JULY 2014 2012 AUGUST Visit us now online at www.NJPhysician.org
In This Issue: Hospital Looking to Buy Your Practice? Evolving Healthcare Provider Risk in the ACA Era Healthcare Groups in New Jersey Embrace Trend Toward More Accountability Aetna and Summit Medical Group Reach Medicare Health Partnership
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Contents
CONTENTS
4
Hospital Looking to Buy Your Practice? Beware of the Antitrust Angle.
6
Evolving Healthcare Provider Risk in the ACA Era
9
Healthcare Groups in NJ Embrace Trend Toward More Accountability
11
Aetna, medical group reach Medicare health partnership
12
Hospital Rounds
14
Rutgers health care study highlights struggle for wellness in low-income communities as state prepares Medicaid ACO rollout
15
Medical News
16
Saint Peter’s, clinician network renew their relationship
16
UnitedHealthcare’s Oxford starts N.J.-only health care network
17
Nearly 10,000 New Jerseyans Could Lose ‘Obamacare’ Health Insurance
18
“Where are the patients supposed to go?”
2 New Jersey Physician
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ArchTech Medical provided an amazingly detailed report with recommendations onon how to to become and compliant terms. I had all the information I needed to attest forwith Meaningful Practice ArchTech Medical provided an amazingly detailed audit report recommendations how become andstay stay compliant with HIPAA security regulations. They provided manyaudit policy and procedure documents,Use. and explained everything in--Valerie, non-technical withterms. HIPAA security regulations. They provided many policy andand procedure documents, andand explained everything in innon-technical with IHIPAA regulations. They provided many policy procedure documents, explained everything non-technical had allsecurity the information I needed toy detai attest for Meaningful Use. --Valerie, Practice Manager, Springfield, NJ ArchTech Medi c al provi d ed an amazi n gl l e d audi t report wi t h recommendati o ns on how to become and stay compl i a nt terms.terms. I hadI all the information I needed to attest for Meaningful Use. --Valerie, Practice Manager, Springfield, had all the information I needed to attest for Meaningful Use. --Valerie, Practice Manager, Springfield,NJNJ
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Hospital Looking to Buy Your Practice? Beware of the Antitrust Angle. If you have been operating your medical practice for a period of time, you may have been contacted by your local hospital with an expression of interest in acquiring your medical practice or entering into another arrangement where your practice and its revenues will be more closely affiliated with the hospital or a hospital affiliate. Hospitals are seeking to more closely align with physicians as a result of market pressures and the implementation of efficiencies and evidence-based medicine protocols required by the Affordable Care Act. In some instances, the hospital will request that the physician or physician group enter into a professional services agreement (‘PSA’). Under a PSA, the physician group will provide services to the hospital while maintaining its existing medical practice. Typically, the hospital will request that the physician or physician group assign their right to bill and collect for professional medical services to the hospital or hospital affiliate, with the physician or physician group paid for its professional services out of the revenues collected for their professional services. In other circumstances, the hospital is interested in acquiring the assets of the practice and directly employing the physicians in either a captive professional corporation or directly by the licensed hospital. In most instances involving the alignment with, or acquisition of, a physician practice by a hospital or a hospital affiliate, both the physician and the hospital are focused on the financial and operational terms of the deal. An issue that can often be overlooked is whether or not the potential alignment or acquisition of the physician practice creates any issues under the federal antitrust laws. In a recent federal court case decided in Idaho, the court found that the acquisition of a primary care practice by a hospital would have an anticompetitive effect upon both the prices charged to third party payors and the ability of a competitor hospital to obtain referrals. As a result, the court found that the acquisition violated the antitrust laws, and the acquisition of the physician group now has to be undone (absent a reversal of the lower court decision on appeal). Saint Alphonsus Medical Center ñ Nampa, Inc. v. St. Lukeís Health System, 214 U.S. Dist. LEXIS 9264 (D. Idaho 2014). (‘St. Luke’s’). Clearly, the expense of being involved as a party to costly antitrust litigation and the unwinding of a PSA arrangement or practice acquisition are both items that a practice will want to avoid. The facts of the St. Luke’s case involved the acquisition by St. Luke’s of the furniture, fixtures and equipment of the Salzer Medical Group, a 40 physician medical practice located in Nampa, Idaho. Of the 40 physicians employed by the group practice, 16 provided adult primary care services and 8 provided pediatric services. The hospital and the medical practice entered into a PSA. Under the PSA, the physicians would provide medical services in Nampa on behalf of St. Luke’s. Most of the services were to be provided in clinics operated by St. Luke’s. In return, St. Luke’s agreed to compensate the medical group and its physicians for performing medical services on behalf of the hospital pursuant to the PSA. St. Luke’s would conduct all managed care contracting and billing for the physician group, and also hired all of the nonphysician employees who had previously worked for the physician group. Following the affiliation, it was estimated that St. Luke’s and Salzer Medical Group would control 80% of the primary care physician market in Nampa, Idaho. This caused concern for both the nearby competitor hospitals (Saint Alphonsus and Treasure Valley) and for third party payors. They were concerned that the concentrated market power which would be held by the hospital and the physician group following the acquisition