8/6/2019 Payers & Providers Midwest Edition Issue of June 14, 2011

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Republican Sandy Praeger, 66, was electedinsurance commissioner of Kansas in 2002,then re-elected in 2006 and 2010. Before that,she served as a state senator from 1993 to

2003, during which she was chair of thehealth committee. In 2008 she served aspresident of the National Association ofInsurance Commissioners.

In this exclusive interviewwith Payers & ProviderseditorDuncan Moore, sheshares her views on healthreform and the difculties itpresents to pragmaticsolution seekers on the statelevel. Part 1 of two parts.

What is your view on thePatient Protection andAffordable Care Act? I think its a marketsolution to getting everyonecovered. Its not a singlepayer. Youve got the folks onthe far left who dont like it,youve got the folks onthe far right who say itsa government take over,which of course it isnt.

I think it strikes abalance in using government to create

nancial assistance, to standardize the rules,and create a more competitive privatemarketplace with subsidies, which needed tobe done if were going to try to get everybody

covered.It has challenges in implementation. The

individual mandate is the most controversial.But the individual mandate or some method of

encouraging people to buycoverage before theyre sick isabsolutely essential.

Do you think the act shouldbe repealed? Altered?Revised?

If the mandate goes awaybut we still have guaranteedissue, there has to be some

method, like an openenrollment period, orpenalties if you wait to buy inor health underwriting if youtry to come in later. Thosewould be acceptable ways ofencouraging people to notwait until theyre sick.

If you haveguaranteed issue, thenwhy would you buy inuntil youre sick? We

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In Brief

Thomson Reutersto Sell Michigan-based

Healthcare Division

Thomson Reuters, the international

information company based in NewYork, has announced plans to sell itshealthcare division, based in AnnArbor, Mich., because it no longeraligns with the companys globalstrategic goals.

The division offers data, analytics,and benchmarking solutions. It hasabout 800 people in Ann Arbor, of2,040 total employees.

Thomson Reuters publishes the listof Top 100 U.S. Hospitals and the Top10 U.S. Health Systems, profiled inPayers & Providers in April and June.The division also publishes a group ofhealthcare indexes and includes acenter for comparative effectiveness

research.We believe we can achieve better

all-in returns for our shareholders bydivesting the healthcare business andre-deploying the proceeds in our corefranchises, said Thomas H. Glocer,CEO of Thomson Reuters, in astatement.

The healthcare division is growingand profitable but lacks the globalscale of other business units, he said.The division had 2010 revenues of$450 million and operating margin ofaround 19%, the company said. Itexpects to divest the business unit bythe end of the year.

Antitrust Case AgainstMichigan Blues May

Proceed, Judge Rules

U.S. District Judge Denise PageHood announced last week that shewill allow a lawsuit against BlueCross Blue Shield of Michigan

Continued on Page 3

NEWS

Sandy Praeger (Continued from Page One)

need to find ways to make this work, so wecan keep the most popular aspects of it. Thenyou have a marketplace that really can

function.It also opens door to more innovation withthe Medicaid program. Then recipients couldbuy products on the individual market andthrough the exchange. Thats the only placethe subsidies are available.

So you think the law can be made to work?

With tweaks, I think so. I like theindividual mandate without medicalunderwriting, except for age, tobacco use,geography, and family status. Three of thoseIm OK with. The age rating I have problemswith. When you do rating bands in three tiers,as healthcare costs for the upper age rangeincrease, it pulls everybody up. It does meanyounger folks pay more than they would haveif rated on their own health status.

In the NationalAssociation ofInsuranceCommissioners weargued that age bandsshould start out with abroader range andgradually narrow. ButCongress didnt acceptour viewpoint. Itsgoing to push young healthy people intosubsidies they probably wouldnt need.

How do you manage to implement the lawwhen your Republican governor andattorney general are so strongly against it?

Our governor [Sam Brownback] and ourattorney general [Derek Schmidt] are stillfighting to repeal. They recognize that ouroffice is charged with implementing the law.Until its repealed I have an obligation toimplement it in the fairest way possible.If we are not ready to run an exchange by2013, then the federal government would runthe exchange for us. While they dont like the

law, they do want us to stay in charge of theprocess.

I do support the notion of everybodyhaving coverage. If you dont have insurance,you dont get healthcare in the appropriatetime and the appropriate place, which is in adoctors office, where they can manage yourcondition. Or else you end up in anemergency room.

This is a private solution. Its very similar towhat our beloved Sen. Nancy Kassebaumproposed back in the mid 90s, when she waschair of the Labor Committee, along with abipartisan group that created a centrist plan.

Its been mislabeled as a government takeoverand I dont think it is.

