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If health reform holds up in the SupremeCourt, 32 million Americans could be coveredthrough private and government insuranceplans.

But there will always be a need to care forat-risk populations. It is expected that 23million individuals will remain uninsured after2014. That doesnt include those who areunderinsured who have insurance, but areunable to pay for care.

The National Academy for State HealthPolicy has taken on the issue of caring formore vulnerable populations. The group haslaunched a Medicaid-Safety Net LearningCollaborative to support states trying toimprove delivery systems with safety netproviders.

Six states have been selected to

participate in the collaborative Alaska, Iowa,Maryland, Maine, Minnesota and Texas. Theyare working with safety nets and stateMedicaid to identify new payment models forthe providers, understanding barriers to safetynets being more involved with the overalldelivery systems, and promoting collaborationbetween Medicaid and safety nets.

NASHP will provide technology,networking opportunities, consultation andother services over the 13-monthcollaboration.

In Minnesota, David Godfrey, director ofthe states Medicaid program, said they havebeen wrestling for some time with how toprovide coverage for non-citizens. There are

pockets of the state like Minneapolis and St.Cloud that have a large number of uninsuredimmigrants. In these areas, there is a largestrain on safety net providers.

Those taking part in the collaborative areMedicaid, the state Department of HumanServices, the Minnesota Healthcare SafetyNet Coalition, and the state Ofce of RuralHealth and Primary Care. Godfrey said theyare working to shore up resources to providehealthcare to this population. They are alsotrying to gure out how to provide coveragesolutions for those that dont have coverage.

We are trying to gure out how to better

support the providers who serve theseindividuals, he said.

They will likely look at grants that can beput toward federally qualied health centersand gearing excess disproportionate sharefunding that the state has toward providersserving this population.

Half of our DSH allotment is notcurrently utilized, so we have some pockets ofmoney around that we could look at forrealigning, he said.

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Payers & Providers Page 2

Top Placement...Bottomless Potential

Advertise Here

(877) 248-2360, ext. 2

In Brief

Ohio Selects New

Medicaid Providers

Beginning next January, two new

providers will serve OhiosMedicare recipients and some ofits current providers will beousted.

The Ohio Department of Joband Family Services have chosennew insurers Aetna Better Healthof Ohio and Meridian HealthPlan, along with incumbentproviders UnitedHealth Group,CareSource and ParamountAdvantage to take part in thestates Medicaid Managed Careprogram which covers childrenand families as well as aged anddisabled residents.

There are approximately 1.6million people eligible for themanaged care program in thestate.

Insurers Centene Corp.,Molina Healthcare Inc.,Amerigroup Corp. and WellCareHealth Plans, Inc. all lost some ofthe states business next year.

According to press release byCentene, the company plans toformally protest the statesdecision-making process.

Ascencsion Teams

With Hospitals In India

To Open Caribbean

Site

Ascension Health Alliance haspartnered with NarayanaHrudayalaya Hopsitals of Indiato create a healthcare city in

Continued on Page 3

NEWS

Pilot Projects (Continued from Page One)

In Iowa, the project will focus on maximizingthe participation of safety net providers intheir home health program, which focuses on

creating medical homes. They are trying toenhance payment for primary care serviceswith safety net providers.

We are building on some pilots the statehas to integrate primary and behavioral healthprograms, said Sarah Dixon Gale, leadcontract manager at the Iowa Primary Care

Association.They are trying to get safety nets involved value-based purchasing and help them

become certied as medical homes.We are trying to see what barriers mibe for safety net providers (to becomecertied), she said. We want to make suthey are able to meet those requirements aparticipate. We are thinking about solutionthat would look different for them than othproviders.

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Medicares value-based purchasing program isscheduled to be implemented in late 2012.The idea of pay-for-performance design isalready being piloted in various locations, butnot a lot of data exists as to its effectiveness.

The Premier Hospital Quality IncentiveDemonstration, run by the Centers forMedicare and Medicaid Services, will beMedicares rst program to measure pay-for-performance.

A study released this month in HealthAffairs found that the demonstration projectdid not necessarily encourage qualityimprovement in low-performing hospitals andthat higher performing hospitals did notimprove more than others.

