25 October 2012

California Edition
Calendar
Oct. 30-Nov. 1
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El Camino Focuses On Senior Health

Will Provide Direct Primary Care Services to Region
El Camino Hospital is launching what it calls a patient-centered medical home devoted to improving the health and quality of life of the regions seniors. Located on El Caminos Mountain View campus, its Senior Health Center will focus on providing primary rather than the tertiary care services offered by the typical hospital. It has a staff of four physicians, including two newly minted in geriatrics, as well as allied health professionals including specially trained nurses, a nutritionist and a pharmacist. According to the American Geriatrics Society, there is only about one geriatrician for every 2,600 patients over the age of 75, but the ratio is expected to rise to one for every 3,800 patients by 2030 as the U.S. population continues to age. Local demographics strongly suggest that the region, which is located about 20 miles south of San Francisco, is no exception to this trend. It is projected that about 300,000 residents of Santa Clara County will be over the age of 65 by 2020, nearly double the current 166,000. These adults will be dealing with a wide array of chronic conditions like arthritis, diabetes and cardiovascular disease, said the centers medical director, Patrick Kearns, M.D.! This makes it imperative to have this 'patientcentered medical home' model that offers a better way to help them manage their ongoing care. The county, which is home to Northern Californias Silicon Valley, also has one of the states highest per-household incomes. At nearly $87,000, it is 44% above the statewide average, strongly suggesting that regions residents will have the purchasing power to demand specically tailored services as they age. El Camino said it will help seniors streamline the care they receive via a data portal that would combine all of their medical records. It will allow them to quickly communicate with their physicians and check tests in a timely fashion. The physicians and allied professionals will check patients diets and medications, offer assessments of future medical risks and provide psychological assessments. Center employees will also work with patients regarding tweaking their Medicare coverage to t their current needs. And at a time when more physicians are grumbling about accepting Medicare patients due to lower payments, El Camino is being ecumenical. Patients can receive care in conjunction with their current doctors, walk into the center to receive primary care on their own, or even be referred from a doctor who is no longer accepting Medicare Part B enrollees.
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November 1-2
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December 3-4

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NEWS
El Camino (Continued from Page One)
Here, the patient comes rst, said Scott Farr, the centers vice president of the continuum of care. Moreover, the Medicare program will begin monetarily penalizing hospitals beginning next year that have large levels of seniors who are readmitted as inpatients within 30 days of discharge. Some hospitals in

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In Brief
CDPH Receives $1 Million Climate Change Grant From CDC
The California Department of Public Health has won a four-year, $1 million grant from the Centers for Disease Control and Prevention to chart the effects of climate change on the health of the states residents. The CDPH will use the money to predict and monitor health effects linked to climate change and implement responses in conjunction with local health departments. Health-related incidents linked to extreme weather events include heat-related illnesses and deaths, and shifts in infectious disease patterns that can be caused by sudden increases in the population of mosquitoes and other insects that can transmit diseases. Climate change is a very serious health issue for Californias public health system to address, said CDPH Director Ron Chapman, M.D. This grant provides critical resources to the California Department of Public Health to plan for and develop an effective response to climate and extreme weather events.!

California are at risk of losing millions of dollars annually, though El Camino is one of the few hospitals in the Bay Area not expected to experience any sort of penalty next year, according to available data. However, El Caminos focus on improving preventative care and disease management may keep potential readmissions in check.