She and Sen. Ted Kennedy, the ranking

Democrat at the time, got HIPAA through.They were also working on a mainstreamcoalition of health insurance reform. We donthave that kind of crossing party lines today.They were close friends. They worked in abipartisan way to create solutions.

HIPAA worked from state solutions forsmall market reforms, and put them intofederal law. The Family and Medical Leave Accame in that time. Reconstructive surgery forbreast cancer, mental health parity, theprohibition against drive-by deliveries,allowing women to stay at least two days inthe hospital -- they were also passed.

What is the most difficult aspect of the healthreform act, from your perspective? Working in the absence of significant

guidance from theDepartment ofHealth and HumanServices. An awfullot of rules andregulations have notbeen developed thatwill be need toinform stateregulators, including

guidance around exchanges. Theyre justbeginning to give guidance to states on ratereview for states that dont have that authority.

HHS has been handed a hugeresponsibility. I dont mean to pick on them.Some of the issues might have been clarifiedby a conference committee, which never wasconvened. So now you have to deal with themthrough the rule and reg process. That justtakes time.

What is potentially the most valuable aspectof the ACA, assuming it goes into fullimplementation?

For me its a combination of no medicalunderwriting, so you dont have people deniedcoverage based on their health condition, andthe subsidies. As we sort through how wemake sure people dont game the system,thats the big unanswered question, the abilityto get financial assistance to buy a privateproduct. Were building on the private systemwe have in this country.

Exchanges will level the playing field, bringreater competition, and add subsidies.Theyre all linked together. Of all of those,getting rid of medical underwriting is mostimportant.

If you dont have insurance, youdont get healthcare in the

appropriate time and theappropriate place, which is in adoctors office.

8/6/2019 Payers & Providers Midwest Edition Issue of June 14, 2011

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In Brief

alleging anticompetitive practicesto move forward.

The lawsuit, filed by the U.S.Justice Department and theMichigan Attorney GeneralsOffice, alleges that Blue Cross hasused exclusive contracts withhospitals and physicians to

disadvantage competing healthplans. (Payers & Providers, 5 Apriland 12 April issues.)

According to the governmentcase, Blue Cross contracts requiredsome hospitals to charge higherrates to other insurers, known asmost favored nation clauses.

The Blues had argued in amotion to dismiss that it is requiredto accept all applicants forinsurance and that the MFN clausehad previously been allowed bythe state insurance regulators. Theinsurer said these contracts helpkeep the states healthcare costslow.

Hood made her intentionsknown during a hearing on arelated class-action lawsuit. Sheindicated she was still drafting herorder and didnt say when shewould issue it.

Wishard Hospital Ends

Bariatric Surgeries

Wishard Health Services inIndianapolis will no longer performbariatric surgery because the service istaking room that is needed by low-income patients.

Wishard is a safety net hospital andoperates at 98% of capacity.

The bariatric service, calledIndiana University Surgical WeightManagement Program at Wishard, didabout 100 procedures a year. Closingthe program will free up beds inintensive care and medical-surgicalfloors for other patients, notably thosecovered by Wishard Advantage, aprogram for people lacking insurance.Wishard Advantage did not cover theweight-loss surgery.

St. Johns Hospital in Joplin, Mo., mightrebuild the destroyed facility on another site,its leaders said last week. A location and planfor the new hospital will be presented toboard members in December, said GaryPulsipher, St. Johns president.

Meanwhile, St. Johns has established amobile hospital that is seeing about 130patients a day in an emergency room. Other

hospitals in the region, including St. JohnsHospital in Springfield, Mo., and St. EdwardMercy Hospital in Fort Smith, Ark., have sentsupplies, equipment, and staff.

The 367-bed hospital was all butdemolished by the tornado on May 22 that hasnow cost 151 lives. Engineers deemed thestructure unsalvageable.

Were not sure if!this hospital will be torndown, but it is unviable for renovation,Pulsipher said. The next step is to move fromthe field hospital to a temporary structure tobe built on the current campus within thenext 6 months. !A location for the permanenthospital is being analyzed now, but will most

likely not be on the current campus.Several survivors of the tornado have sinc

succumbed to a rare fungal infection.Zygomycosis, also known as mucormycosis,comes from soil or vegetable matter that isdriven into the skin by the force of thetornados winds. Under normal circumstanchealthy persons immune systems can repelthe fungus, but people who are immuno-

compromised or who have been severelyinjured may become infected, and eventualldie.

Doctors estimated that at least nine injurepatients have the infection, and it hascontributed to at least two deaths. The funguaggressively necrotizes flesh and shuts downthe blood supply to the skin, which must thebe surgically removed. One patient had anarm amputated to try to control the fungus,but still died. The Springfield-Greene County HealthDepartment sent a memo to local providersalerting them to the dangers of the unusual

infection.