would lead St. Luke’s to negotiate higher fees with health insurers, leading to both higher health insurance premiums and claims payments. The competitor hospitals were also concerned that if the acquisition took place, St. Luke’s would put pressure on the group practice physicians to steer patients away from the competitor hospitals for procedures such as CT scans and MRIs and would send them to St. Luke’s instead, which would result in both a drop in referrals of patients to the competitor hospitals and the potential layoff of a significant number of staff members. As a result of these concerns, the competitors of St. Luke’s which operated hospitals in Nampa filed a lawsuit seeking to enjoin the acquisition from taking place. The Federal Trade Commission and the State of Idaho were also parties to the litigation. St. Luke’s relied heavily on its goal of advancing the objectives of the Affordable Care Act in its defense of the lawsuit (the ‘ACA defense).’ At first, the federal district court denied the motion for a preliminary injunction and allowed the acquisition to proceed while the matter went to trial. However, at the conclusion of the trial, the court held that the acquisition was, in fact, anticompetitive and ordered divestiture of the affiliation between St. Luke’s and the physician practice. While the court praised St. Luke’s for its efforts in implementing the goals of the Affordable Care Act, it ultimately concluded that the ACA defense advanced by St. Luke’s did not serve as a justification for the antitrust violations alleged by the plaintiffs. The court found that that the acquisition was intended by St. Luke’s and the physician practice to improve patient outcomes, and the court was convinced that it would have that effect if left intact. As is the case here in New Jersey, the court noted that the quality of patient care in Idaho is outstanding, but that the cost of such care is substantially above the national average. The court also found that St. Luke’s had exhibited ‘foresight and vision’ in purchasing independent physician groups to assemble a team committed to practicing integrated medicine in a system where compensation depends on patient outcomes. However,
4 New Jersey Physician
the court ultimately concluded that the acquisition resulted in an anticompetitive effect. The court found that ìit appears highly likely that health care costs will rise as a combined entity obtains a dominant market position that will enable it to (1) negotiate higher reimbursement rates from health insurance plans that will be passed onto the consumer, and (2) raise rates for ancillary services (like x-rays) to the higher hospital billing rate, since the acquired physicians would be encouraged to shift their referrals for such services to the hospital. ‘The court concluded that even though St. Luke’s was to be applauded for its efforts to improve the delivery of health care in the Treasure Valley, ‘there are other ways to achieve the same effect that do not run afoul of the antitrust laws and do not run such a risk of increased costs.’ Generally, most physician practice affiliations or acquisitions do not require review and approval by the Federal Trade Commission prior to the transaction being consummated. While New Jersey has its own antitrust laws, New Jersey normally follows federal antitrust law interpretation and analysis in reviewing antitrust questions. Therefore, it is likely that any New Jersey lawsuit alleging antitrust claims would be initiated in federal court. However, if a federal court (or state court) in New Jersey were to review a similar set of facts as those considered by the Idaho federal court in the St. Luke’s case, it is likely that a similar antitrust analysis and result would be reached. If you are approached by a hospital or hospital affiliate which has expressed an interest in acquiring your practice or in entering into a professional services agreement with your practice, you should ask the hospital if they have conducted an analysis of the proposed transaction under the federal antitrust laws to ensure that the proposed acquisition or affiliation would not have an anticompetitive effect. Whether or not the transaction would be viewed as anticompetitive may be based on a number of factors, such as the physician or physician group’s medical specialty or specialties; the size of the relevant geographic market; the percentage of market share that the affiliating hospital and physician group will control in the relevant market and specialty or specialties following the affiliation or acquisition; the number of competing physicians in the relevant specialty or specialties who will remain either as independent practitioners in the community or in affiliations with competitor hospitals following the acquisition; payor mix; the population density of the relevant market, and other factors such as ease of transportation to alternate providers. By asking the right questions, you can hopefully avoid the unfortunate circumstances that the Idaho physicians and St. Luke’s found themselves in when they were ordered by the court to undo their transaction. By Beth Christian of Giordano, Halleran and Ciesla, 732-741-3900
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Friendly, Compassionate Staff to Serve the Urban Patient The Smith Center for Infectious Diseases and Urban Health was developed to address infectious diseases in the inner city. This non-profit center, which is initially focusing on HIV, recognizes that inner city patients face many unique challenges in their daily lives. These challenges interfere with treatment of infectious diseases and foster an environment where infectious diseases are easily spread. When you treat a person with HIV, you greatly reduce the chances of transmission and treat the whole community. In the past 10 years there have been incredible advances in HIV treatment. We at the Smith Center believe that by using novel approaches we can rid New Jersey of HIV. We have designed programs to incentivize patients to continue their medications. We have created a personal atmosphere, where each patient is known by her or his first name. We work with our patients to ensure that we are providing the best service possible.
