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Special Feature: Sovereign Health Vein and Vascular Institute New Jersey Health Insurance Exchange/Marketplace Insurer, N.J. Medical Associations Seek Solution to Surprise Out-Of-Network Medical Bills
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A fully integrated multi-specialty community healthcare system providing clinical excellence and convenient care to
NORTH JERSEY & NEW YORK RESIDENTS Built from the ground up right here in the Garden State, Sovereign Health System has called New Jersey home for more than 20 years. After two decades of steady growth, Sovereign Health System continues to expand its physician ranks, cutting-edge services, and conveniently located facilities to better serve the people of New Jersey and New York. Sovereign knows it’s important to have that one-on-one connection with your nurse and doctor. That’s why at Sovereign you are treated like family -- and why our latest patient-satisfaction rating is 95%. Sovereign provides you with multi-specialty care, ongoing support, and comprehensive services in one fully integrated community healthcare system. In short, we offer peace of mind . . . close to home.
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A fully integrated multi-specialty community healthcare system...CLOSE TO HOME
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Special Feature
Sovereign Health Vein and Vascular Institute
CONTENTS
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12
4
New Jersey Health Insurance Exchange/Marketplace
Insurer, N.J. Medical Associations Seek Solution to Surprise Out-Of-Network Medical Bills
13
Hospital Rounds
13
Saint Michael’s Hospital Files for Ch. 11; Hopes Move Will Hasten Sale to Prime
14
Prime Takeover of Saint Clare’s Delayed Until Later in 2015
14
Princeton Medicine Group Gets ‘Patient Centered Medical Home’ Designation
15
N.J. Health Care Organizations Get $2M in Funding Through Two Programs August 2015
3
Special Feature
Sovereign Health
Vein and Vascular Institute
One of the Spectacular Jewels in Sovereign Health System’s Multi-Faceted Crown By Iris Goldberg For more than two decades Sovereign Health System has been steadily growing and continues to evolve. Its beginnings date back to 1992 when urologist John H. Hajjar, MD, FACS, MBA, who today serves as CEO and Chairman of Sovereign, opened an ambulatory surgery center (ASC) in Fair Lawn, New Jersey, one of the first of its kind in Bergen County. There, Dr. Hajjar could use emerging laser technology to treat patients with enlarged prostates on an outpatient basis. Charging considerably less than what a hospital would be paid for the same procedure - Dr. Hajjar’s surgery center was at the forefront of cost-effective ambulatory care, now preferred by physicians and patients alike whenever possible. Fast forward to 2005 and by then the Sovereign organization had grown to include three full same day surgery centers performing minimally invasive urologic and orthopedic procedures, including hip and knee replacements, accomplished with small incisions. Sovereign Health was on its way to becoming a leader in providing patient care at a lower cost while maintaining the highest quality of standards. Today, Sovereign is a fully integrated community healthcare system, managing 13 ASCs throughout New Jersey, New York and Florida, with others in Manhattan and Connecticut on the not too distant horizon. Additionally, Sovereign Health now includes cancer centers, urgent care centers and a multidisciplinary physician group, attracting and recruiting specialists from every field. These are all supported by ancillary services such as anesthesia and laboratory, as well as state-of-the-art medical information technology. Dr. Hajjar recently discussed Sovereign Health’s history, mission and organization with New Jersey TV personality, Steve Adubato. Click here to view. This past June, in keeping with Dr. Hajjar’s mission to create and grow a physician-owned and physician-led, vertically integrated Dr. Steve Elias health system with centers of excellence to deliver high-quality, cost-effective patient care, Sovereign Health welcomed renowned vascular surgeon Steve Elias, MD, who specializes in the minimally invasive management of vein disease. Dr. Elias utilizes innovative technology to successfully treat patients with symptomatic venous disorders and associated cosmetic issues. As Director of Sovereign Health’s Vein and Vascular Institute, Dr. Elias will train vascular surgeons, interventional radiologists and interventional cardiologists in the cutting edge techniques he has perfected. As this proceeds, it is the hope that many of these physicians will join Sovereign to grow the team of vein and vascular specialists. Dr. Elias shares that a great number of patients are treated for bulging varicose veins. Besides their unattractive appearance, most varicose veins cause symptoms such as: heaviness, aching, swelling or throbbing that can interfere with the quality of one’s life. Some other patients with small spider veins are usually concerned primarily with the cosmetic component. At the other end of the spectrum, as Dr. Elias points out, are those who suffer from complications of vein disease such as blood clots known as superficial (vein) phlebitis or deep vein thrombosis (DVT). Some have significant skin changes or ulcers at their ankles because of veins that are not functioning properly. “The misconception about vein disease, I think, on the part of other physicians, is that it is purely a cosmetic issue and that treatment is
