Payers & Providers Midwest Edition – Issue of November 15, 2011

8/3/2019 Payers & Providers Midwest Edition Issue of November 15, 2011

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Walmart is apparently intending to create anetwork of cheap, quality primary care clinicsthroughout its thousands of stores, accordingto a story on NPR on Nov. 9. The countrys

largest retailer confused the issue, however, byputting out a statement later that day denyingthe thrust of the story. John Agwunobi, M.D., president ofWalmart Health and Wellness, said thedocument on which NPR based its report wasoverwritten and incorrect.We are not building anational, integrated, low-cost primary care healthcare platform.

That comment leftopen the question of whatWalmart is actually doing.

The company has longbeen interested in using itsthousands of storelocations and brandmuscle to offer basichealth services. In 2007 itannounced plans to open 400 instore clinics.It built only 140 of them. Other retailers, suchas Walgreens and CVS, have far more retailclinics. There are about 1,300 store-basedclinics in the country, according to MerchantMedicine, a Minnesota research rm.

Walmart has 4,400 retail locations in theU.S. and employs 1.4 million Americans,making it the largest private employer. It got itsstart in Arkansas and has more than 1,000

locations in the Midwest.Walmarts request for information from

vendors, downloadable from the NPR website, states that the company intends to builda national, integrated, low-cost primary carehealthcare platform that will provide

preventative and chroniccare services that arecurrently out of reach formillions of Americans.Walmart intends to do thisin an affordable andaccessible way whilemaintaining or improving

quality outcomes.It is reaching out to

potential partners whohave a care model orcapability that can helpdramatically drive down the

cost of care. The company says it aims tobecome the largest provider of primaryhealthcare services in the nation by drivingdown the cost of services and products whilemaintaining a high quality of care. Services to

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Payers & Providers Page 2

Top Placement...Bottomless Potential

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In Brief

Internal MedicineGroup is Bought

by NorthShore System

NorthShore University Health System

has acquired a 15-physician practicein Highland Park, Ill., in the wealthynorthern suburbs of Chicago.Ravinia Associates in InternalMedicine will join a growing numberof phycisians practices that havethrown their lot with NorthShore. Thepractice is close to NorthShoresHighland Park Hospital, and only sixmiles from Lake Forest Hospital, whichwas acquired by NorthwesternMemorial HealthCare, a rival toNorthShore.

NorthShore now has about 740doctors in its physicians group. Robert Block, M.D., president ofthe physicians group, said Ravinia

Associates needed to get out fromunder rising operational costs and theproblems of administering the practice.NorthShore could run the practicemore effectively than the doctorsthemselves, he said.

Medicaid Cutbacksin Wisconsin to Affect

65,000 Poor People

Wisconsin lawmakers passed ameasure last week that would exclude65,000 people -- half of them children-- from the states indigent care

programs.The vote in the Joint Finance

Committee split 11 to 4, with allRepublicans voting in favor of thecutbacks and all Democrats votingagainst.

Medicaid covers about one fth ofthe population in Wisconsin, or 1.2million residents. The administration ofGov. Scott Walker, a Republican,wants to trim benets for about250,000 residents, raise premiums for

Continued on Page 3

NEWS

Walmart (Continued from Page One)

be offered include clinical care, diagnostics,preventative care, and wellness products.

The RFI provides a list of chronic diseases

Walmart wants to tackle, among themdiabetes, asthma, obesity, COPD,osteoporosis, HIV, arthritis, kidney disease,and high cholesterol. Its list of preventativeand diagnostic interests run a full gamut ofservices.

According to an article in the McKinseyQuarterlyfrom 2002, Walmart effectivelyrevolutionized the retailing industry, withpricing and productivity benets that spreadthroughout the U.S. economy known as theWalmart Effect. Its innovations in informationtechnology, supply-chain management,distribution set the pace. And it also became

famous for hardball tactics with suppliers thatsliced their prot margins while making themdependent on Walmart for sales volume.

With a market share of 9% in generalmerchandise in 1987, Walmart enjoyed aproductivity advantage of 40% over itscompetitors, measured by real sales peremployee. By 1995 it hadattained a share of 27% andenjoyed a productivity premiumof 48%.

Walmarts primary-careconcept is a really ambitiousre-imagination of what you can

do in a retail clinic, said BobKocher, M.D., a formerMcKinsey consultant, WhiteHouse advisor, and BrookingsInstitution scholar, in aconversation with NPR. Itshould lead to better prices forpatients. Health-care is oneplace where prices seldom falland theres not much competition aroundvalue. William M. Dwyer, a healthcare futuristbased in Kansas City, Mo., said the Walmartconcept doesnt look the same as the CVS or

Walgreens play.It could take retail medicine to a whole

new Steve Jobs era, particularly in primarycare, he said.! They will not be hesitant tohire physician assistants and nursepractitioners and get the cost downdramatically.