Dr. Stephen Smith - named a Top Doctor of New Jersey by Castle Connolly 310 Central Avenue, Suite # 307 • East Orange, NJ 07018 Phone: 973-809-4450 Fax: 973-395-4120 • www.smithcenternj.org
August 2014
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Evolving Healthcare Provider Risk in the ACA Era By Ron Gillaspie With the Affordable Care Act (ACA) enacted and underway, the healthcare provider landscape is evolving at an unprecedented rate. Providers are feeling pressured to align themselves with Accountable Care Organizations (ACO), a new healthcare delivery and payment model formulated to mitigate increasing medical costs while improving quality of care. The success of the ACO model is at the heart of the Affordable Care Act. The Centers for Medicare and Medicaid Services (CMS), one of the main forces behind the ACA, have clearly expressed their goal of controlling aggregate costs for all beneficiaries, along with decreasing service volume and measurably improving the quality of care. An ACO is a legal structure through which healthcare providers must deliver the full spectrum or continuum of care to a designated population. ACO’s are being formed by hospitals, hospital systems with affiliated physicians, and by multi-specialty physician groups. To qualify for participation in the Medicaid Shared Savings program (MSSP), an ACO must apply to CMS, submitting a full description of the methods by which the ACO will deliver quality care, along with detail on how it will lower costs to the population it will serve. An ACO must have the analytical and IT capabilities necessary to receive and report performance data, along with the ability to distribute shared savings and to repay losses and manage and monitor its operations. The CMS ACO model provides for participation in the MSSP. An ACO will have two initial choices under the MSSP Program, with the first option a three-year commitment with the first two years on a shared savings basis and the 3rd year on a shared savings and shared loss basis. The second choice will be for 3 full years on a shared savings and shared loss basis. The ultimate goal of the Medicare CMS ACO approach will be to have all ACOís functioning under a fully capitated basis. The private health insurance market has simultaneously been experimenting with the ACO model, with hundreds already functioning throughout the U.S. The rapid changes and evolving ACO landscape are creating a host of new risks to the provider world, some of which are insurable, and some outside of the scope of current insurance protection. The goal of all providers and ACOís should be to understand the scope of the new and developing risks, and to take the necessary steps to mitigate their exposure through risk management techniques and risk transfer (insurance) tools. It is essential that a provider take the necessary steps to align with ACO(s) that are highly qualified and adequately financed to take on the management of the ACO operations, including qualified leaders, cutting edge analytical tools and IT systems, the ability to integrate EMR systems, and a philosophy of measurably improved healthcare outcomes while controlling and reducing costs. The success of an ACO in the shared savings model will be a function of the successful implementation of all of these variables. Evolving Provider and ACO Risk and Insurance Solutions Medical Malpractice The cost containment goal within the ACO model can inherently impact the perceived perspective by patients that medical decisions may be affected by the prioritization of providers to realize shared savings through reduced care/lower costs. The ACA requisite that care must be measurably improved may balance the tension that naturally exists between cost containment and medical liability, but will take time to be fully understood. The potential vicarious medical malpractice liability expansion is real, largely due to the model mandating the full continuance of care required by the ACO. Providers will now have to participate under a team approach, with the Care Organization responsible for full care across all specialties. The possibility of vicarious liability allegations cuts in all directions, ACO to provider, provider to ACO and provider to provider. Cyber Breach/HIPAA Integrated Electronic Medical Records (EMR) will be a fundamental ingredient in the success of all ACO’s, necessary for improving the quality of care for the patient population and also to proof results. EMR has been an evolving risk to providers, with new expectations of immediate knowledge of patient data and the ability to make quicker and more accurate decisions. EMR under the ACO model will drastically increase cyber, breach and HIPAA exposures to providers due to the extensive patient information sharing that will be necessary across all providers in the Organization. It will be critical that the ACO and its providers have cutting edge data security and the proper breach insurance in place. Regulatory Liability The essence of the new ACA/ACO model runs against the grain of traditional anti-trust, STARK and self-referral rules, with the new ACO entities now incentivized to provide full continuum of care for the patient population. A full understanding of the changing rules and the implementation of the necessary steps toward compliance are critical to the success of the ACO/provider. It is essential that an ACO be structured in a compliant fashion so that it is not in violation of anti-trust laws. All new ACO’s should have CMS, in conjunction with DOJ and FTC, review its eligibility for the MSSP shared savings program. This is necessary to balance the efficiencies of providing care to a large patient population.
6 New Jersey Physician
A broad regulatory policy will be essential for ACO’s and providers to adequately protect against the changing and ever more complex regulatory exposures. Directors and Officers Liability (D&O)/Employment Practices Liability (EPL)/Fiduciary Liability The exposure to the Directors and Officers of an ACO can result from a number of unique scenarios. Discovery under medical malpractice cases could reach into the corporate boardroom, with plaintiffs trying to proof widespread institutional policies that may impede appropriate treatment due to physician compensation formulas and withheld resource utilization. The ACO Board and management will also be held responsible for the success or failure of the execution of the business plan. This will include compliance with the approved ACO structure, failure to protect the ACO through correct risk taking options, integrated information system and profit/loss dissemination, adequate accounting and protection against prior liabilities of merged practices and proper contract negotiations. From an employment practices liability standpoint, beyond the normal exposures that exist, the ACO will need to be weary of wrongful economic credentialing or discrimination. Managed Care Errors and Omission Policies will be necessary to address credentialing, network management and utilization review (all non-direct patient care) exposures. Provider Stop Loss Policies, originated in the HMO era, will become a financial tool to transfer risk to an insurance carrier for the large financial risk that will be present under the MSSP model. The risk will grow substantially under the full capitation model. This same risk will also apply as the ACO model is applied to the private marketplace. In summary, the ACO era is fully upon us with new and evolving provider risks that must be carefully addressed through proper indemnification contracts and well constructed insurance programs. The blurring of lines between insurers and providers has never been more dynamic, with health insurers buying hospital systems and healthcare providers effectively becoming insurers. It is imperative that providers and ACO’s have a full understanding of their risks and the tools that are available to effectively mitigate and transfer these evolving exposures. Ron Gillaspie CIC, ExecVP/COO Boynton & Boynton Insurance Agency 732 747 0800 / rgillaspie@boyntonandboynton.com
August 2014