4 New Jersey Physician
not covered by insurance. In fact, most procedures and care are covered by insurance because of the significant impact vein disease has on quality of life,” Dr. Elias offers. He goes on to explain that the vast majority of vein patients are, in fact, symptomatic. For patients with blood clots, as well, Dr. Elias relates that often primary care physicians tend to under-treat by merely prescribing anti-coagulants without referring to a vein specialist. “Unfortunately, what happens is we see these patients three to five years down the line and now their legs are swollen or they’re developing ulcers because their veins cannot carry the blood back up the leg due to chronic scarring and narrowing of the veins from previous DVT. This is called post phlebitic syndrome,” Dr. Elias reports. “Yes, initially, blood thinners are okay but now we have minimally invasive techniques that can dissolve the acute clot and preserve the function of the veins so that patients don’t wind up with these complications,” he emphasizes. Dr. Elias is passionate about changing the mindset of patients and referring physicians alike, who may still think of vein treatment as it was years ago. “Ninety-five percent of what we offer to manage vein disease involves a few needle sticks, local anesthesia, perhaps mild sedation and takes no more than half an hour to complete,” informs Dr. Elias. “This is not your grandmother’s stripping,” he adds. “You can drive yourself there and drive yourself home and the next day play tennis, golf, exercise – whatever you normally do.” Click here to view Dr. Elias performing a MOCA procedure of the great saphenous vein using the ClariVein device. While it is true that patients with vein disease do not, for the most part face possible loss of life or limb, Dr. Elias knows how devastating it is for patients to lose the good quality of their lives. “To be able to offer the technology we now have and restore a patient’s quality of life – that’s really gratifying to me,” Dr. Elias shares. “And that’s why a big part of my job, as I see it, is to get the word out to primary care physicians, emergency room physicians and others. These patients need, at the very least, to have a consultation with a vein specialist,” he strongly states. In terms of interacting with other physicians, Dr. Elias is also extremely involved with educating specialists who currently treat vein disease and want to take things to the next level, as well as those who have just completed their fellowship training in vascular surgery and are starting out. Recognized for his considerable expertise by the companies that develop new, minimally invasive technologies for treating vein disease, Dr. Elias is called upon to help pioneer their implementation. Paul Angresano, VP, New Business Development at Sovereign Health Medical Group was instrumental in bringing Dr. Elias to Sovereign. “He’s one of the fathers of treating vein disease in the world. So, people come from all over to interact with him and be proctored by him,” Mr. Angresano says, explaining why Dr. Elias and the Vein and Vascular Institute under his direction, are a most valuable addition to the Sovereign organization. In fact, going forward it is the hope that many of the vein specialists who receive enhanced training there will ultimately join the Sovereign Health System. As Dr. Hajjar envisioned, the creation of centers of excellence for many medical specialties such as orthopedics, urology, urgent care, cancer treatment and management of vein disease is the foundation upon which Sovereign Health is built. “To achieve that goal we sought out Dr. Elias to be a part of that,” shares Mr. Angresano. “From my perspective that was one of the things that attracted me to come here, “ Dr. Elias confides. “To be able to develop a vein and vascular center was very appealing to me because I come in contact with multiple people who are treating vein disease or want to treat vein disease. Now we can get the right people who are knowledgeable and have the good skill sets to come and join us,” Dr. Elias elaborates. “The goal at Sovereign is to be able to offer good health care, not necessarily in a hospital setting but within the community. Sovereign has many places to offer this care but we need to get the right people in place to provide it.” Dr. Elias feels that he has arrived at Sovereign at a very appropriate time in his career because his goals right now are very much in line with the principles upon which Sovereign Health is based. Offering topnotch health care must be partnered with providing the academic environment that allows physicians to expand their horizons. He wants other specialists who have an interest in developing their expertise to the highest level to eventually join the Sovereign team. “The challenge for us who are where we want to be professionally is to teach others how to get there and to even exceed us, “ Dr. Elias strongly believes. For Dr. Hajjar and the others who are involved in furthering the mission to provide high quality, costeffective health care through an integrated physiciandriven health care system, prioritizing education is the cornerstone. As the Sovereign Health System continues to evolve, it’s all about passing the torch.