If Walmart brought the same tactics to bearon medicine as in general retailing, with thesame result, it could be devastating not onlyfor suppliers but also for traditional physicianspractices, especially in rural areas whereWalmart has a strong presence.

If I was a primary-care physician (orassociation) I would boycott Walmart, anddirect my patients away from their pharma

Dwyer said. Glen Stream, M.D., president of theAmerican Academy of Family Physicians iLeawood, Kan., said he would be gravelyconcerned that this is going to fragment caAt a time when we now clearly understandthat people having a source of comprehenand continuous care in one location is afeature that improves quality of care anddrives down costs.

Retail analysts are skeptical. It is a veryvery different business than retailing, saidColin McGranahan, an analyst with SanfoBernstein. It requires extremely different

competencies, not many of which Walmarhas today. Its a business and a market thatof very smart people have tried to streamliover time, and its ummoxed most of thosfolks. Walmart as a corporation and employehas a troubled history in the healthcare are

Long notorious for not offeringhealth insurance for the vastmajority of its low-wageemployees, it indirectly steeredthem toward Medicaid andindigent care programs. For myears Walmart offered insuran

to part-timers only after two yeof employment. Under externapressure, the company alteredrequirement to one year in 200

In October the companybacktracked from that policy,saying new part-time workers wput in fewer than 24 hours a wwould be ineligible for insuran

while premiums would go up steeply andcoverage would be slimmed down.

The current health care system isunsustainable for everyone and, like otherbusinesses, we've had to make choices we

wish we didn't have to make, said Walmaspokesman Greg Rossiter.

Walmarts U.S. sales have been stagnanthe past two years. Some commentatorssuggested that moving into health clinicswould be a way to attract more shoppers ithe store who would buy generalmerchandise.

Walmart is being advised in this procesPricewaterhouseCoopers . A copy of allsubmissions is to be directed to a director PwC whose name and email address appeon the RFI.

William M. DwyerHealthcare Futurist


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Page 3Payers & Providers

Longer ALOS!*

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*For our ads, not your hospital

NEWS

In Brief

others, and terminate coverage for ayear if a family misses a payment.

This year federal payments will fallbecause of a reduction in federal aidto the states. That leaves the stategovernment on the hook for a largershare of the total expenses.

The proposals are intended to save

$298 million a year.A single parent with two children

who earns more than $27,795 a yearwould have an annual premium of$1,390, compared to $120 before thechange.

State Rep. Tamara Grigsby, aDemocrat from Milwaukee, predictedthat many poor families would leavethe program because they dont haveenough money to pay the newpremiums.

Michigan Senate BillWould Authorize Basic

Health ExchangeThe Michigan Senate last weekapproved a bill authorizing creation ofa health insurance exchange. Gov.Rick Snyder, a Republican, indicatedhe was in favor of the bill, whichcreates a minimal, basic exchangethat meets the requirements of theAffordable Care Act.

Under the bill, families andbusinesses of less than 50 peoplecould shop online in an environmentcomparable to Orbitz.com orTravelocity.com.

The state would create a seven-member board to oversee the online

marketplace. A toll-free phone linewould answer questions fromconsumers.

The Republican bill goes againstthe wishes of many conservatives andTea Party afliates who eschew anycooperation with the federal law,which they hope will be overturnedby the U.S. Supreme Court.

But Snyder pointed out that such abill lets the state take charge of itsown destiny, rather than letting thefederal government impose a morebureaucratic solution. If the law isoverturned, the exchange can quietlybe allowed to expire.

The percentage of Americans who get healthinsurance through their employers dropped toa new low of 44.5% in the third quarter, aGallup poll revealed last week. The causeswere the high rate of unemployment andunderemployment, plus the declining numberof employers who offer a health plan to theirworkers.

In 2008, when Gallup rst surveyed therate of insurance coverage, the rate was49.8%. It has been sliding steadily since.

Over that period the rate of uninsured rosefrom 14.6% to 17.3%, the highest on record.Those covered by a government health plan(Medicare, Medicaid, military or veteransplan) went from 22.9% to 25.1%, downslightly from a peak of 25.7% earlier this year.

At the same time that the rate of insurancecoverage has declined, the quality of thatcoverage has also taken some hits. Manyemployers, desperate to stem the steep rise inexpenses associated with employee

healthcare, are thinning out their plans orasking employees to absorb more of the costburden. Providers sometimes nd that patiendont have the nancial means to contributetheir share, whether through copays,coinsurance, or deductibles.