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Healthcare Groups in NJ Embrace Trend Toward More Accountability Andrew Kitchenman Eight applicants seek to join Medicaid demonstration project slated to start in late 2014 A state pilot program aimed at improving accountability and coordination of healthcare provided to Medicaid recipients has attracted eight applicants from across the state – a sign of the potential that healthcare providers see for the program. The Medicaid Accountable Care Organization demonstration project will provide incentives for organizations that reduce costs while still improving their patients’ health. By realigning incentives, the project aims to attain those healthcare goals while also reducing the frequency of costly visits to hospitals and doctors’ offices. The New Jersey project is unique compared to other ACO programs around the country because it includes all Medicaid patients within a geographic area, rather than just those whose healthcare is managed by certain insurers. In addition, the ACOs in New Jersey must include all of the hospitals that serve people who live with the ACO’s ZIP codes, as well as 75 percent of the primary-care providers and at least four mental-health providers. While established regional coalitions of healthcare providers – the Camden Coalition of Healthcare Providers, the Trenton Health Team and potentially the Greater Newark Healthcare Coalition – were expected to apply for the three-year project, five other groups joined them. “Last year it was looking like two, maybe three, so to have eight applicants is a big win for New Jersey and a big win for better care in Medicaid,” said Jeff Brown, executive director of the Affiliated Accountable Care Organizations, a project of the nonprofit New Jersey Health Care Quality Institute that aims to serve as a trade group for the ACOs. In addition to the Camden, Trenton and Newark coalitions, the applicants include Coastal Healthcare Coalition Inc., including Atlantic City and Ventnor; the Health Cumberland Initiative Inc., including Bridgeton, Millville, Vineland and rural areas in Cumberland County; the Healthy Gloucester Initiative Inc., including Paulsboro, Woodbury and Woodbury Heights; New Brunswick Health Partners, including New Brunswick and sections of Franklin Township; and Passaic County Comprehensive Accountable Care Organization Inc., including sections of Paterson. Coastal Healthcare Coalition’s Vincent Papaccio said the coalition chose to focus on Atlantic City and Ventnor because the narrowly defined geographic area would allow its partners to better target their resources and measure their success. Papaccio is senior vice president and chief operating officer of Reliance Medical Group, a private medical practice and coalition partner. While the Coastal Healthcare Coalition partners are already doing chronic disease management and coordinating patient care, joining the Medicaid ACO will allow them to share data and prevent patients with chronic health problems from slipping through the cracks by shifting from one provider to another, Papaccio said. “With shared information, we’re hoping that there’s shared effort,” said Papaccio, adding that if the coalition can identify and help patients who use healthcare services the most to manage their conditions, it will significantly reduce costs and improve patient health. First Meeting in August The coalition will have its first board meeting in August and plans to form its community advisory group this fall, noting that behavioral health, pain management and community groups must participate for the ACO to be successful. “The (healthcare) system still seems to be high-cost and still broken,” Papaccio said, but he added that is hopeful that, by collaborating, the ACO partners won’t repeat past mistakes and learn from one another. Brown said his organization has been working with the eight ACOs to complete their applications, adding that the strength of the applications was a testament to the work done by the groups, as well as to the support of the Nicholson Foundation, which has provided funding to the Affiliated Accountable Care Organizations. Brown added that while all of the ACOs will feature collaborations among providers, each organization reflects the unique features of its community. “New Jersey was a good opportunity for testing the success of these collaborations” because of the range of participants, Brown said. He said he was pleased that the organizations seeking to participate run the gamut from dense urban areas to sprawling rural sections of the state. Rutgers Center for State Health Policy Director Joel Cantor noted that several of the ACO applicants cover geographic areas similar to those studied in a paper he co-wrote last year. That study found that there was wide variation in how residents in August 2014
9
different areas use hospitals, and that significant savings could be realized if areas with more intense hospital use changed their usage patterns to match the areas with less intense use. The range of applicants encouraged Cantor, who is an NJ Spotlight columnist. “There’s tremendous diversity among the applicants,” including geography, socioeconomic characteristics and density, Cantor noted. “The possibility of learning from the demonstration is that much greater.” The Rutgers center has been hired as part of the project to help measure whether savings occur, as well as to provide some measurements of the quality of care, although the ACOs themselves are primarily responsible for tracking healthcare quality. The center also will assist the state in assessing “gain sharing” plans – how the ACO organizations will divide payments they will receive if they save money while meeting the healthcare quality goals. In addition, the center will help the state write annual reports evaluating the three-year project. Outreach Deemed Essential One element that several of the new applicants must work on is engaging with community mental or behavioral health and social-service providers, which will be essential to providing the coordinated care that many Medicaid recipients need. Brown said these organizations can learn from the Camden, Trenton and Newark groups, which have already actively engaged with local organizations. Another major project for all of the applicants will be to sign contracts with the five Medicaid managed care organizations, the insurers who manage care for Medicaid recipients.
“The governor has trumpeted the potential to improve care and save money” through the project, Brown noted. Brown suggested that insurers have a stake in the anticipated cost savings. “I’m confident that the managed care companies are going to engage with ACOs in the near future and work with them collaboratively,” he said. State Department of Human Services spokeswoman Nicole Brossoie said in an email that the state expects to certify applicants in the late fall and that the demonstration project will start later in the year. AACO representatives are recommending that the project start on January 1, 2015, which would coincide with the start of many managed care organization contracts. New Brunswick Health Partners Executive Director Dr. Alfred F. Tallia said the organization sees significant opportunities to improve healthcare quality and contain costs through the ACO, which includes longtime rivals Robert Wood Johnson University Hospital and Saint Peter’s University Hospital, as well as Rutgers University’s Robert Wood Johnson Medical School. “We’re pretty lucky that we have university resources,” which will support behavioral health in the ACO, said Tallia, who also leads Robert Wood Johnson Partners, which includes providers in a partnership between RWJUH and Rutgers. Negotiations with insurers will occur once the state has certified New Brunswick Health Partners’ participation in the project, Tallia said. “We’re anticipating that we’ll be able to have a good outcome in terms of those negotiations,” Tallia added, noting that Horizon NJ Health has signaled interest in participating in the ACO. Tallia also credited the AACO with making his organization’s application possible.
