8/6/2019 Payers & Providers Midwest Edition Issue of June 28, 2011

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The House of Medicine commemorated the150th anniversary of the Civil War in its owninimitable way last week, with the coreelement in the 2010 health reform law

standing in as a proxy forabolition.

For two days at theAmerican MedicalAssociations annual Houseof Delegates meeting inChicago, physicians fromthe more conservativeSoutheastern states rose todenounce the individualmandate. By requiring thatevery person purchasehealth insurance, thedelegates argued, the

federal government wasusurping the states rightsto solve the healthcarecrisis in their own way.

They urged the AMA to reverse its stancesupporting the mandate, evidently hoping thiswould weaken public support for theAccountable Care Act and hasten its demise inthe courts or Congress.

Let the states innovate, said DavidMcKalip, M.D., a Florida delegate. Allow thestates to experiment, nd an option not toemploy the mandate but still cover theuninsured.

As physicians we want choice, saidMichael Greene, M.D., a family doctor fromGeorgia. We choose our practice style,choose which state we practice in, depending

on the medical malpractice laws.Each state ought to have the rightto craft the specic solution thatworks best in that state, Greenesaid. What works forMassachusetts probably will notwork for Georgia or some otherstate. Massachusetts, of course, isthe state that instituted mandatoryinsurance coverage in 2006,which served as the model for theDemocrats bill in 2010.

Richard Warner, M.D., apsychiatrist from Kansas, warned

that continued support for theindividual mandate would bedivisive in the country and themedical association.

At the federal level it is an invitation forcontinued intrusion into the practice ofmedicine, he said. At the state level its likelyto be much less so.

But for every doctor who opposed themandate, another argued that to approve therepeal would be a step backward for the AMAand the country as a whole.

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October 13-14

July 8-10

Calendar

28 June 2011

September 14-16

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E-Mailinfo@payersandproviders.comwith

the details of your event, or call(877) 248-2360, ext. 3. It will be

published in the Calendar section,space permitting.

www.lakesidecommunityhealthcare.com

Midwest Edition

AMA Debates Individual MandateRegional Differences Color Views on Reform Law

Continued on Next Page

Lisa Egbert, M.D.Ohio Delegate, AMA

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In Brief

Two New HospitalsProposed in DistantSuburb of Chicago

The Illinois Certicate of Need

committee staff has found serious faultwith two applications for newhospitals in McHenry County, a distantsuburb northwest of Chicago.

The staff of the Illinois HealthFacilities and Services Review Boardsaid that both proposals, each for a128 bed facility, didnt meet requiredstandards. The board is expected tovote on the applications June 28, andis not required to follow the staffsrecommendations.

The $233 million hospital inHuntley was proposed by CentegraHealth System, and the $200 millionhospital in Crystal Lake, by MercyHealth System.

Several nearby providers --Sherman Hospital in Elgin, AdvocateGood Shepherd Hospital inBarrington, and the St. Alexius MedicalCenter in Hoffman Estates -- havewritten letters to the committee askingit to delay consideration of theapplications.

Minnesota HomeHealth Owner Charged

with Medicaid Fraud

Federal prosecutors in Minneapolischarged Joseph Vah Lavien, 57, orBrooklyn Park, Minn., with defraudingMedicaid of more than $400,000.

Lavien, owner ofPalm HealthcareServices Inc., allegedly submitted falseinvoices to the Minnesota Departmentof Human Services for in-homepersonal care. The U.S. AttorneysOfce said he billed for services notprovided, billed for more services thanauthorized and more services than

Continued on Page 3

NEWS

AMA Mandate Debate (Continued from Page One)

David Butsch, M.D., from Barre, Vt., saidthe states right argument would simply let thestates determine who would be insured. Many

doctors defended the policy as best forpatients. Robert McAfee, M.D., from Maine,described the lobstermen, loggers and farmersin his state who were facing huge premiumincreases in the individual market afterlegislative changes. To leave this decisionexclusively to the states is the worst possibledecision for those patients, he said.

And Melissa Garretson, M.D., ofStephenville, Texas, speaking for the AmericanAcademy of Pediatrics, said: We heard a lotyesterday about physicians who are angryabout the individual mandate. I have 700,000kids in Texas who cant get coverage who are

angry too. She pointed out that children whohave health insurance grow up to be healthieradults. Thats the science. Were scientists.We take an oath to care for our patients, notour own interests.

The debate was precipitated by a sharpdecline in AMA membership, which droppedfrom 228,150 in 2009 to 215,854 in 2010.The AMA has been ghting membershipdeclines for years, and this represented aquickening of the pace. Membership fell mostmarkedly in the South. W. Jeff Terry, M.D., a urologist fromAlabama, said many doctors in his state were

angry at the AMA because it supported thereform law, and withdrew from theorganization. By allowing states rights, weallow individual creativity, he argued.Overturning the policy would represent anopportunity to learn more about the individualmandate, and how it has worked out inplaces such as Massachusetts, he added. The resolution to overturn support forindividual responsibility, as the AMA prefers tocall it, was proposed by the delegations fromArkansas, Florida, Georgia, Kansas,Oklahoma, and the District of Columbia. Itwas also supported by the American Academy

of Facial Plastic and Reconstructive Surgery,the American Association of NeurologicalSurgeons, and the American Society ofGeneral Surgeons.

