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99:
Calendar
3 May 2012
E-Mail
info@payersandproviders.com with
the details of your event, or call
(877) 248-2360, ext. 3. It will be
published in the Calendar section,
space permitting.
California Edition
Californias hospitals and a leading labor
union struck an agreement to kill two
contentious voter initiatives that were well on
their way to placement on the November
ballot.
In what they are calling a visionary
agreement, the SEIU-United Healthcare
Workers West and the California Hospital
Association announced Wednesday they
would collaborate on issues affecting
healthcare costs and quality, although the two-
page pact they released was short on specics.
But in lieu of the agreement, the SEIU-
UHW abandoned its effort to put before voters
this fall initiatives that would have impacted
hospital charges and charity care if approved.
The union had already spent millions of
dollars to gather signatures for the initiatives,
which would have placed a minimum oor on
hospital charity care spending and a ceiling on
how much facilities could charge for
providing services. The CHA had pledged an
equally expensive ght to make sure neither
passed voter muster.
We made clear we would mount a very
aggressive opposition campaign, said Jan
Emerson-Shea, the CHAs vice president of
external communications.
Although the debate about
uncompensated and charity care has reached
a national level after numerous reports of
facilities providing community benets at
levels far below the value of their tax
exemptions, the ballot initiatives had drawn
re from the hospital sector for selectively
exempting either for-prot facilities or those
with long-term union contracts in place. A
report by the states Legislative Analyst also
predicted the passage of both initiatives could
lead to hospital closures.
The SEIU-UHW had gathered about
850,000 signatures apiece for the initiatives.
They were in the process of being veried by
county clerks throughout California when the
two parties said they had reached the
agreement.
We had enough signatures to get this
qualied, said SEIU-UHW Communications
Director Steven Trossman, who added that
about 550,000 signatures apiece were
required to do so. But this gives us an
opportunity to work on a much, much broader
range of problems. Ultimately, (the signature
gathering) ended up being a better investment
by many times over.
Both the SEIU and the CHA said they
would enter into discussions to replace or
May 23-25
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SEIU Agrees To Kill Ballot Initiatives
Comes to Long-Term Agreement With Hospitals
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May 17-20
June 10-13
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Continued on Next Page
WEBINAR Thursday, May 24, 2012 10 A.M. PDT
HOSPITAL DISTRICTS: MAPPING THE FUTURE
Please join Michael A. Dowell, partner, Hinshaw & Culbertson, Walter Kopp, president, Medical
Management Services, Inc. and Cleo E. Burtley, manager, The Camden Group, to discuss the
future of hospital district management. More Info @:
http://www.healthwebsummit.com/pp052412.htm
a HealthcareWebSummit Event co-sponsored by PAYERS & PROVIDERS
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Payers & Providers Page 2
Top Placement...
Bottomless Potential
Advertise Here
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In Brief
KFF Projects $1.3 Billion
In Insurance Rebates
The Menlo Park-based Kaiser Family
Foundation has estimated that
consumers and businesses will
receive about $1.3 billion in rebates
later this year from health insurers
that spent more on administrative
expenses than permitted under the
Patient Protection and Affordable
Care Act.
The large group market is
expected to reap the most money:
$541 million. The individual market
will receive $426 million, and the
small group market will receive $377
million.
Altogether, about 31% of those
consumers who purchased individual
policies will receive a rebate,
followed by 28% of the small group
market and 19% of the large group
market.
Texas is expected to rebate the
largest amount, $186 million,
followed by Florida, at $148 million.
Data for California was unavailable.
This study shows that asking
insurance companies to put more of
their premium dollar towards patient
care rather than administration and
prots is not only popular but also
effective," said KFF President and
CEO Drew Altman. There are
tangible benets for consumers and
employers.

L.A. Care Health Plan
Wins EPA Asthma
Award
L.A. Care Health Plan, the Medi-Cal
managed care insurer for Los Angeles
County, has won an award from the
U.S. Environmental Protection
Agency for its asthma care programs.