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The Cumberland and Gloucester organizations are both partnerships between Inspira Health Network, which operates the hospitals in the areas covered by the organizations, and CompleteCare Health Network, which operates the federally qualified health centers in the area. “We applied because we believe that the current system needs to have some strong revisions in terms of encouraging cooperation among the many people who provide care and engage patients in an a higher degree of responsibility in their own well-being,” said A. James Boote, Inspira vice president of ambulatory services and the executive director of the Cumberland and Gloucester groups. Boote emphasized that most of the factors that affect patients’ health aren’t under the direct control of healthcare providers, so the ACOs must engage in a wide range of partnerships. He cited as an example a patient with a respiratory condition that is worsened by hot summer weather and seasonal allergies, who may benefit from having a window-unit air conditioner installed in a bedroom. He noted that Cumberland has a large number of agricultural workers who haven’t lived in the area long enough to develop a relationship with a doctor, which presents a challenge to providers in that area. St. Joseph’s Healthcare System in Paterson is the key partner in the Passaic County Comprehensive Accountable Care Organization Inc. Organization President Harold Tepper also serves as St. Joseph’s vice president for physician practices and ambulatory services. Tepper said in an emailed response to questions that St. Joseph’s believes in the ACO concept and is eager to increase care coordination for the Medicaid population. He described his organization as being in its early stages.
Aetna, medical group reach Medicare health partnership By Beth Fitzgerald The collaboration between Summit and Aetna’s Medicare Advantage program is similar to an accountable care organization and uses shared data, financial incentives and collaborative care management to improve the health of the population. It is expected to cover about 1,000 of Aetna’s Medicare Advantage members in Summit’s Union, Morris, Essex and Somerset county region. With the Summit deal, Aetna said 16,000 of its New Jersey Medicare Advantage plan members, or about a quarter of its 66,000 Medicare Advantage population, are now served by this collaborative care model. “By working together, Aetna and Summit Medical Group are committed to improving health care for Medicare Advantage patients, and helping to ensure that their health care needs are identified and coordinated,” said Walter C. Wengel, III, Aetna New Jersey vice president. The Medicare collaboration is one of Aetna’s numerous value-based, patient-centered programs across the state that seek to give health care providers financial incentives to coordinate care in ways that both improve population health and avoid unnecessary spending. In New Jersey, Aetna said about 135,000 of its members are now enrolled in these value-based collaborative arrangements, and that its goal is to reach 215,000, or nearly 20 percent of its New Jersey membership, by year-end. Aetna said nationwide 1.5 million of its members are served by these new care-delivery programs. “Summit Medical Group has demonstrated significant experience in providing high quality, coordinated care and we are excited to partner with Aetna in this collaboration model,” said Dr. Jeff LeBenger, chief executive of Summit Medical Group. “We look forward to caring for the Aetna Medicare members who will benefit from the enhanced level of care and service available through this agreement.” Aetna said it’s not unusual for Medicare members to have complex health care needs that go undetected. Under the collaboration, Aetna nurses will work with Summit physicians to share information and resources in order to improve care and to reach out directly to patients. Aetna said a study of its Medicare collaboration found that it significantly reduced hospital admissions and readmissions, increased preventive care and reduced health care costs. “The careful tracking of quality metrics is a critical part of why collaborative agreements, such as Medicare provider collaborations and ACOs, are successful at improving patient care and are fundamental to the incentive structure,” said John Lawrence, president for Aetna in New Jersey. He said the Medicare collaboration includes a shared savings model that rewards Summit physicians for meeting certain quality and efficiency measures, including: preventive care and screenings, better management of chronic conditions such as diabetes and heart failure and reductions in avoidable hospital readmission and ER visits. Summit is New Jersey’s largest privately held multispecialty medical practice, with more than 325 practitioners in 76 specialties and 1,600 employees. Summit has a 42-acre health care campus in Berkeley Heights and 43 other practice locations in central and northern New Jersey. August 2014
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Hospital Rounds
HOSPITAL ROUNDS
State board approves for-profit Prime’s purchase of Saint Clare’s Health System By Beth Fitzgerald The acquisition of Saint Clare's Health System by California-based Prime Healthcare Services has cleared a major hurdle with the unanimous approval Thursday of the New Jersey State Health Planning Board. State Health Commissioner Mary O’Dowd now has 120 days to make a final decision, according to department spokeswoman Donna Leusner. Saint Clare’s, which has been operating at a deficit, has hospitals in Denville, Dover and Boonton. The state has given Prime approval to acquire St. Mary’s Hospital in Passaic, and Prime is currently seeking state approval to take over Saint Michael’s Medical Center in Newark. Saint Clare’s Chief Executive Les Hirsch said in a statement Friday that the health system “is pleased that yesterday the State Health Planning Board unanimously supported the transfer of ownership of Saint Clare’s facilities to Prime Healthcare Services.” Hirsch said: “The meeting was a positive discussion among all the parties present. Yesterday’s actions are an important milestone in the regulatory review process because it moves us closer to the completion of the transaction for Prime to acquire Saint Clare’s.” India Hayes Larrier, who represents New Jersey Citizen Action and its Campaign to Protect Community Healthcare, said she is concerned that Prime’s for-profit health care model won’t be in the best interests of the communities served by Saint Clare’s. She said among the conditions imposed on the sale by the state health planning board is that Prime negotiate in good faith with health insurance providers. Larrier said: “If Prime does not negotiate insurance contracts in good faith, then people will pay more because those hospitals will be out of network. Our concerns are that Prime’s business model will possibly make health care in the communities where they are taking over unaffordable.”