The AMAs support of a mandate wasapproved in June 2006 on a resolution fromthe California Medical Association. Theassociation afrmed by voice vote a policyproposing that individuals making $49,000 ormore, or families earnings $100,000 and up,pay a tax penalty if they dont buy insurance.Lower-income individuals should receive taxcredits and subsidies to help them affordinsurance, the policy said.

The AMAs position in support of the biCongress was deemed crucial to its passagand these provisions were written into the

generally as the AMA recommended.During the debate on June 19 and 20, mdoctors expressed concern that the issue wso polarizing that it would weaken the AMDaniel Johnson, M.D., a radiologist fromLouisiana and former AMA president, warnthat if we defeat this we will leave this hovery divided. A delegate from Kansas saidLets try to nd a middle ground. Lisa Egbert, M.D., an obstetrician fromKettering, Ohio, who is on the board of theAMAs political action committee, offered amendment to allow states to explorealternatives to the individual mandate.

The intent was to bridge the differenceshe said in an interview. Everybodyrecognizes we need better coverage. Amandate done down from the governmentprobably not the best thing. Maybe theresother ways of doing it, like tax penalties, tacredits, incentives. I just think we got so min what the government is doing with this.

Physicians in her hometown are askingWhy is the AMA on board with theAffordable Care Act? she said. Well, wesupported parts of it. We didnt support othparts. The perception is we just jumped in all of it. We have a communication proble

Her amendment was dismissed by thespeaker, and several other physicians objecto such amendments as attempts to waterdown a clear position. This is not acompromise, said Thomas Sullivan, M.D.cardiologist from Massachusetts. It weakethe AMAs efforts over many years to coveruninsured.

In the nal vote, the House went 326 yto 165 no, or 66.4% in favor of keeping thexisting policy supporting individualresponsibility.

The vote of the House today wasoverwhelming, said Cecil Wilson, M.D., t

AMAs outgoing president, in a newsconference afterward. Fully two-thirds of members of this House today said our poliis good. It does not need to be changed

Wilson said he did not believe the debaover reform played a major role in the dromembership, pointing out that the decline only 1% to 2% more than in previous year

In March 2010 we looked at the bill asaid, On balance is there enough to improhealthcare in this country, despite its defec

We said, Yes, this is a major win,Wilson said. Its not the nal; its a start tohealth system reform.

8/6/2019 Payers & Providers Midwest Edition Issue of June 28, 2011

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NEWS

In Brief

could be performed on a particularday or month, billed for supervision,and submitted false records.

The total loss to Medicaid wasestimated at $412,227. In addition,Lavien allegedly cost MinnesotaCare,a state program to pay insurancepremiums for low-income residents,

$83,939.

Chicago Weight-LossDoctor is on the Lam

After Fraud Indictment

The Chicago ofce of the FBI isleading a nationwide manhunt forGautam Gupta, M.D., who wascharged with one count of mail fraud,healthcare fraud, and conspiracy bythe U.S. attorneys ofce inSpringeld, Ill.

Gupta owns and operates the

Nutrition Clinic, which has ofces inArlington Heights, Chicago,

Naperville, Rockford, and SouthBeloit.

The criminal complaint says thatGupt submitted claims to Blue CrossBlue Shield of Illinois as well as theIllinois Medicaid program forunnecessary procedures or proceduresin connection with weight-losstreatments that were not performed.

Between June 2001 and January2010, the Nutrition Clinic received$25 million for claims paid on behalfof clinic patients, the complaintalleges.

Gupta was described as a white

male of Indian descent, 57 years old,5 feet 5 inches tall, 160 pounds, withgraying black hair sometimes worn ina ponytail, and brown eyes. Heresided in Rockford.

The charges were announced byRobert D. Grant, special agent incharge of the Chicago ofce of theFBI; Hiram Grau, director of theIllinois State Police; and Lamont PughIII, special agent in charge of theDepartment of Health and HumanServices -- Ofce of InspectorGeneral.

Minnesota leads the nation in the percentageof privately insured persons participating inhealth savings accounts, at 14.9% (507,307people). Other Midwestern states with hightake-up of HSAs include Ohio (10.6%;728,868) and Indiana (also 10.6%; 384,772),according to Americas Health InsurancePlans, the health insurance lobby inWashington.

The percentages were released as part of astudy showing that enrollment in HSAsjumped 14% in 2010. They now cover 11.4million people. In general the upper Midwesthas the strongest participation in HSAs, as a

portion of the population, of any region.The fastest growing market segment was forlarge-group coverage, rising by 26% to 6.3

million covered lives. Next came individualcoverage, up by 15% to 2.4 million lives.About 2.8 million were enrolled in the smalgroup market, which dropped by 7%.

HSAs were authorized by Congress startiin January 2004. AHIPs annual census of theplans shows that enrollment has nearlydoubled since January 2008, when 6.1 milliwere covered.