The L.A. Care program, known
as L.A. Cares About Asthma, builds
on collaborations with community-
Continued on Page 3
NEWS
improve the current hospital pricing system
and protect the neediest patients by
addressing uncompensated care in hospitals
in a manner that accounts for low Medicare
and Medi-Cal payments, a joint statement
said. And according to Emerson-Shea, the
CHA would try and open up communications
between the SEIU and its member hospitals
that were not unionized. The SEIU has the
goal of allowing up to 100,000 hospital
employees statewide to vote on union
Federal prosecutors unsealed on Wednesday
sweeping indictments of more than 100 clinic
operators, durable medical equipment
business owners and physicians nationwide as
part of an ongoing crackdown on Medicare
fraud.
Altogether, 107 individuals are facing
prosecution, accused of bilking Medicare of
more than $452 million. Eight are facing
charges in the Los Angeles area. Indictments
were also brought against suspects in Miami,
Tampa, Chicago, Houston, Detroit and Baton
Rouge.
These indictments remind us that
Medicare is an attractive target for criminals.
But it should also remind those criminals that
they risk prosecution and prison time every
time they submit a false claim, said Assistant
Attorney General Lanny A. Breuer.
Ofcials said claims analysis led to most
of the prosecutions.
Those indicted in Southern California are
accused of bilking Medicare of more than $20
million.
One of the indictments involves two
physicians, August Ohemeng, M.D. of Buena
Park and George Tarryk, M.D. of Long Beach.
Both work at the Pacic Clinic in Long Beach.
They are accused of conspiring with the clinic
manager and owners of two durable medical
equipment companies of prescribing nearly
400 enteral feeding regimens for Medicare
enrollees that did not need them, leading to
claims payments totaling about $3 million.
Tarryk had his medical license revoked by
the California Medical Board in 2005 for
overprescribing medications, but the
revocation was stayed after he adhered to two
years of probation.
In three other cases, the suspects were
accused of submitting false claims for
wheelchairs, taking kickbacks for patient
referrals and billing for home health services
in lieu of providing massages.
In addition to the indictments, the
Centers for Medicare and Medicaid Services
is moving to suspend payments to 52 different
contractors nationwide.
representation by 2015.
The CHA would also assist in the unions
Lets Get Healthy California campaign to cut
the states incidences of chronic diseases such
as diabetes.
Both parties had been in preliminary
discussions for months about some form of
joint venture, although the inexorable move of
the initiatives onto the November ballot had
intensied the conversation, Emerson-Shea
said.
SEIU (Continued from Page One)
Eight Indicted For Medicare Fraud
L.A.-Area Clinics, DME Businesses Are Implicated
FOLLOW THE MONEY
]
CALIFORNIAS HEALTHCARE INDUSTRY AND
POLTICAL FINANCE
CALL (877) 248-2360, ext. 2 to order
OR CLICK HERE
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Page 3
Payers & Providers
Longer ALOS!*
Advertise Here
(877) 248-2360, ext. 2
*For our ads, not your hospital
In Brief
based organizations to identify
environmental triggers and other
asthma management skills.
L.A. Care was one of four
organizations to receive the EPAs
National Environmental Leadership
Award in Asthma, and the only health
plan.
The program has been tailored
to be culturally sensitive and
responsive to the needs of the diverse
patient population we serve,
especially in the most ethnically
diverse county in the nation, said
Elaine Batchlor, M.D., L.A. Cares
chief medical ofcer.
Health Net Expands
Narrow Network Health
Plan Into Orange County

Woodland Hills-based insurer Health
Net has expanded its SmartCare
narrow network product into Orange
County.
SmartCare, which offers about a
25% discount on premiums compared
to a full network, debuted in Los
Angeles, San Bernardino and San
Diego Counties last March. Its
attracted more than 200 medium-
sized employer groups to date.