The Cleveland Clinic announced last week that

it will shutter Huron Hospital in Septemberbecause of declining patient census andmounting financial losses.

Community leaders in the east side ofCleveland vowed to fight the closure, sayingthe largely minority neighborhood depends onthe hospitals emergency and trauma care, notto mention the jobs and economic activity thatanchor the area. Occupancy declined from78% of staffed beds in 2005 to 52% so far thisyear, the Cleveland Clinic said. Since 2001 the

hospital has lost $77.5 million and has not

broken even in any single year. Losses in 20were $22 million.The health system intends to open a

community health center in October as areplacement for the inpatient facility. Thehealth center would still probably lose monebut on the order of $6 million to $8 million.

Clinic officials said sufficient inpatient anemergency services are available at the mainCleveland Clinic campus or UniversityHospital, both within 3 miles of Huron.

Cleveland Clinic to Shutter FacilityCommunity Leaders Oppose Huron Decision

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St. Johns to Rebuild on New SiteRare Fungal Infection Endangers Tornado Survivors

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8/6/2019 Payers & Providers Midwest Edition Issue of June 14, 2011

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In the nearly 20 years I have been writing andcommenting on the business of healthcare, Ihave prided myself on staying healthy and outof the hospital. To my shock and surprise, I wassuddenly taken ill on a Tuesday evening in lateApril. Within an hour I was incapacitated, andthough I was sure the spell would pass, withinthree hours it was apparent that Ineeded to go to the emergency room,immediately.

I shufed into the nearest hospitaland, suppressing my nausea, said, Ithink I have a kidney stone.

That night in the ER was followedin three days by a second trip to theER culminating in admission. I hadntbeen a patient in an emergency roomsince 1979. I hadnt spent a night in ahospital since 1972.

As a professional observer ofmedicine and hospitals, this offereda fruitful, if unwelcome,opportunity: What would patient-centeredquality care in one of the Thomson Reuters Top100 hospitals (proled in the 5 April edition ofthis newsletter) actually feel like?

My observations:

If you can avoid it (I obviously couldnt) donot allow yourself to be admitted to aninpatient unit at 11 p.m. on a Friday. Virtuallynothing will happen all weekend.

I got perfectly ne nursing care, but mymedical care was haphazard, uncoordinated,and impossible to follow. A stream of medicalresidents rounded and asked the samequestions over and over. None were able toexplain my case or give an overarchingexplanation of what was happening. They didagree that I did not have a kidney stone, andoffered a wide variety of theories that mightaccount for my symptoms. They didnt seem to

talk to each other. No one seemed to be incharge.In the emergency room I had been promised

a consult with a urologist the next day. Yet nourologist appeared, or any other seniorphysician who seemed concerned that mycondition was not improving. In my frustration Istarted yelling at the medical residents.

Me: Nobody seems to be managing mycase. Do I have a care plan?

Resident: Yes, of course.Me: I dont believe you. I want to see it.Resident: Its in the computer.

Me: Show it to me.Resident: I cant.Me: Why not?Resident: The computer is in the hallway.Me: Cant you make a printout?Resident: No, we dont have printers on th

unit computers.Me: Dont you have a laptop yo

can bring in here?Resident: No. I will see what I

do.I never saw or heard from this

medical resident again.

In desperation I called my persfamily practice physician, who hasent me to the ER in the rst placesee if he could shake something lo

Im sorry, I cant help you, hesaid. I dont have privileges at thospital.

What I had been led to beliewould be an overnight stay

gradually morphed into three long, delirious dpunctuated by replenishments of my morphindrip. My girlfriend recently told me she thougwas going to die.

It is difcult from this remove, six weeks la

to recall the sense of helplessness, defeat, anda while, hopelessness, that overwhelmed me.Would I just drift on, day after day, unable to eor drink, getting progressively weaker, sicker,thinner, more drug dependent, with nobody ato gure out what was wrong with me? Wouldget an infection? Would I never leave this bed

So forget about patient-centered care, at leon the weekend. Fifteen years after the birth oquality care movement, what you will get isinstitution-centered and physician-centered cEven in the nominally best hospitals, you stillhave to be your own advocate.

If you dont have a family member to look

on your behalf, or if that family member is unto do it, then you are in trouble.

OPINION

Dont Enter the Hospital on a FridayPatient-Centered Care Doesnt Exist on Weekend

Duncan Moore is the editor of Payers &

Providers. He is a former correspondent fo

The Kansas City Star, Modern Healthcare, a

Bloomberg News.

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