18 November 2010
California Edition
Calendar
Study Says California is Lowest-Ranked State in U.S.
December 3-4
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A PAYERS & PROVIDERS EXCLUSIVE WHITE PAPER
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the details of your event, or call
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published in the Calendar section,
space permitting.
Care Lags For Special Needs Kids
California is the worst place in the nation for
delivering healthcare to special needs children,
according to a new study that suggests the
The study, commissioned by the Lucile
Packard Foundation for Children’s Health in
Palto Alto and performed by researchers at the
Oregon Health and Science University in
Portland, concluded that only 17.1% of special
needs children in California receive healthcare
that meet minimum criteria for quality,
compared to more than 40% nationwide. That
places California 51st overall, behind the 49
other states and the District of Columbia.
Minimum standards include one well-care
researchers said should be within easy reach.
“These children are one of the most
vulnerable segments of our society, and in
many senses the system in California is not
doing well for them,” said Packard Foundation
Chief Executive Ofcer David Alexander, M.D.
“This is particularly concerning because
advances in medical care mean that many
children are surviving who previously would
not have, and it will become increasingly
difcult for our already overburdened system to
care for them adequately.”
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The study did not focus on the specic
quality of healthcare delivered to the state’s
1.4 million special needs children, who have
at least one chronic condition requiring
complex care such as cerebral palsy, autism
or heart disease (although the overwhelming
majority have two or more).
As a matter of fact, the prevalence of
special needs children is lower than the
national average – 14.5% in California versus
nearly 20% nationwide.
Instead, it critiqued the patchwork of
agencies charged with some aspect of
matching special needs children with the care
they require. They include the California
Department of Educational Services, the
Department of Health Care Services and
various agencies on the county and state
levels.
For example, 17.5% of parents who have
children with special needs in California
spend an average of 11 hours per week
seeking care for their kids. That’s compared
with 5.5% nationwide. Only 12.1% of special
needs children in the state receive early
intervention services such as speech or
physical and service coordination between
Continued on Next Page
 Payers & Providers
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In Brief
Rubin Named Stanford
Hospital CEO
UCLA Health System Chief
Operating Officer Amir Dan Rubin
has been named chief executive
officer of Stanford Hospital &
Clinics.
Rubin, 40, will assume the top
spot at Stanford on Jan. 3. He will
succeed Martha Marsh, who retired
in September.
“His deep knowledge of
academic medical centers, track
record of success in developing
patient-centered clinical
environments, and commitment to
innovation...will be a tremendous
asset,” said Stanford Hospital board
chair Maryann Byerwalter.
Stanford is currently in the
midst of designing and building a
$2 billion replacement facility
adjacent to its current campus in
Palo Alto.
Prior to serving at UCLA,
Rubin was COO at Stony Brook
University Hospital in New York.
He holds a bachelor’s degree from
UC Berkeley and MHA and MBA
degrees from the University of
Michigan.
KPC Acquires Victor
Valley At Auction
A U.S. Bankruptcy Court has
approved Riverside-based KPC
Global Healthcare’s bid to
purchase Victor Valley Community
Hospital.
KPC bid $37 million at an
auction earlier this month for the
106-bed hospital, beating out a bid
from rival hospital operator Prime
Healthcare.
Victor Valley filed for Chapter
11 bankruptcy protection in
September, citing more than $20
million in debt. Officials blamed
Continued on Page 3
NEWS
Special Needs (Continued from Page One)
such therapies. That compares to 26.7% of
children nationwide.
According to Christina Bethell, the
OHSU associate professor who is the lead
author of the study, Californians typically
must navigate between several bureaucracies
in both their communities and in Sacramento
to nd accommodations for their children.
“It is not happening the way it should for
families,” she said. “There are a lot of barriers
they have to navigate.”
Bethell added that many private
employers also contribute to the gridlock by
not providing exible work hours to parents
with special needs children, often making it
difcult for them to make medical
appointments during the daytime.
Partly as a result, less than 55% of
special needs children statewide receive
routine preventive care, compared with more
than 69% nationwide. And more than 36% of
parents have had to cut back on work or quit
their jobs altogether to care for their children,
versus a nationwide average of just 16%.
CDPH Fines 12 Hospitals For Errors
Most Penalized For Retained Surgical Instruments
The California Department of Public Health
issued 14 administrative penalties to 12
hospitals last week, with nes totaling
$575,000.
Nine of the penalties involved retained
surgical objects, one of the most common
reasons for a penalty being levied.
The hospitals penalized included:
California Pacic Medical Center in San
Francisco received administrative two
penalties and nes totaling $125,000 for two
incidents involving retained objects during
surgery. In one instance, a retractor blade was
left in a patient undergoing a mitral valve
replacement, resulting in a ne of $50,000.
In the second incident, a sponge was retained
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Page 2
Insurance for special needs children is
also an issue. According to the study, 65.3% of
special needs kids in California have
insurance adequate to their needs, versus
nearly 77% nationwide. This leaves gaps in
some aspects of their care, especially for
addressing mental health issues, according to
the study,
Needs were also skewed by income and
ethnicity, with special needs children from
lower-income families and African-American
and Latino children having more issues
accessing care than more afuent or white
households.
The report made several
recommendations, including the improvement
of insurance coverage and the introduction of
mental health parity. It also noted that the
Affordable Care and Patient Protection Act
should help addess some of the issues at its
more powerful provisions go into effect later
this decade.
Bethell also noted that the recently
enacted Medi-Cal waiver should help.
in a kidney transplant patient. That resulted in
a $75,000 ne. It’s the second and third
penalties levied against the hospital.
UCSF Medical Center also received two
administrative penalties, its third and fourth.
One was for administering a blood thinner to
a newborn that was 10 times the prescribed
dose. The other penalty was for leaving a drill
bit in the skull of a patient who underwent
brain surgery. The nes totaled $50,000.
Scripps Memorial Hospital in La Jolla
received its fourth administrative penalty and a
$50,000 ne for leaving a surgical towel in an
80-year-old patient. The towel remained in the
Continued on Next Page
Payers & Providers NEWS Page 3