It has proven to be popular with
employers seeking an
easy to use plan that delivers more
affordable value, said Steve Sell,
president of Health Nets western
region.
Altogether, Health Net has
contracted with nine medical groups
in Orange County to provide care. It
has contracted with 40 medical
groups in the four counties where it
offers the product.
We believe that
SmartCares strategic alliances and
focus on promoting healthy habits will
help improve the patient experience
and help keep costs affordable for
members, said Dan Frank, chief
executive ofcer of Prospect Medical
Group, one of Health Nets contracted
providers.
NEWS
Prime Stent Care Under Scrutiny
Report Suggests Desert Valley Pushed Procedure
Ontario-based hospital operator Prime
Healthcare Services has drawn scrutiny for
cardiac stent procedures performed at 83-
bed Desert Valley Hospital in Victorville.
According to the investigative
journalism website California Watch, Desert
Valley performed four times as many heart
stent implants as the typical hospital in
California with a limited heart care license.
Desert Valley was fully licensed by state
regulators last March. The California
Department of Public Health said in a
statement that the hospital passed two
inspections prior to its granting of full
licensure.
Under a limited license, Desert Valley
was only able to perform stent procedures
during emergencies. California Watch
uncovered four incidents of stents being
inserted in non-emergency situations that led
to patient death or injury. Two patients died,
and one injured patient was in need of a heart
transplant.
State health inspectors have cited Desert
Valley four times for cardiac care lapses since
2007, including a 2008 incident involving the
death of a relatively healthy 72-year-old
patient. Regulators uncovered at least 18
incidents where stents were implanted at the
hospital outside of the purview for a facility
with a limited license.
However, data analyzed by California
Watch also reported that patient deaths at the
hospital for stents are within the statewide
average mortality rates. A Prime spokesman
said stent procedures can be unpredictable.
HEALTHCARES BEST ADVERTISING VALUE
]
PAYERS & PROVIDERS reaches 5,000 hospital, health plan and non-
prot executives statewide. There is no better venue for marketing
your organization or conference, or recruiting new staff.
CALL (877) 248-2360, ext. 2
OR CLICK HERE
Molina Reports Improved Earnings
Modest Gains In Income, Big Boost in Revenue
Long Beach-based Medicaid managed care
insurer Molina Healthcare reported slightly
higher earnings and signicantly more
revenue for the rst quarter of 2012,
attributable in part to growth of new
programs in California.
Molina reported net income of $18.1
million for the rst quarter of 2012, up
about 4% from the $17.4 million reported
during the rst quarter of 2011. Revenue
was $1.37 billion, up about 23% from the
$1.11 billion during the year-ago quarter.
Molina Chief Executive Ofcer J. Mario
Molina, M.D. attributed the revenue growth
to the movement of Seniors and Persons
With Disabilities in California to managed
care. Enrollment in that program more than
doubled, from 14,000 at the end of March
2011 to 37,000 at the end of March 2012.
That overall population for Molina in nine
states grew more than 60%, from 155,600 in
March 2011 to 246,000 in March 2012.
California health plan revenue has grown
nearly 20% since the rst quarter of 2011,
Molina said. Our revenue growth in Texas is
even more dramatic. With the regional and
benet expansions that were effective March
1, 2012, our Texas health plan added nearly
125,000 members and $900 million in
annualized revenue. Enrollment in the Lone
Star State grew from 128,000 in March 2011
to 280,000 in March 2012.
The company reiterated its 2012 earnings
guidance of $1.75 per share.
!"#!$%!&'(&!)!&'(&!*#!+"#,-.!/!+-0123,-.!+4*52.6278%!99:
Payers & Providers Page 4
OPINION
Keeping Score On Patient Ratings
Despite Provider Misgivings, They Carry More Weight
Robert Wachter, M.D, is the associate
chairman of the department of medicine at
the UC San Francisco.