Dr. Elias concentrates on the images shown on the monitor to guide the catheter.
Dr. Elias uses dye to more clearly view any blockages in the vein.
August 2015
5
If you are a physician and are interested in joining the Sovereign Health Medical Group, please contact : Paul Angresano, VP, New Business Development at 201-855-8376 / pangresano@sovms.com
Sovereign Health
Sovereign Health
SurgiCare
Development & management company for ambulatory surgery centers (ASC). Same-day procedures performed in a convenient, caring setting. SURGEM, LLC., has new facilities in select markets in New Jersey, New York and Florida with additional facilities coming soon. Our 13 centers are conveniently located, staffed with highy skilled, caring physicians and nurses, equipped with the latest technology, and designed to provide an optional patient experience in a spotless facility and comfortable setting. We treat you the way we would want ourselves or our family members to be treated, and that approach is reflected in everything we do - and in our consistently high patient-satisfaction ratings. Carlstadt 630 Broad St 201-355-1700
Mahwah 400 Franklin Turnpike 201-766-1550
Englewood Cliffs 630 East Palisade Ave 201-503-1522
Oradell 555 Kinderkamack Rd 201-265-8173
Fair Lawn 15-01 Broadway 201-703-8487
Ridgewood 1124 East Ridgewood Ave 201-493-2310
Freehold* 901 West Main St., Suite 302 732-303-1616
SJCH Pediatric (Fair Lawn) 14-01 Broadway 201-791-0100 Wayne 246 Hamburg Turnpike 973-790-0954
Jersey City 631 Grand St 201-830-2280
University Center for Ambulatory Surgery (Somerset) 2 Worlds Fair Dr 732-748-1117 Manhattan, NY** 800 2nd Ave (7th Floor) 212-419-1016
Cancer Care The Physicians of Sovereign Health Cancer Care are fellowship trained to treat malignancies of any site
Sovereign Health Cancer Care offers our patients state-of-the-art technology in a compassionate outpatient setting. With VMAT IRMT and cone beam IGRT, radiotherapy is delivered precisely and safely every day. Our oncology experts have published extensively in the nations’ leading peer reviewed journals and have vast experience treating cancers of all sites, including prostate, breast, lung, brain and cancers of the gastrointestinal and gynecologic systems. Hackensack 20 Woodridge Ave 201-880-7580
New Brunswick - Saint Peter’s 215 Easton Ave 732-745-8590
Jersey City 631 Grand St 201-942-3999
Wayne - Saint Joseph’s 234 Hamburg Turnpike 973-310-0300
Boca Raton, FL 1905 Clint Moore Rd 561-544-5501
Sovereign Health Medical Group
*Located in CentraState Medical Center **Administrative services agreement
Sovereign Health Medical Group was created by physicians with the needs of patients and other physicians foremost in mind
Sovereign Health Urgent Care
Get immediate medical care at Sovereign Health Urgent Care When an injury or illness occurs and you are in need of medical attention on an immediate basis, visiting an urgent care clinic is a smart move. Your time is important, and we are dedicated to seeing you as quickly as possible. Our priority is providing excellent patient care in an efficient manner. Fair Lawn 15-01 Broadway 201-794-3600
6 New Jersey Physician
Glen Rock 85 Harristown Rd 201-479-5450
Hewitt 1900 Union Valley Rd 973-728-5930
•
Breast Surgery
•
Orthopedic Surgery
•
Cardiology
•
Pathology
•
Colon-Rectal Surgery
•
Podiatry
•
Gastroenterology
•
Urgent Care Facilities
•
Ears, Nose & Throat (ENT)
•
Urogynecology
•
Emergency Medicine
•
Urology
•
General Surgery
•
Radiation Oncology
•
Hematology & Oncology
•
Vein & Vascular Care
•
Internal Medicine
•
Other Specialties
•
Neurology
REMEMBER WHY YOU BECAME A DOCTOR?