Longer ALOS!* Fines (Continued from Page Two)

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*For our ads, not your hospital
In Brief
late payments from the Medi-Cal
program for its financial
predicament, spurred in part by the
recent state budget impasse.
Officials with KPC, which
focused primarily on medical
group management a decade ago
but now owns six hospitals in
Southern California, said it would
spend $25 million over the next
five years to improve the facility,
which was built in the late 1960s.
As the not-for-profit Victor
Valley is being acquired by a for-
profit operator, the California
Attorney General’s office must
approve the deal.
West Coast University
Helps Fund
Recuperative Care
Program
patient for nearly four months before it was
detected and removed.
Southwest Healthcare in Murrieta
received its seventh administrative penalty –
the most in the state – for leaving a
malleable retractor in the abdomen of a
maternity patient who underwent an
emergency splenectomy. Since the incident
occurred prior to an increase in monetary
penalties that went into effect last year, the
hospital was ned just $25,000, the lowest
amount allowed. CDPH ofcials say the
penalty will not interfere with Southwest’s
agreement to improve patient care in order
to retain its eligibility for the Medicare and
Medi-Cal programs.
Western Medical Center in Santa Ana
received its third administrative penalty and
a $75,000 ne for storing vaccines at below-
freezing temperatures, possibly degrading or
destroying their effectiveness. More than
1,600 newborns received hepatitis
vaccinations from the damaged stock.
Palomar Medical Center in Escondido
received its rst administrative penalty of
$50,000 when a patient in its intensive care
unit fell out of bed unnoticed by staff. The
patient went into a cardiac arrest before
discovered and eventually died.
Kindred Hospital in Westminster was
ned $25,000 for not providing appropriate
care for an obese patient being treated for a
brain injury. The patient suffered extensive
pressure ulcers and a weight loss of more than
80 pounds.
Hanford Community Medical Center
received a $25,000 penalty for retaining guide
wires in a patient who underwent a breast
biopsy. It’s the hospital’s second penalty.
Citrus Valley Medical Center’s Covina
campus received its rst penalty and a
$25,000 ne. for leaving a metal part in a
patient’s chest during a heart bypass
procedure.
USC University Hospital in Los Angeles
received its rst penalty and a $25,000 ne for
providing a patient with cystic brosis an
overdose of medication that led to kidney
failure.
Petaluma Valley Hospital received its rst
administrative penalty and a $25,000 ne for
leaving a sponge in a surgical patient.
Placentia Linda Medical Center received
its rst administrative penalty and a $25,000
ne for installing a right-side knee joint
replacement in a patient’s left leg. The
prosthesis had to be removed and replaced
with a correct one.
CDPH ofcials to date say that 112
hospitals have been penalized, with nes
totaling $5.325 million. Of those penalties, 39
are in varying stages of appeal.

