Support the overall development of Strategic Clinical Networks and care models that build on bestevidence and practice, and provide specific planning support as required.

Today, you are in a similar planning and performance leadership role in a major healthcare system. An in-demand speaker and strategist on healthcare design and operations, you have earned your reputation forvision and organizational design. With Alberta Health Services, you can continue to pioneer transformation

in the vanguard of complex healthcare delivery.

All responses to Caldwell Partners are confidential. Please indicate your interest in Project 111104at www.caldwellpartners.com/apply.php

Caldwell Partners, Premier providers of executive search

Website: www.caldwellpartners.com/apply.php.


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Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

Revenue Cycle Analyst/Senior Analyst

Catholic Health Partners is the largest health system in Ohio and one of the largest nonprofithealth systems in America. CHP has been recognized as one of the Best Employers in Ohioand named a 2011 Best Place to Work by the Cincinnati Business Courier. Thomson Reuters

has also named CHP as one of the top 10 U.S. health systems, based on our hospitals clinicalperformance.

Positions will assume responsibility for all acute and non-acute Revenue Cycle analytical needs,including maintenance of scorecards, dashboards and ad hoc reporting using a variety ofsource systems and presentation software. The Senior Revenue Cycle Analyst will also beresponsible for providing analytical insight regarding all reports, discovering root causes anddeveloping corrective action plans and recommending modifications to established practicesand procedures or system functionality. The Senior position will also participate inimplementation of new and existing functionality to support revenue cycle processes.

Qualifications:

- Bachelors degree in Business or Technology (advanced degree preferred for Senior levelposition)

- 3 to 5+ years of experience in revenue cycle analytics in a hospital or physician setting usingbusiness intelligence tools

- Database expertise, including SQL

- Expert knowledge of Excel and Access

- The ability to create and present reports to C levelExcellent computer, proofreading, written/verbal communication and interpersonal skills

- The ability to work independently, proactively with limited supervision and also as a teamplayer

- The ability to work under pressure and maintain confidentiality

Please send resume via email to: [email protected] (please indicate specificposition of interest) or apply online at www.health-partners.org. Catholic Health Partners, 615

Elsinore Place, Cincinnati, OH 45202

CHP values a culture strengthened by diversity and inclusion. We welcome the different ideas,experiences, perspectives and talents of a diverse workforce. EOE

E-mail Address: [email protected]


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Page 7Payers & Providers MARKETPLACE/EMPLOYMENT

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Payers & Providers Midwest Edition – Issue of December 20, 2011