The demonstration began in 2003 with266 participating hospitals. The organizationssubscribed to Premiers hospital benchmarkingservice, agreed to track their scores on qualitymeasures and receive nancial incentivesbased on their performance.

For three years, only the hospitals thatperformed the highest received incentives. In

2006, the markers were changed to rewardimprovement and good performance acroslarger range of measures. The change wasmeant to provide more rewards to lower-performing hospitals.

They found that the quality of the highperforming hospitals improved more in theearly part of the demonstration than in thesecond half. The study authors attribute thipossible factors including: they had reachequality improvement ceiling, that thechanges actually decreased incentives or t

hospitals enthusiasm for the project wore As for the low-performing hospitals, thauthors found that, even with the changes incentives, these hospitals still failed toimprove during the second half of thedemonstration. This could be because theilow scores still kept incentives out of theirreach.

Another possibility is that they used amajority of their resources in the initial yeaof the demonstration, making them unablecontinue improvements beyond that time.

Data Still Lacking On P4P ProgramsConflicting Opinions as Medicare Ramps It Up

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Page 3Payers & Providers

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(877) 248-2360, ext. 2

*For our ads, not your hospital

NEWS

In Brief

Grand Cayman, the largest ofthe Cayman Islands.

The $2 billion, 15-yearproject is scheduled to breakground in August. Thehealthcare city will include ahospital, educational facility,biotech park and assited livingcommunity located on a 200-acre site.

Ascension will providefacilities planning, supplychain management andbiomedical engineering. Thehospital is expected to have2,000 beds when completedand provide services to thearea including heart surgery,organ transplants andorthopedics.

FDA Promotes

Restrictions On

Antibiotics

The U.S. Food and DrugAdministration has announced avoluntary initiative to reduce theamount of antibiotics used infood-producing animals.

The organizations goal is toeducate farmers and animalproducers that antibiotics shouldbe used only to address diseaseand health problems and not forproduction purposes likegrowth enhancement.

The FDA created threedocuments published in theFederal Register. One is for theindustry and recommendsphasing out the agricultural use ofantibiotics. The second is a guidefor drug companies to change thelabeling on the products andmove toward veterinary oversightof the medications. Third is toeducate veterinarians on their partin the process.

Cleveland HeartLab Inc. has created a newit campaign, aimed at informing the publicabout the link between inammation andcardiovascular disease.

The it, or inammation testing,campaign focuses on awareness and educationaimed at patients at risk or heart disease andtheir healthcare providers. The campaignincludes advertising, brochures, remindercards and educational materials providinginformation on the testing and its benets.

The heart labs panel of tests providesbroader prognostic coverage than traditionalblood tests and enables a determination of the

degree to which someone is at risk for acardiovascular event, according to a pressrelease by the organization.

The company contends that arterial

inammation is a better predictor of heartattack and stroke than cholesterol levels.

Our new it campaign is designed toengage patients about the benets ofinammation testing and its role in advancecardiovascular risk assessment like theyvenever been before, said chief medical ofceMarc S. Penn, M.D., chief medical ofcer.The campaign will generate increasedunderstanding of inammation testing and tsignicant role it plays in the assessment ofcardiovascular disease.

Cleveland HeartLab Inc., based inCleveland, Ohio, is a specialty clinical

laboratory and cardiovascular diseasemanagement company providing diagnostictests used in the management and preventioof heart disease.

HeartLab Focuses on InflammationStresses Its Link to Many Cardiovascular Ailments

OSF-Rockford Call Off Their MergerFTC Pressure Cited in Decision to Kill Hospital Dea

antitrust claims, but said later in a statemthat ghting the challenge would take twyears and require a substantial commitmofnancial and human resources. Theyconcluded that the resources would be bspent toward the provision of health carservices.

In a statement on its website, OSF anRockford said, We remain condent thaafliation would have better positioned uachieve the goals of increasing quality ansafety while improving efciencies for thregion, our patients and this community.

The groups said that both health systwill explore other avenues to achieveefciencies and cost savings and improv

quality.

The leadership ofOSF Healthcare andRockford Health last week ended their effortsto merge the two health systems.