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Id never consider trying a new restaurant or
hotel without reading the on-line ratings of
TripAdvisor or Yelp. I seldom even bother with
professional restaurant or travel critics.
Until recently, there was little patient-generated
information about doctors, practices or
hospitals to help inform patient decisions. But
that is rapidly changing, and the results may be
every bit as transformative as they have been in
traditionally consumer-centric
industries like hospitality.
Even if one embraces the
value of listening to the patient,
several questions arise. Should
we care about the patients voice
because of its inherent value, or
because it can tell us something
important about other
dimensions of quality? How best
should patient judgments be
collected and disseminated
through formal surveys or that
electronic scrum known as the
Internet? And what are some of the
unanticipated or negative
consequences of measuring patient
satisfaction and experience? All of
these questions are being debated actively.
For the past few years, Medicare has been
administering the Hospital Consumer
Assessment of Healthcare Providers and
Systems survey to a random sample of
300-1,000 patients discharged from every U.S.
hospital. Results are now posted on Medicares
Hospital Compare website. Starting in late
2012, hospital payments will be at risk as part
of Medicares pay-for-performance program,
known as Value-based Purchasing.
When I lecture about VBP, I often ask
audiences what weights they believe should be
given to clinical quality data vs. HCAHPS
survey results. Physicians invariably give
answers like 80-20 or 90-10. Ive even heard
some say 100-0 the patients voice should
carry no weight.
Medicare has chosen a 70-30 ratio. Fully
30% of a hospitals bonus or cut under VBP
will be determined by patient survey responses.
For a large hospital like mine, our score on a
single item (rate the quality of nurse
communication) could be worth over $60,000
a year.
The knowledge that patient experience
scores now carry real weight has provided
tangible focus to efforts to promote patient-
centeredness.
For example, UCSF Medical Center now
pays employees bonuses based on patient
satisfaction scores and these scores have
improved markedly since this practice began.
On my own medical service, the patient
satisfaction committee now scours our results
and has launched a program to observe our
physicians as they interact with patients, then
provide feedback. There is even a
communication checklist that offers
something of a script, with items
such as Knock/Ask (Hi, is it ok if I
come in), Concerns (Id like to
review a few things with you, but
rst, is there anything youd like to
be sure we talk about today?) and
Check Understanding (To be sure
Ive been clear, can you just repeat
back to me your understanding of
the plan?).
While the idea of scripting can seem
inauthentic it can be extremely
useful. I now use a script of my own
when introducing myself to a
hospitalized patient.
Since many patients and families
still dont quite understand what a hospitalist is
or does, I often say something like, You may get
a survey after you leave, asking did you have
any sense that someone was in charge of your
care in the hospital. I hope youll answer yes,
because that is precisely my job to be your
orchestra conductor while youre here. Patients
seem to get it.
As we work our way through this new world
of patient surveys and ratings, there will be
some hazards to overcome and some unfair
results to contend with. Well need to anticipate
these problems and mitigate them, and to try to
bring some order to a chaotic marketplace.
These seem like surmountable issues, and I am
condent that the outcome of capturing the
patients voice and giving it some real weight is
better care.
By
Robert Wachter,
M.D.
Op-ed submissions of up to 600 words are
welcomed. Please e-mail proposals to
editor@payersandproviders.com
!"#!$%!&'(&!)!&'(&!*#!+"#,-.!/!+-0123,-.!+4*52.6278%!99:
MARKETPLACE/EMPLOYMENT
Payers & Providers Page 5
!
MarinSonoma !PA is a heallhcare nelwork represenling our
local physician members. I t is the net work providing heal th
care and administ ering benefi ts for HMO members in Marin
and Sonoma Counlies. MarinSonoma !PA is made up oI experl
medical and administrative staff dedicated to ensuring that you
receive the highest quality health care available.