Anthem Unveils Incentive Program

Regional nursing education hub
West Coast University has pledged
$50,000 toward funding a program
in the Los Angeles area designed to
helped homeless patients Gift Cards, Other Items For Healthier Behavior
discharged from area hospitals.
The pledge will go toward the
Los Angeles Recuperative Care Anthem Blue Cross of California has conditions such as diabetes.
program, which houses homeless introduced a new gift-based program “Incentives are powerful and effective
patients discharged from hospitals specically intended to encourage enrollees motivators that can positively inuence
at motels while they receive
assistance in finding housing and to engage in healthier behaviors. behaviors," said Pam Kehaly, president of
other social services. Known as Anthem Health Rewards, the Anthem Blue Cross in California.
The program was launched by program provides items such as gift cards and The program will be introduced to
the Hospital Association of deposits into employee health savings Anthem’s self-insured employer groups on
Southern California, the National
accounts if they complete a health risk January 1. It will be rolled out to other groups
Health Foundation and the Orange
County-based Illumination assessment or participate in programs that over time. The benet is a “buy-up” purchased
Foundation last month. It is partly promote wellness or help manage chronic beyond the standard group premiums.
in response to challenges faced by
hospitals that treat homeless
patients.
The program is modeled after HEALTHCARE’S BEST ADVERTISING VALUE
a similar one launched in Orange
County that has proven successful
in finding homeless patients PAYERS & PROVIDERS reaches 5,000 hospital, health plan and non-prot executives
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Payers & Providers
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OPINION Page 4
The Looming Consequences of SGR
A Permanent Fix is Needed to an Ongoing Problem
The sustainable growth rate (SGR) formula program. It would also buy time for newly
is a flawed payment methodology applied elected officials to study this complex issue.
by the Centers for Medicare & Medicaid The long-term goal is to replace the SGR with
Services (CMS) that threatens to devastate a system that more accurately reflects the cost
doctors’ payments for services provided to of care. The estimated price tag for the 13-
Medicare beneficiaries. It also threatens to month “fix” could be up to $20 billion. A
stanch the lifeblood of billing companies long-term fix could cost $300 billion to $400
and other medical community colleagues billion over the next decade.
and impair the very health of Medicare For the past several years, physicians
patients. have faced the prospect of massive cuts in
Organizations such as the American their Medicare fee-schedule payments unless
Medical Association and the Congress intervenes to prevent the
Healthcare Billing and cuts from occurring. The
Management Association are congressional solution over the past
taking action in an attempt several years has been to delay the
save patients, physicians, their cuts, essentially kicking the can
families, and others from the down the road but not addressing
combined 27% SGR-related the core problem. Physicians are
cuts that will go into effect on suffering whiplash from the roller-
December 1, 2010 and January coaster ride of continuous delays
1, 2011. and administrative snafus over the
In a September letter to the past several years and three delays
House Speaker and the Senate this year alone. !
Majority Leader, I implored Because of piecemeal patches,
Congress to permanently fix the some physicians had to seek loans
catastrophic problem. By Scott to meet payroll and keep their practices
Failure to provide even a Everson open. Some doctors deferred their own
temporary fix to avoid the pay cut compensation. During the current
would be irresponsible to Medicare Medicare enrollment season for
beneficiaries. Worse, failure to act physicians, if Congress fails to fix the
would likely force many physicians to limit SGR problem, HBMA member companies are
the number of Medicare patients they could reporting that more physicians will cease
see, resulting in millions of Medicare seeing Medicare patients or dramatically
patients losing access to vital healthcare. reduce the number of seniors they see. This
Concerned about the viability of their could delay seniors’ access to their physicians
practice, some doctors have already and negatively impact their health.
stopped adding Medicare patients. The HBMA and AMA think the “doc fix”
HBMA urged lawmakers to permanently is imperative and critical.
rescind both the 23.2% scheduled cut on The CMS has reduced the estimates to a
December 1, 2010 and the projected 6.5% 23% cut in December and a 1.9% cut Jan. 1.
cut slated for January 2011 and extend a The stakes, however, are still high for
2.2% increase at least in 2011. Today, everyone concerned, the consequences dire
individual HBMA members are taking a and the window of opportunity even
grassroots approach by individually asking narrower.
their Congressional leaders to fix the
problem.
HBMA and the AMA both seek a long- Scott Everson is VP of business development
term solution to the SGR problem. AMA for PracticeMax and Healthcare Billing and
members are now pushing for a vote on a Management Association president.
1% physician pay increase for one year,
starting Jan. 1, and to delay a final vote on
Op-ed submissions of up to 600 words are
the SGR for 13 months. welcomed. Please e-mail proposals to
The latest temporary fix is designed to editor@payersandproviders.com,
boost doctors’ confidence in the Medicare
!!!"#$#!%&!'(&)*+!,!'*-./0)*+!'1%2/+3/456!778
Payers & Providers MARKETPLACE/EMPLOYMENT Page 5

SENIOR MEDICARE COMPLIANCE ADVISOR - Along with the Compliance Ofcer and Privacy & Information Security Ofcer,
serves as the focal point for all Medicare Advantage compliance activities. Coordinates and communicates all assigned Medicare
Advantage compliance activities internally and with L.A. Care's contracted provider network. Along with the Compliance Ofcer, is
L.A. Care's liaison with Centers for Medicare & Medicaid Services (CMS) and other federal agencies concerning L.A. Care's
Medicare Advantage product(s). Ensures that L.A. Care and its subcontracted provider network is compliant with all CMS federal
regulatory requirements. This is achieved by working with internal and external staff to correct performance deciencies, ensuring
staff are aware of CMS reporting requirements and reports are submitted to CMS identifying internal areas for improvement.
Responsible for performing internal audits, monitors implementation of corrective measures, and interpretation of CMS requirements.
Working knowledge of federal and state requirements is required, as well as highly developed analytical skills and excellent written
and verbal communication skills.