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Rutgers health care study highlights struggle for wellness in low-income communities as state prepares Medicaid ACO rollout By Beth Fitzgerald Low-income New Jersey communities have higher rates of avoidable hospitals visits — ailments that could be managed in a doctor's office if caught earlier — according to a report released Wednesday by the Rutgers Center for State Health Policy. The study points to factors outside the health care system, like homelessness and lack of fresh, healthy food, driving high hospital use in some poor communities, while for others the key issues are health care related, such as insufficient primary medical care. The report comes as New Jersey prepares to launch later this year its new Medicaid Accountable Care Organization pilot program. The program will seek to deliver coordinated medical care in low-income communities, in an effort to improve population health while reducing wasted spending in the state’s Medicaid program, which has an annual budget of more than $10 billion. An analysis of hospital billing records and demographic data by Rutgers researchers across 13 low-income communities in New Jersey found that as an area’s per capita income rises, the number of patients who seek medical care in the hospital falls dramatically. But the Rutgers team also discovered that hospital systems in some low-income areas perform better than expected, given their per capita income and other socioeconomic disadvantages. For example, Camden performs better than expected after statistically adjusting for the city’s high level of socioeconomic disadvantage. But high rates of avoidable visits in Jersey City and Asbury Park changed little after socioeconomic adjustments, suggesting that avoidable hospitalizations reflect factors other than income, such as the lack of access to primary care doctors. “The findings show how well a hospital system can perform in the face of poverty,” said Rachel Cahill, director of health care improvement and transformation at the Nicholson Foundation, which funded the Rutgers study. “The fact that some low-income areas are performing well despite their dire situations indicates that there is great potential for improvement.” The report, Cahill says, has important policy implications as New Jersey rolls out the three-year Medicaid ACO pilot. Eight community-based health care coalitions throughout New Jersey have applied to the state to create Medicaid ACOs, which will assume responsibility to care for Medicaid members within their geographic territory. The Medicaid ACOs will receive a share of the money that Medicaid saves if they can deliver high quality, efficient care. “In many low-income communities, lowering avoidable hospital use and cost requires emphasis on the social determinants of health,” said the report’s lead author, Derek DeLia, associate research professor at the CSHP. “This is especially true in communities that perform better than expected after adjusting for socioeconomic factors. In these communities, interventions that give special consideration to the daily stresses and problems associated with poverty — such as unsafe neighborhoods, unstable housing, lack of transportation, or limited access to healthy foods — can play a greater role in improving health and reducing avoidable medical episodes than a purely medical care focus.” Linda Schwimmer, vice president of the New Jersey Health Care Quality Institute, said: “The results of this study are illuminating and can help guide future efforts to improve care in these communities. We know that many factors beyond the provision of health care services contribute to a person’s overall health, and many of those factors, like housing, proper nutrition (and) educational opportunity, are largely tied to the income and the overall wealth of a given community.” In addition to broader societal challenges, “many of these communities lack certain health care infrastructure — like primary care — that can exacerbate the situation. The upshot is that this report will help these communities better understand what is driving readmissions and other health care utilization, and will help developing Medicaid ACOs and other provider collaborations better target their interventions and community partnerships.” The Camden Coalition of Healthcare Providers, which has been working to improve health care to the poor in Camden for more than a decade, is among the groups that plan to become a Medicaid ACO. And DeLia said the Camden is already looking beyond health care to tackle the social factors that drive public health. “In Camden they realize that people who are in the hospital multiple times are people who have unstable housing. So they have decided they need to talk to the housing authority and get these patients connected with a stable housing situation.” And he said the other communities creating Medicaid ACOs “probably understand that it is not just medical, you’ll have to deal with housing, transportation, child care,” and a range of other factors outside the walls of the hospital that impact population health.
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Medical News
QualCare health plan is starting diseasemanagement program, hoping to stem rising health care costs By Beth Fitzgerald
A health plan that QualCare manages for hundreds of New Jersey employers is launching a disease management program this fall aimed at helping workers and their families better manage chronic disease like diabetes and hypertension — with the goal of fostering a healthier, more productive workforce and ultimately holding the line on health care spending. The new program, “Keeping in Touch,” is being offered to employers enrolled in QualCare’s Affiliated Physician & Employers Health Plan. John Sarno, a plan trustee, is president of the Employers Association of New Jersey; EANJ member employers can opt to join the health plan and account for about half the plan’s 1,250 member employers. Sarno said the plan covers employees and their family members. Sarno said the program has hired a medical director and nurse case managers to coach individual workers on ways to better manage chronic diseases and make lifestyle changes aimed at improving their health. The program will kick off Oct. 14, when Dr. Christopher Valerian, the new medical director, will lead a meeting to explain the program to employers. “This voluntary program is designed to ensure that covered employees remain healthy, productive and happy,” Sarno said. “Working with a nurse case manager, participating employees will receive information and advice on their health care needs, preventative care and lifestyle choices — all within a confidential relationship.” Sarno said employers won’t pay a fee to participate in the disease management program, whose costs will be spread throughout the entire membership. Sarno cited heath care industry estimates that between 8 percent and 12 percent of a given population likely has a chronic disease, while “for another 15 to 20 percent, a chronic disease could be prevented” with early intervention. Improving the care of chronic disease will ultimately benefit the entire membership, Sarno said, since a major cost driver in health care is chronic disease like heart failure, diabetes or asthma. “If we can help employees manage their health care more efficiently, then long term that will benefit the entire group,” Sarno said. He said the program is “an investment in the long-term sustainability of the health plan.” And, he said, in the short term employers will benefit as better disease management fosters a healthier, more productive workforce.