The Affordable Care Act attempts to covemore people by offering subsidies to people

they can buy private insurance, or obtaincoverage through Medicaid.

The percentage of 18- to 26-year-olds whdont have health insurance has gone down,mainly because of a part of the law that allowthem to be covered on their parents policieAt the same time, the rate of uninsurance harisen among those aged 25 to 64.

The poll was part of the Gallup-HealthwaWell-Being Index. The survey was conductedby telephone interview between July andSeptember, contacting 90,070 adults in all 5states.

The American Academy of Family Physiciansestimates that health insurance exchanges willreduce the number of uninsured in Illinois by5% between now and 2020. Gordana Krkic, vice president ofgovernment relations for the Illinois Academyof Family Physicians, said the introduction ofstate health insurance exchanges is likely tocause painful disruptions for many in the healthinsurance industry. But family physicians arewell-positioned to drive and shape healthexchanges and other consumer-orientedinsurance reforms.

State legislatures will be grappling withcreation and implementation of the exchangesin the sessions that begin in January. The Illinoislegislature intended to take up the issue in itsveto session in October and November, but sofar no bill has been passed.

Health insurance exchanges are among thekeystone innovations in the Affordable CareAct. Each state is called upon to built an onlineexchange where families and small employersmay comparison shop for health plans, andgure out what subsidies they may qualify for.States have wide leeway to decide howcomprehensive or how passive their exchange

may be. States that dont enact qualifying

legislation and build their own exchange wibe swept into a federally operated exchange

The AAFP has developed eight principlesfor that call for

1. fair representation of stakeholders;2. enhanced access to and payment for th

patient-centered medical home, or PCMH;3. standardized contracting;4. primary care targets;5. robust primary care-based essential

benets;6. presumption of eligibility;7. rewards for quality; and8. protection for consumers and

physicians.Meanwhile, the insurance industry

lobbyists have said that exchanges shouldfocus on affordability and efciency and notpursue an active purchaser model.

In a comment letter to the Centers forMedicare and Medicaid Services in advanceof the Oct. 31 deadline, Americas HealthInsurance Plans asked federal regulators toallow the widest range of state exibility inestablishing and regulating the insuranceexchanges.

Family Docs Weigh in on ExchangesAAPF Asks that Consumer Needs Come First

Employer Insurance Hits New LowMore Now Covered Through Government Plans


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Payers & Providers Page

Employers and health plans are quicklyawakening to the extraordinary cost ofspecialty pharmaceuticals. This category ofdrugs, which treat cancer, rheumatoid arthritis,multiple sclerosis and other complex diseases,already costs $64 billion annually, or 22% ofall pharmaceutical spending. Development ofnew drugs, plus an aging workforce facingchronic and acute conditions, are contributingto annual cost increases of 16%.

In many instances these specialty drugs areprescribed for individuals for whom they won'twork at a yearly cost of as much as $80,000.

The genetic makeup of a person or tumor

may indicate whether the drug will be effectiveor cause damaging side effects. A growingnumber of pharmacogenomic tests areavailable to help determine which patients arecandidates for certain drugs.But ensuring that theappropriate testing is donecontinues to be a challenge.

Consider the anti-tumordrug Herceptin, originally usedin late-stage breast cancer andnow also used for some early-stage types of cancer. Salestripled to $1.2 billion per year

from 2001 to 2006, at up to$60,000 per patient.

Meanwhile, it wasbecoming clear the drugworked in only 25% to 30% ofbreast cancers that had highlevels of HER2 protein. By2006, guidelines called forstandard HER2 testing in patientswith invasive breast cancer todetermine the drug'sappropriateness. Even so, a 2009 review ofmedical literature suggested that HER2 testingwas underused, translating into potentially

millions of dollars in unnecessary costs anddistress for patients who endure difculttreatments that are futile.

Quantifying and controlling total spendingon specialty pharmaceuticals is difcult forhealth plans because many are injected orinfused in the doctor's ofce and, therefore,billed under the medical benet, rather thanthe pharmacy benet.

Health plans can take steps to manage costsand quality by using tools that supportappropriate decisionmaking and utilization. An

employer that wants to make sure these expendrugs reach patients who will benetand noused needlessly on others who will notcan its health plan these questions:

* How much are we spending on specialtypharmaceuticals? Plans that try to measure thcost are best prepared to manage it. New toolcan help identify spending on specialty drugs,well as the pharmacogenomic tests that helpdetermine appropriateness for a specic patie

* Is the plan spending on the right therapitoday and as growth accelerates in the future?Evidence-based tools can help plans andproviders support their policies for coverage a

appropriate use. Ask whether your plan is usinan automated system to ensure that when aphysician orders a specialty medication it is inaccordance with evidence-based guidelines fo

that diagnosis.* How is the plan mana

high demand for the explodnumber of pharmacogenomdiagnostic tests? Tests todetermine whether a patientgenetic match for a certaintreatment are coming onto tmarket so rapidly that it isnearly impossible for physic

to be aware of them all. Thegoal of managed care is not reduce the use of tests, butrather use them where needto optimize their impact. Itwould be short-sighted to dean appropriate $200 test thacould determine whether an

$80,000 cancer drug will beeffective; in turn, it would bewasteful and cause unnecessar

suffering to use a powerful therapy if a test codetermine in advance that it would not work.