For complete job description, qualications/requirements, visit our website: www.lacare.org

To apply, email resume with salary history and requirement to: recruiter@lacare.org referencing “Payers & Providers Ad”

ASSOCIATE MEDICAL DIRECTOR FOR CLINICAL INTEGRATED SOLUTIONS

(Los Angeles, CA)
The Associate Medical Director for COPE Health Solutions’ Clinical Integration Solutions service line will serve as the
Director of the Camino de Salud Network and Product Leader for Provider Practice Redesign. The Associate Medical Director
will play a key role in launching the Provider Practice Redesign product into other marketplaces outside of the Camino de
Salud, Long Beach, and Westside/South Bay Networks.
Provider Practice Redesign (PPR) is one component of Clinical Integration Solutions, designed to expand access to specialty
care services within the community.
Camino de Salud “Healthy Road” Network is a public-private partnership between LAC+USC Healthcare Network, four
private hospitals, numerous community clinics and private physician ofces, Keck School of Medicine at USC, and the USC
School of Pharmacy.

QUALIFICATIONS
• M.D. with a non-restricted license and board certication
• Minimum 2 years of full-time experience in practice (not including residency training) in one or more of the following:
private physician practice, hospital-based practice and inpatient care.)
• Master’s degree is strongly preferred
• Procient in Microsoft Ofce Programs (Outlook, Word, Excel, Access and PowerPoint) and experience with Internet
research.

To apply and learn more visit: www.copehealthsolutions.org/careers

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Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

SENIOR DIRECTOR, MANAGED CARE ANALYTICS

(San Francisco, CA)
Catholic Healthcare West, headquartered in San Francisco, CA, is a system of 41 hospitals and medical centers in California,
Arizona, and Nevada. Founded in 1986, it is the eighth largest health system in the nation and the largest not-for-prot
provider in California. CHW is committed to delivering compassionate, high-quality, affordable health care services with
special attention to the poor and underserved. The CHW network of nearly 10,000 physicians and approximately 54,000
employees provides health care services to more than ve million people annually.

We are currently seeking a dynamic leader for the position of Senior Director, Managed Care Analytics. This position is
responsible for the overall leadership and management of CHW’s Analytics & Application Team (16 FTEs) to support over $3
billion in managed care negotiations across CHW’s 40+ acute care hospital, afliate physician groups, joint ventures and
other business development projects throughout California, Arizona & Nevada. This position will innovate and develop
reimbursement rate structures to maximize CHW’s reimbursement and operating margins. In addition, the Senior Director
will provide leadership of the statewide development and implementation of accurate, timely analyses and proposals in
preparation for, during, and after payer negotiations.

QUALIFICATIONS
Bachelors degree. Masters degree preferred. Equivalent experience and record of accomplishments may be considered.
Minimum of ten years progressive responsibility in the healthcare environment. A thorough senior practitioner's
understanding of the healthcare industry, managed care, fee-for-service reimbursement structures, nancial modeling,
capitation, and knowledge of relevant federal and state regulations is mandatory.

SPECIFIC KNOWLEDGE AND SKILLS

• Comprehensive, advanced knowledge of healthcare managed care principles
• High degree of advanced analytical and problem solving skills with specic application to hospital, medical and
actuarial data
• Advanced capitation and capitation management skills, including a working knowledge of actuarial analysis and
risk evaluation methodologies, calculating and evaluation reimbursement rates, and forecasting effect on revenues
and expenses
• Must be able to effectively function in situations involving high-level negotiation activities and possess effective
negotiating skills
• Knowledge of legal principles and regulatory requirements relating to managed care risk and fee-for-service
contracting
• Comprehensive knowledge of healthcare market and hospital operations
• Advanced knowledge of hospital nance and accounting, including cost accounting principles and operations
• Knowledge of MSDRGs, APCs and other coding methodologies as they apply to managed care

Apply online: www.chwcareers.org or email your resume to Lori Burt: lori.burt@chw.edu

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Payers & Providers MARKETPLACE/EMPLOYMENT Page 7

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