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Saint Peter’s, clinician network renew their relationship By Beth Fitzgerald Saint Peter's Healthcare System and Partners In Care, a major New Jersey physician-owned clinician network and health care management company, on Monday announced that the hospital's 200 physicians and clinicians, including pediatricians, adult primary care doctors and specialists, will join the Partners In Care network. The physicians of New Brunswick-based Saint Peter’s will have access to East Brunswick-based Partners In Care’s suite of benefits and services designed to improve the efficiency and delivery of care. The physicians will receive additional revenue for care coordination activities in Partners In Care’s care coordination and population health management programs with health plans and self-insured employers. In a joint announcement, the two organizations said Partners In Care was originally founded in 1995 as a joint venture between Saint Peter's University Hospital and its physician network, United Medical Group. In 2005, Partners In Care transitioned to physician-only ownership. “This monumental milestone agreement brings our company full circle for the betterment of health care in our community,” stated Dr. Steven Goldberg, chairman and a founding physician of PIC. “It fits nicely with our mission to deliver better health and better care at a lower cost for the patients we serve.” “We are very excited about rekindling our relationship with Saint Peter’s in the changing and challenging health care environment,” added Ralph Tang, PIC chief executive. “It is a key component of our strategy to provide a comprehensive and effective clinically integrated network and care delivery system in Central Jersey and beyond.” “The renewal of our ties with Partners In Care is a boon to our physicians and the patients they serve,” said Ronald C. Rak, chief executive of Saint Peter’s Healthcare System. “We look forward to a successful and long-lasting joint venture that aids in the delivery of top quality health care.” PIC is an Independent Physician Association and health care management company with expertise in care coordination, accountable care and population health management. The company works to improve patient health and lower health care costs for clients, which include commercial and managed Medicare health plans; self-insured employers and public sector employers, including local and state government agencies; joint health insurance funds; municipalities; and school districts. PIC’s provider network includes more than 650 physicians and other health care professionals in 14 of 21 counties, primarily in central and southern New Jersey.
UnitedHealthcare’s Oxford starts N.J.-only health care network By Beth Fitzgerald
UnitedHealthcare's Oxford division is launching a New Jersey-only network of doctors and hospitals that will provide lower-cost health plans to employers who use the 18,000 doctors and 65 hospitals in the new Oxford Garden State Network. Chuck Cerniglia, vice president, small business sales for UnitedHealthcare, said employers on average will see 10 percent lower health insurance premiums if they choose the new health plans in the Garden State Network, which launches Sept. 1. “It limits access to New Jersey-only providers and it is a solution for New Jersey employers where a smaller network offers a reduction in cost,” he said. He added that employers will continue to have the option of offering their employees the company’s larger networks alongside the more limited — but also more affordable — Garden State network. He said while a New Jersey-only network won’t work for all employers, many clearly are seeking less-expensive health care options. “There needs to be more competitive, lower cost (health plans) in the marketplace that employers can take advantage of,” Cerniglia said. “There is the rising cost of health care, and we need to find ways to lower that cost.” The Garden State network has 13 different plan designs that follow the Affordable Care Act guidelines for the different benefit levels: bronze, silver, gold and platinum. Cerniglia said for some New Jersey employers “this will be the perfect option for them.” The rising cost of health care has prompted employers to consider dropping health coverage and “This could be the defining line of offering coverage or not offering coverage if it hits the right price point.”
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Insurance broker David Oscar of Altigro in Fairfield said health insurers are moving to so-called “narrow networks” that deliver lower premiums in exchange for restricting members to a smaller group of health care providers. He said he will analyze the Garden State Network and determine if it would help his clients. “At first glance, it looks like it would be worth it to investigate this,” Oscar said. He said one client, a business with 30 employees, would save $4,000 a month in health care premiums by switching to the Garden State Network. Oscar said he needs to determine if the client will be satisfied with the providers in the new network, and with any changes in plan design that go along with making the switch, but “If you are talking about $4,000 a month, that is not a shabby number.” UnitedHealthcare has about 1.5 million members in New Jersey, the majority of them in employer-based health plans. Cerniglia said existing clients may switch to the Garden State Network, which he predicted will also bring new business to the company. “I can tell you that we’ve had an overwhelming response from brokers in the community.” He said hundreds of brokers have taken part in webinars “to learn more about these products.”