SOVEREIGN HEALTH DOES. To take care of patients, not paperwork To deal with health conditions, not health plans To be a physician, not an administrator
Join our physician-owned, physician-led medical group, and practice medicine the way it’s meant to be practiced – with the patient always coming first and the physician truly sovereign.
JOHN HAJJAR, MD, FACS, MBA Founder, Chairman, and CEO
My reason for becoming a physician is simple: I wanted to help people. Sovereign truly is a physician-led, vertically integrated healthcare system that does just that. Our mission is to deliver high-quality, cost-effective care through our exceptionally skilled physicians and staff at our conveniently located state-of-the-art facilities.
GLENN A. GMYREK, MD Chief Medical Officer
My goal as a physician, first and foremost, is to help people feel better. In today’s healthcare environment we all know this can be very challenging. Fortunately, at Sovereign Health Medical Group, I have been able to practice medicine without any of the distractions that can make a physician’s job tougher than it already is.
PHYSICIAN-LED, MANAGEMENT DRIVEN To learn more about “The Sovereign Difference,” contact Paul Angresano, Vice President, at 201-855-8376 or pangresano@sovms.com, or visit www.sovereignhealthsystem.com CORPORATE OFFICE: SOVEREIGN MEDICAL SERVICES, INC., 85 HARRISTOWN RD., GLEN ROCK NJ, 07452, 201-834-1100
WWW.SOVEREIGNHEALTHSYSTEM.COM
Health Insurance
New Jersey health insurance exchange / marketplace
3 individual exchange carriers request double digit rate hikes on some plans By Louise Norris King v. Burwell – subsidies safe On June 25, the Supreme Court ruled that subsidies are legal in every state, including those that use Healthcare.gov. That means subsidies are safe for the 182,000 people in New Jersey who currently receive them, and they’ll also continue to be available for future enrollees. New Jersey has a federally-run exchange, and plaintiffs in the case argued that the ACA only allows for subsidies in state-run exchanges. Over the last few years, Governor Christie has twice vetoed legislation that would have put the state on a path to creating its own exchange. But NJ Senator Nia Gill introduced the legislation again in 2015. Her bill, S540, would create a state-run exchange in New Jersey – but it didn’t advance out of committee during the 2015 session. Gill has been critical of Gov. Christie’s vetoes of the prior exchange-creation legislation, noting that New Jersey subsidies wouldn’t have been dependent on outcome of the King case if the state had created its own exchange. If the King plaintiffs had prevailed, coverage would become unaffordable for most of the people who would have lost subsidies, and it would also have become unaffordable for tens of thousands of other New Jersey residents who buy their own health insurance without subsidies. The American Academy of Actuaries estimated that premiums market-wide would have increased by at least 35 percent in states where subsidies are eliminated – and it could have been as high as 55 percent – in addition to the regular annual rate hikes based on medical cost inflation. Luckily for the residents, employers, medical providers, and insurance market stability, subsidies have passed the Supreme Court test and are here to stay. 2016 rates Healthcare.gov’s rate review tool allows consumers to see proposed rate increases of ten percent or more, although singledigit proposed rate hikes don’t show up on the list. In New Jersey, three individual market exchange plans have requested rate increases of at least ten percent: Horizon Blue Cross Blue Shield, Oxford Health Plans, and Freelancer’s CO-OP. The highest among them is a proposed 18 percent increase for the CO-OP. Although Horizon BCBS has requested a double-digit rate increase for three of its EPO plans, another EPO – expected to cover two-thirds of the company’s Advantage EPO enrollees by the end of this year – will see a rate increase of less than ten percent in 2016. The other two exchange carriers, AmeriHealth and Oscar, did not request double digit rate hikes for 2016. Rates are currently under review, and it will be several weeks before they’re finalized. If approved, the proposed double digit rate increases will apply to about half of the current exchange population, although enrollees will be able to switch to a different plan during open enrollment in order to avoid rate increases. Open enrollment begins again on November 1, for coverage effective January 1, 2016. Open enrollment will once again be three months long, ending on January 31. In addition to the individual exchange plans, some small group and off-exchange plans have submitted rate proposals that include double-digit rate hikes. How many people have enrolled? 