UTILIZATION REVIEW NURSE SUPERVISOR
Novato, CA
Job Summary: Thi s posi t i on supervi ses U/ R and Case
Management activi ties for commerci al and Medicare enroll-
ees. Candidate must be knowledgeable about Nurse Practice
Act, JCAHO, NCQA, HMO and Medicare rules, pertinent state/
federal regulations, and hold a current, unrestricted California
Registered Nurse license.
Principal Accountabilities: Pl ans, organi zes, and oversees
UR Nurses to provide day-to-day oversight for UR activi ties.
Evaluates accuracy, productivity, timeliness and ensures customer
satisfaction. Demonstrates a comprehensive understanding of
contracts, including division of financial responsibility regarding
making UR determinations. Possesses ability to research medical
necessity criteria and maintain current knowledge of UR, Medical
and Risk Management Policies. Ensures collaboration bet ween
Benefits Coordinators and UR RNs. Ensures organizational adher-
ence to ICE, NCQA and health plan regulatory requirements, and
maintains clinical skill and knowledge necessary to set standards.
Assists with identifying pat terns and trends, and develops and
implements corrective actions when necessary. Reviews referral/
service requests on assigned patients in accordance with NCQA
timeliness standards and health plan benefit structure. Educates
and supports members in accessing care using their HMO ben-
efits. Identifies and refers patients to disease management and
Wellness Programs when relevant. Assesses members physical,
psychological, social, environmental, financial and functional sta-
tus, and informs treating physician of clinically relevant findings.
Provides complex case management to patients consistent with
Marin IPA Case Management Policy 029.
Qualifications: Current California RN License. Bachelor Science
Degree, Nursing. Minimum 5 years of supervisory and 7 years
of clinical experience. Experience required in one or more of
the following: Utilization Management, Heal th plan, Medicare,
Case Management. Cert i fi cat ion in Case Management, pre-
ferred. Bilingual, Spanish, preferred. Knowledge of heal th care
and medical procedures. Interpersonal /human relations skills.
At t ent iveness to det ai l. Supervisory ski l ls including t imely
feedback. Abili ty to priori tize duties and delegate responsibili-
ties. Good clinical judgment and cri tical thinking skills. Abili ty to
organize and priori tize workload. Computer li teracy.
To apply, please send your resume in text, .doc or .pdf
format to wseeley@marinsonomaipa.com
Please reference job posting: IPA2012-5
Please visit www.LaSalleMedical.com for
further details and to submit resume
LaSalle Medical Associates is one of the l argest
Independent Practice Association (IPA) groups in the
Inland Empire and operates four (4) primary care clin-
ics. We are hiring three (3) compassionate, mission-
oriented, board eligible physicians in Family Medicine,
Internal Medicine, and Pediatrics. Candidates must be
commi t ted to serving a diverse population wi th cour-
tesy and respect. Our clinics are posi tive work environ-
ments wi th a fully staffed support team. Join us to
share your passion for patient care and diversi ty.
Job Location for positions: San Bernardino, CA and/
or Hesperia CA.
Our benefit package includes:
Competi tive Base Salary
Malpractice coverage (provided by CAP-
Cooperative of American Physicians)
9 Paid Holidays
Medical /Dental /Life coverage
401(k) Retirement Plan
Interested candidates may fax their CV to (909)380-8026,
or email a.canton@lasallemedicalassociates.com
PRIMARY CARE PHYSICIAN
INLAND EMPIRE
!"#!$%!&'(&!)!&'(&!*#!+"#,-.!/!+-0123,-.!+4*52.6278%!99:
Payers & Providers
MARKETPLACE/EMPLOYMENT
Page 6
It costs up to $27,000 to fill a healthcare job*
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Employment listings begin at just $1.65 a word
Call (877) 248-2360, ext. 2
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*New England Journal of Medicine, 2004.
SEEKING A NEW POSITION?
CAN HELP.
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