Here are percentages of enrollment inother Midwestern states, in declining order:

Illinois: 9.2% (690,509 people)

Wisconsin: 8.5% (301,216)

Michigan: 6.8% (408,758)

Iowa: 6.7% (132,175) Missouri: 5.0% (177,925)

Kansas: 4.2% (71,440)

Medicaid patients in Indiana resumed using

Planned Parenthood clinics on Saturday, June25, a day after a federal judge set aside thestates law sidelining the agency as a providerbecause it offers abortion services.

On May 10, Gov. Mitch Daniels signed thelaw removing Planned Parenthood from theMedicaid program. The agency asked for aninjunction to halt implementation of the law.

Federal ofcials, including Don Berwick,M.D., chief of the Centers for Medicare andMedicaid Services, said the state was out of linewith national requirements permitting patientsto see any provider of their choice that acceptsMedicaid reimbursement. The Department of

Justice also led a brief supporting the agency.Private donations totaling more than

$100,000 from around the country had allowedPlanned Parenthood to continue seeing indigentpatients, but the money ran out after severalweeks.

U.S. District Judge Tanya Walton Pratt

wrote that if the federal government withhelMedicaid money from Indiana due to the lawit could lead to a loss of $5 billion to the staand touch as many as 1 million state residen

Denying the injunction could pit thefederal government against the state of Indiain a high-stakes political impasse, she said her ruling. And if dogma trumps pragmatismand neither side budges, Indianas mostvulnerable citizens could end up paying theprice as the collateral damage of a partisanbattle.

The Indiana attorney generals ofce saidthe state would probably appeal the ruling.

Planned Parenthood typically receivedabout $1.3 million a year in Medicaid fundsfor about 9,300 clients, to cover a variety ofreproductive services, including pap smearsmammograms, birth control counseling, aswell as abortions.

U.S. Judge Overturns Indiana LawPlanned Parenthood Sees Medicaid Patients Again

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Payers & Providers Page

It seems that about three or four times a day, Iget asked the following question: Are yougoing to be an accountable care organizationand apply for the Medicare Shared SavingsProgram or Pioneer Program?

And my honest response is, Arent thosetwo different questions?

Is Dean Health Systems going to be anaccountable care organization? My answer isdenitively yes. In fact, we already are one. Idene an ACO as an organizationthat delivers patient-centered,high-quality care, that is

effective, ef

cient, and notwasteful, e.g. a system thatdelivers better care at a lowercost.

This has been Deans visionand strategic direction for manyyears, and if what were calling avalue model these days isaccountable care, then yes, wealready practice that way, andwill continue to do so.

Whether we apply for theMSSP or Pioneer Program is anentirely different question. My

answer to that is, Werestudying both programs on theirrisks and their merits, and Im hopeful that wewill participate.!

Even if a strictly business or nancialanalysis suggests that MSSP and Pioneer maynot be the most prudent path for us to take, wemay choose to participate anyway. This wouldbe because:! A) We believe it is the right thingto do to ensure the delivery of better care at alower cost for our patients; and/or B) Weenvision that the shift that MSSP advances, fromvolume-based to value-based care, is adirection we must continue to follow to assure

sustainability of our industry; and/or C) Webelieve that status quo fee-for-service Medicaretoday will not be the status quo fee-for-serviceMedicare tomorrow.!

While I know that there has been a frenzy ofgenerally negative feedback over recent monthsabout the draft ACO rule, I am personallyoptimistic that it was a good faith effort tocatalyze our industrys necessary shift fromvalue-based care to volume-based care. Is itimperfect? Yes, but its not that imperfect, nor isit irreparable.!

For example, is retrospective assignment athat bad?! I dont think so. If we truly believe the merits of delivering patient-centric,coordinated, and value-based care, shouldnt deliver that model of care to all patientsregardless of whether we know in advance thathose patients are part of our ACO?! Given thathere is no risk in the one-sided ACO model uyear three, and given that by year two we shoknow who 85% of our ACO assignees are, do

retrospective assignment reallpose signicant incremental r

And are 65 quality measur

with the need to improve upothem within three years,impossible to handle?! I woulargue not, for several reasons:As systems, we dont have toactually do the measuringourselves (e.g. claims measurB) We conduct thosemeasurements already (forexample, service measures); aC) We are already rewarded fothe outcomes (e.g. meaningfumeasures).

Given the imperative for

quality improvement tocomplement cost reduction iour journey to value-based care, we cant knowhere were going unless we expand our quametrics, and we certainly cant change what wcant measure.

Im a glass-half-full type of person, and Imtrying to think positively about the road aheadUltimately, the sustainability of our industrydepends upon our ability to deliver a model ohealthcare steeped in value rather than volumand its time that all of us begin that journey inearnest.! Sooner or later, we all need to becomaccountable for delivering better care at a low

cost. Whether MSSP and Pioneer will be thecatalysts to do so, Im not sure, but if not nownot this, then when and how?

OPINION

Accountable Care for EverybodyParticipating in CMS Program is Another Question

By Craig Samitt, M.D.

Craig Samitt, M.D., has been president and

CEO of Dean Health Systems in Madison, W

since 2006.

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