Accountable, DMHC Settle Charges

Monitor Will be Installed at IPAs Corporate Offices
The Department of Managed Health Care has reached terms with a Signal Hill-based medical group it had accused earlier this year of allowing non-medical professionals to make prior authorization decisions regarding care. The DMHC had issued a cease-and-desist order against the Accountable Health Care IPA last July. It claimed two of its employees, including the son of Chief Executive Ofcer George Jayatilaka, M.D., had been making medical necessity decisions for patients even though they lacked the proper credentials to do so. Only a licensed physician has the authority to make such decisions by law. Druvi Jayatilaka and Ambarish Pathak had been conducting medical necessity reviews and making decisions about patient care between December 2008 and when the DMHC issued its order, according to records. At the time the order was issued, Accountable was providing care to 148,000 patients from nine different health plans under a riskbearing arrangement. As part of the settlement, which was reached on Oct. 4 and is known as a stipulated agreement, the cease and desist order was replaced by a consent decree. Under the terms of the agreement, Accountable has agreed to install an outside monitor to ensure it is brought into compliance with the laws regarding prior medical authorizations. The monitor, Frank Stevens of the Berkeley Research Groups Los Angeles ofce, will also conduct audits to determine the specic relationship between the health plans that contracted with Accountable and their enrollees whose care were affected by its decisions. DMHC spokesperson Marta Green said that the agency had appointed monitors in the past, but that it was relatively rare. Both Stevens and Berkeley has provided such services on behalf of the DMHC in the past, Green added. Accountable will pay for the monitor for at least three years, although Stevens and the Berkeley Group will answer only to the DMHC. Accountable has also agreed to follow any recommendations made by monitor and the DMHC. Care managers approved by the DMHC will also be appointed by Accountable to any patients whose care may have been impacted by faulty medical necessity decisions. Accountable also agreed to undergo a prospective review of all claims it has handled since January 2009 and make up any improperly reconciled payments and interest.
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Kaiser Gets Highest Ratings For Medicare Plans

All of the Medicare Advantage plans Oakland-based Kaiser Permanente offers in California received the highest ratings from the Centers for Medicare and Medicaid Services.

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Continued on Page 3

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Longer ALOS!*

NEWS
ACO (Continued from Page One)
Additionally, Accountable will make a voluntary $500,000 grant over the next two years to an organization that provides care to uninsured or underinsured individuals. Should Accountable breach the

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agreement with the DMHC, the agency reserves the right to re-delegate the lives it is managing to other risk-bearing providers. Accountable would not be entitled to a hearing prior to such a decision.

In Brief
The plans received ve-star ratings from CMS, which judges them on a variety of healthcare delivery and preventative health measures. Only 11 plans out of more than 560 rated nationwide received ve stars. Six of them are operated by Kaiser. A ve-star rating is a reection of the high quality care and commitment to customer service we offer our Kaiser Permanente members. Our integrated health care delivery system, dedication to preventive care, and caring physicians and staff, empower our members to maximize their total health, said Edward Ellison, M.D, executive medical director for the Southern California Permanente Medical Group. We encourage seniors to use this rating system when selecting a Medicare plan to ensure it meets CMS's high standards. Along with the ratings, plans that receive ve stars receive an expanded open enrollment period for Medicare enrollees that begins on Dec. 8 and ends on Nov. 30.

Odd Start To Martello Board Hearing

Witness Tried to Serve Her a Lawsuit Before Testifying
A hearing that may lead to revocation of a litigious South Pasadena physicians medical license began in Los Angeles on Monday with a few odd twists. The hearing before an administrative law judge is to determine whether gross negligence and unprofessional conduct charges levied against Jeannette Y. Martello, M.D., by the California Medical Board have merit. But Martellos attorney, Michael Gonzalez, focused initially on excluding Payers & Providers Publisher Ron Shinkman from the proceeding. Gonzalez claimed that Shinkman could provide testimony that would impeach two of the Medical Boards witnesses and therefore should be kept from hearing their testimony. Both witnesses had been sued by Martello because she claimed she did not receive proper payment for care she rendered to them or family members. Shinkman had interviewed them for an investigative article about Martello that was published last May. However, California Administrative Law Judge Eric Sawyer ruled that Shinkmans testimony would not be relevant and allowed him to remain. But Sawyer did eject from the hearing room a process server attempting to deliver a lawsuit to Martello led by one of the witnesses who testied on Monday Seroj Meserkhani. Meserkhani, a Glendale attorney, was sued by Martello when she deemed payments from his insurer were insufcient to cover the care she rendered his critically injured daughter in 2009. The suit was later dismissed after the California Department of Managed Care sued Martello for balance billing her patients and intervened. Martellos appeal of the dismissal was rejected. Meserkhani said the stress of the litigation prompted his wife, a teacher with the Los Angeles Unied School District, to take a disability-related retirement. He said he is seeking damages for intentional iniction of emotional distress and malicious prosecution. Martello, a UCLA-trained plastic surgeon who also holds a law degree from UC Berkeley, has led suits against at least 70 people in Los Angeles County in recent years, according to a Payers & Providers investigation. Most of those lawsuits were for payments she claimed were owed by patients. The Medical Board is attempting to revoke Martellos license, claiming unprofessional conduct stemming from her balance billing and negligence in the care of a patient who received breast implants that inicted so much damage on her body they had to be removed. The hearing is expected to continue through Nov. 1, said Deputy California Attorney General Cindy Lopez, who is prosecuting the case on behalf of the Medical Board.