The Federal Trade Commission won acourt ruling last month to allow theorganization time to pursue antitrust claimsregarding the buyout. The FTC contested thatmerging two of the three health systems inRockford, Ill. would reduce competition andallow OSF to raise prices.

The FTC found that the merger would giveOSF, based in Peoria, Ill., almost 60% marketshare of patient admissions; 64% of themarket of patient days; and 37% of theprimary care market.

Initially, OSF and Rockford contested the

https://www.managedcarestore.com/pandp/p&pblueprintebook.htm

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Payers & Providers Page

Late last month I was privileged to testify beforethe U.S. Senate Finance CommitteesSubcommittee on Health as part of a hearingaddressing prescription drug abuse within theMedicare and Medicaidmarketplace. As our nation ages,this will become an increasinglyimportant topic if we are to makesure that seniors get the safemedications they need, and onlywhat they need.

The culture in the UnitedStates is to turn to prescriptionsfor whatever ails us, but that can

often lead to over prescribing ortaking drugs that dangerouslyinteract with each other. Thisconcern is particularly heightenedamong older adults where it is notuncommon for seniors to betaking eight or more medicationssimultaneous, sometimesprescribed by different physicians.A number of these drugs may be non-geriatricfriendly and as such put individuals at risk fordizziness, falls and motor vehicle accidents.

This is a very real problem which summonsour healthcare community to do a far better job

when it comes prescribing medications for theelderly. It is our moral, legal and societalobligation to ensure that all aspects of a seniorshealth are addressed and that includesappropriate medication therapy. The best wayto do this is through the establishment ofprograms that are focused on drug utilization,the monitoring of the appropriateness ofprescriptions and alerts to seniors and theirphysicians when potential risks are found.

Medicare Advantage plans play aparticularly important role in protecting seniorsfrom the dangerous effects of prescription drugabuse. For 35 years!SCAN Health Plan has beenfocused on the unique needs of seniors.Through a combination of care coordination,utilization management, and a well-thought-outformulary structure, we have put programs inplace which we believe go a long way towardensuring safety in medication management andwhich, at the recent hearing, Senator CharlesGrassley (R-IA) called a pattern for everyoneelse.

SCANs Medication Therapy ManagementProgram includes a team of 60 case managers

who assist members in understanding the purof their medication regimen. With members, tcase managers review medications on a regulbasis and help members better manage their

medications. We also reviewpharmacy claims and notify amembers physician of duplicator senior-inappropriate drugs.

In addition to case managerSCAN employs certied geriatrpharmacists who ensure that aldrugs covered in our formularyclinically effective for seniors. Fhigh-risk members, this clinica

team also reviews all medicatioproles on a regular basis andcommunicates directly withmembers and their prescribingphysicians about any drug theissues that surface. And, as anaccredited provider of continumedical education, we routineoffers physicians online

educational modules and tools focusedspecically on proper medication for seniors.Beyond these safeguards SCAN has joined wiall other health plans who offer Medicare Partin instituting a Fraud, Waste and Abuse progra

to detect and prevent fraudulent behavior.! Thinitiative relies on data-mining programs, frauand abuse identication software, and othersophisticated tools to determine whetherprescribing patterns are appropriate, identifypotential problem pharmacies, and identifyenrollees with unusual or excessive prescriptiutilization patterns.

Medicare beneciaries, particularly the frelderly, need coordinated, integrated care toassure their safety regarding prescriptionmedications. The greatest danger to patients isunintended consequences of drug-to-druginteractions that can harm the very patients ou

medical system is striving to help. Models thathe patient at the center of care can go a long in assuring they receive the medication therapthat truly benets them.

OPINION

The Problem Of Seniors And DrugsThey Are Overprescribed, Creating Real Dangers

Timothy Schwab, M.D., is chief medical offic

for SCAN Health Plan, which is based in

Southern California.

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By

Timothy Schwab,

M.D.

Op-ed submissions of up to 600 words are

welcomed. Please e-mail proposals to

editor@payersandproviders.com

8/2/2019 Payers & Providers Midwest Edition Issue of April 17, 2012

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*New England Journal of Medicine, 2004.

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