Nearly 10,000 New Jerseyans Could Lose ‘Obamacare’ Health Insurance Andrew Kitchenman Federal officials say they must produce proof of citizenship or immigration documents by Sept. 5
Nearly 10,000 New Jersey residents are in danger of losing their health insurance since the federal government doesn’t have proof of their citizenship or immigration status. That has prompted federal officials and local healthcare advocates to begin a push to reach those people before they lose their coverage. The approximately 9,600 residents in question bought insurance through the federal insurance marketplace, which began enrolling residents last fall for health plans that started Jan. 1. The marketplace and state-based exchanges were a central provision of the 2010 Affordable Care Act. The ACA limited access to the marketplace to U.S. citizens and immigrants with permanent resident -- or “green card” -- status. Problems arose for some marketplace enrollees when the Social Security or permanent resident card number they provided in their application didn’t match federal records. Now, they must provide documents confirming their status by Sept. 5 or they will lose their health insurance on Sept. 30. It’s not clear whether some of the 9,600 residents are undocumented or illegal immigrants. Federal officials said the inconsistency between the applications and federal records doesn’t necessarily mean there is a problem with an individual’s insurance marketplace eligibility. But it does mean that more information is needed to verify the resident’s status. “However, if these supporting documents are not received, health insurance plans will be terminated in order to ensure program integrity and protect taxpayer dollars,” according to a statement from the Centers for Medicare & Medicaid Services (CMS). CMS officials said the 9,600 New Jersey residents were among 310,000 consumers nationally who haven’t responded to federal attempts to contact them via mail, email and telephone. Federal officials have been able to close roughly 450,000 other cases and have made progress on an additional 210,000 cases. The marketplace administration began sending notices this week informing the remaining people of the imminent potential loss of their coverage. The issue has raised concerns among Garden State healthcare advocates. Maura Collinsgru of New Jersey Citizen Action said that some residents are likely unaware of the urgency of the situation. “It’s another situation where our concern is heightened by the lack of involvement from the state of New Jersey,” said Collinsgru, referring to Gov. Chris Christie’s rejection of a state-based exchange and the subsequent loss of federal funding. Collinsgru said state and local advocates will be reaching out to residents, but their capacity to reach the entire public in a brief period of time is limited. “Community-based organizations, enrollment assisters and healthcare providers are all working to get the word out in their communities, but it would really help to have a governor who would amplify the message,” Collinsgru said. Earlier this year, the Christie administration requested that $7.67 million in federal funding that had been awarded to the state to support a state exchange instead be largely used to support expansion of Medicaid eligibility. Federal officials indicated they would only have approved using the money for marketplace-related expenses, including August 2014
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marketing, a use supported by healthcare advocates. But the state didn’t agree to that condition, and lost the funding. Collinsgru said the possibility that some residents could lose health insurance due to a lack of information about proper documentation highlights the importance of keeping the public informed about the marketplace. The ACA provided funding for outreach for state-based exchanges, leaving limited funds for federal marketplace outreach. “The task here is really one of education,” Collinsgru said. The federal health insurance marketplace also faces a potentially major legal challenge over whether low- to middle-income marketplace enrollees are eligibile for federal tax credits to subsidize their insurance purchases. At the end of the last open enrollment period in mid-April, there were 161,775 people in New Jersey who had enrolled in marketplace insurance plans. No official updates on either additional enrollees or the number of enrollees who are paying for their insurance have been released since then. The next open enrollment period begins on Nov. 15. Christie did agree to expand Medicaid eligibility, which has led to a more than 200,000-person increase in New Jersey FamilyCare enrollment. CMS Administrator Marilyn Tavenner noted in a statement that federal officials have been trying to reach marketplace enrollees about inconsistencies in their applications for several weeks. “We want as many consumers as possible to remain enrolled in Marketplace coverage, so we are giving these individuals a last chance to submit their documents before their coverage through the Marketplace will end,” she said. Federal officials are urging people who receive the notices to log onto their accounts on the marketplace website, and select their current application to upload their documents. They can also find information on the site about local organizations that can help with the application. In addition, they can call (800) 318-2596 to learn what documents they need to submit and whether the marketplace administrators have received their information. Two more rounds of phone calls and one more email will be sent to the 9,600 affected New Jerseyans before the deadline. Those who don’t respond will then receive a final cancellation notice. “Since this is an urgent matter, we are activating our networks on the ground to reach people directly in the communities where they live,” Tavenner said. “Whether it is online, via our call center, or with one of our local partners, consumers will have a number of ways to find the help they need to continue their coverage.” Another round of data verification -- focusing on inconsistencies between enrollees’ reported and federally recorded incomes -- will occur later this year.
“Where are the patients supposed to go?” This question is not only on the mind of Rebecca Porter but also other former patients of American Imaging MRI Centers throughout northern New Jersey. The company’s 14 MRI centers were shut down last month by the State of New Jersey’s Medicaid Control Fraud Unit in a case labeled Operation RayScam. Investigators say that the operators of American Imaging lived a lavish lifestyle as a result of patient referrals obtained through hundreds of thousands of dollars in illegal kickbacks to doctors. Now those arrests have created a situation that orthopedic surgeon Dr. Ernesto Tolentino says is a first in his 42 years of practicing medicine. “Never had an issue of this particular nature.” The issue comes s a result of the arrests as well as the seizure of evidence. Patients are unable to get their medical records or recent MRI exams. “I was wondering about that last night because I have to get my mammogram because they have that over there,” said Eloise Grant is a former patient. Dr. Tolentino adds that the situation has already impacted patients at his practice. “It prevents a conclusion concerning the patient and it also causes the insurance companies and the patient a much greater fee.” A spokesperson for the New Jersey Attorney General’s office told PIX11 News the following via a statement: “We are aware that there is an issue and we are working with the New Jersey Department of Health to resolve the matter as quickly as possible.” To which an optimistic Porter says, “Well maybe the state will come through for us. What can you do? We’ll just have to wait and see.”
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