UCLA Offering Patient Advocacy Certification

In a sign that the eld of patient advocacy is growing more legitimate, UCLA is now offering a certication program in the eld. The certication program includes eight courses and would take one to two years to complete, based on material posted on the UCLA website. It is open to anyone with a bachelors degree and certain healthcare professionals with an associate degree, such as nurses and respiratory therapists. Patient advocates work with patients and providers to create realistic courses of care and often negotiate lower prices for those who are uninsured or have high out-ofpocket courses. However, few certicated programs are available in the eld, and there is no state-level sanction or certication.

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Payers & Providers

OPINION

Page 4

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Why EMTALA Is In Need Of A Retool

Years of Cost-Shifting to Patients Requires Change
One of my most vivid childhood memories ushered us into an era where controlling costs was when, as a teenager, I broke my arm is accomplished by our health plans deploying playing softball at school. The pain was increasingly exclusive medical provider excruciating, but it was the quest to get networks. That will expose consumers to medical treatment for my fractured increased cost sharing if and when in appendage that is most memorable. emergency situations they nd themselves The private hospital closest to my school being treated by non-contracting doctors and in South Central Los Angeles hospitals. turned my mother and me away EMTALA and the related because we had no medical laws in California need updating insurance. As a consequence, where hospital-to-hospital transfer with my arm resting on a of emergency patients is clipboard, we had to take a very concerned. long bus ride to the county Unlike in 1986 when the hospital in East Los Angeles remedy was implemented, today where I nally received most of us with medical insurance treatment after enduring many share in the cost of the medical hours of extreme pain. care we receive, often to the tune Our federal government of thousands of dollars a year. And came to the rescue for people our share is even greater when we like me by passing the are cared for by doctors and Emergency Medical Treatment hospitals that are not contracted and Active Labor Act (EMTALA). with our health insurance plans. By Enacted in 1986 as part of the So, these laws should be Jim Lott Consolidated Omnibus Budget changed so that when patients must Reconciliation Act, EMTALA be transferred from one hospital to requires Medicare-participating hospitals to another providing the higher level of care treat people needing emergency care without required, staff at both hospitals can work regard to their medical insurance status or together to match patients with hospitals ability to pay. participating in the network developed by their EMTALA also requires hospitals to accept health plans. transfers of emergency patients regardless of Given the nearly wholesale their medical insurance status if the care implementation of electronic health records by needed is not provided by the hospitals to providers in recent years as a result of the which the patients were taken. A more HITECH stimulus funds, such matching could stringent state law was enacted soon theoretically be performed with a few thereafter that mimicked EMTALA except it keystrokes in a hospitals emergency applied to all hospitals licensed to provide department or at a nursing station. emergency medical services. Fines for Transferring patients from one hospital to breaching these requirements can be as much the nearest hospital capable of providing the as $50,000 per incident. medical treatment needed may not be in the But that was then and this is now. Back patients best interest, especially if their then , health plans pretty much included all treating physicians determine patients can be the doctors and hospitals serving their regions safely transported to hospitals participating in in their provider networks. Not so now, the provider networks developed by their particularly with the rising popularity of the health plans. so-called narrow networks health plans are offering to their customers in lieu of lower Jim Lott is the executive vice president of the premiums. Hospital Association of Southern California. Narrow networks are likely to gain more traction as plans compete on Californias health insurance exchange starting almost Op-ed submissions of up to 600 words are exactly one year from now. welcomed. Please e-mail proposals to Good or bad, the Affordable Care Act has
editor@payersandproviders.com

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