* Do physicians, patients, labs and payers

all the information they need at the point of cto help choose the right tests and perform theThe best programs use decision support viaautomation and notications at the point of cwith evidence-based criteria as the basis of thsupport.

OPINION

Monitor Specialty PharmaceuticalsHealth Plans Have Tools to Match Drugs to Patients

Matthew Zubiller is vice president of advanc

diagnostics management at McKesson Hea

Solutions. Reprinted and excerpted with

permission from Business Insurance [May 30

2011]. Crain Communications, Inc.

S,B

By Matthew Zubiller


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MARKETPLACE/EMPLOYMENTPayers & Providers Page 5

VICE PRESIDENT OF FINANCE

For more than 170 years Rush University Medical Center, located just west of downtown Chicago, hasbeen leading the way in developing innovative and often life-saving treatments. Today Rush is a thrivingcenter for patient care and research, in the midst of a transformation to recongure its campus andprocesses to support its vision of becoming the medical center of choice in Chicago and among the verybest in the United States.

Rush University Medical Center seeks a highly self-motivated and accomplished Vice President of Financeto oversee all activities of the Corporate Finance Departments of the Medical Center and Rush Oak ParkHospital. The academic medical center comprises Rush University Medical Center, Rush University, RushOak Park Hospital, Rush Health, Rush Children's Hospital and the Bowman Health Center, allowing forinteraction with a wide spectrum of corporate hospital and university administrators, the board of directors,physicians and clinical staff.

Reporting to the Senior Vice president/Chief Financial Ofcer of the Medical Center, you will beresponsible for the following:

General accounting operations

Financial systems supporting corporate nance, decision support and budget ofce Fund accounting; payroll; accounts payable and xed assets Taxation compliance and reporting University nancial affairs External audits for federal and state funds and pension plans Executive analysis on all nancial reports; knowledge of latest developments in the accounting eld Joint venture nance Mergers and acquisitions External nancial reporting for obligated group

Requirements:

Bachelor's degree in accounting/nance/business. CPA and/or MBA. Senior level nancial experience in an academic healthcare organization. Excellent leadership qualities. Progressive and innovative thinker. Ability to effectively interact with all levels of personnel.

To apply and learn more, please visit: http://www.jobsatrush.com/.Please reference job # 2011-1635, and mention Payers & Providers


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Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

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.

!VP OF MANAGED CARENational Surgical Hospitals (NSH), a rapidly growing Chicago-based specialty surgical hospital company, is seeking a VP of

Managed Care to strategically & operationally spearhead company managed care initiatives. The VP of Managed Care will:

Develop, implement & manage the managed care strategic initiatives & contracting with national 3rd party pay

Develop & implement sales & broker/consultant strategies

Develop managed care strategic plans & marketing forecasts

Develop strategy to maximize the effectiveness of contractual agreements on quality,

nancial viability & customer satisfaction

Plan & promote favorable public relations with payors

Maintain dialogue with managed care payors

Provide analysis & review of managed care contracts

Develop tools & processes to maximize the nancial return of managed care contracts

Track & trend outcomes from managed care contracts

Support individual facilities in contract administration & negotiations

Masters Degree in Health Care, Public Health or Business Administration preferred; min. 5 yrs. recent experience in a senior le

position dealing with managed care strategies required. Must have demonstrated comprehensive knowledge of healthcare

systems; existing relationships with large payors in terms of managed care contracting; highly developed communication &

organizational skills; ability to work collaboratively & credibly with payors to achieve common objectives.

Position is Chicago-based. Relocation will be required if not currently residing in the area.

NSH offers a highly competitive compensation & benets package. For condential consideration, please e-mail resume to:

Susan Nash

Director of Executive Recruitment

E-mail Address: [email protected]


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Page 7Payers & Providers MARKETPLACE/EMPLOYMENT

SEEKING A NEW POSITION?

CAN HELP.

We publish advertisements for those seekingnew career

opportunities for just $1.25 a word.

If you prefer discretion, well handle allresponses to your ad.

Call (877) 248-2360, ext. 2, or [email protected].

Documents

Payers & Providers Midwest Edition – Issue of November 15, 2011