254,316 people enrolled in the New Jersey exchange during the second open enrollment period, from November 15 to February 22, and 83 percent of them qualified for premium subsidies. The enrollment total includes 133,215 renewals from 2014, of which 75,712 were “active” renewals (as opposed to auto-renewals). Of the active renewals, 45,197 picked a new plan for 2015 rather than keeping their existing 2014 coverage for another year. Joel Cantor, director of the Rutgers Center for State Health Policy, had estimated that total private plan enrollment in the New Jersey exchange could reach 250,000 people by the end of the 2015 open enrollment period, and it turns out that his prediction was pretty spot-on. Another 60,757 New Jersey exchange enrollees were eligible for Medicaid or CHIP between November 15 and February 22. Open enrollment for 2015 has ended, and this applies to plans purchased outside the exchange as well as plans within the exchange. Most applicants can only purchase 2015 coverage at this point if they have a qualifying event (Native Americans and those who qualify for Medicaid/CHIP can enroll year-round). People who don’t have health insurance coverage in 2015 will face a much more significant penalty than they did last year: $325 per uninsured adult (half that amount for children under 18), or 2 percent of household income, whichever is greater. Two new carriers in 2015 brings exchange total to five In 2014, only three carriers participated in the exchange in New Jersey: Horizon Blue Cross Blue Shield, AmeriHealth, and Health Republic of New Jersey (Freelancer’s CO-OP). For 2015, two more carriers have joined them: UnitedHealthcare (Oxford Health Plans) and Oscar Health Insurance.
8 New Jersey Physician
Health Republic is a new consumer oriented and operated plan, or co-op, created under a provision of the ACA, and Oscar Health Insurance is an innovative new carrier that started in New York last year and is expanding to New Jersey. What about premiums? In the Newark area, the second-lowest-cost silver plan (the benchmark plan) could be less expensive in 2015 than it was in 2014. According to data from the Kaiser Family Foundation, the average in 2014 for a 40 year old non-smoker was $322 per month, and that’s dropped to $316 per month for 2015 (though in most areas, staying with the benchmark plan means switching carriers for 2015). In Bergen County, the carriers offering the lowest-cost silver and bronze plans, as well as the second lowest-cost silver plan, are all different from the carriers that offered those plans in 2014 – highlighting the importance of shopping around during open enrollment. The New York Times Upshot has an interactive map that further details the importance of shopping around during the 2015 open enrollment period. For New Jersey residents (Newark area) who had the benchmark plan in 2014 and opt to simply renew that same plan, the average rate increase for 2015 is roughly 11 percent. But people who shop around and switch to the new benchmark plan will see an average rate increase of just 2.2 percent. And across all plans and metal levels in the exchange, an analysis from the Commonwealth Fund found an average 2015 premium increase of just 2 percent for a 40 year-old non-smoker. The relatively low level of competition in 2014 – just three carriers in the exchange – is one of the reasons given for the higherthan-average premiums in New Jersey during the first open enrollment period. According to a report released by the U.S. Department of Health and Human Services (HHS), the average 2014 cost for a bronze plan —the lowest-cost option — in New Jersey was $332 in 2014, compared to a national average of $249 a month. But the entry of two new carriers has helped to hold down the average benchmark plan rates for 2015. An HHS survey in mid-June found that New Jersey had the highest average after-subsidy cost for health insurance among the 36 states where HHS is running the exchange: $148 in New Jersey, compared with an average of $82 across all 36 states. This is indicative of not only higher unsubsidized premiums, but also higher average incomes in NJ, and perhaps an affinity for plans with higher metal levels. For people with the same income level (assuming they are subsidy-eligible), it doesn’t matter what state they live in or how expensive the unsubsidized premiums are — the subsidy amounts will differ, but the after subsidy premiums for silver plans will be the same, since the ACA sets net premiums as a percentage of income. Targeted outreach and more experienced navigators Navigator organizations in New Jersey have more data and experience in the second open enrollment period than they did a year ago. They have zip code based information in terms of where people have enrolled and where there are still large pockets of eligible people, so they can better target their outreach. Get Enrolled America’s New Jersey branch learned last year that recurring enrollment events work better than one-time events, and also that people are more likely to enroll after being contacted at least four times. They’re incorporating that information in their enrollment strategies for 2015. The New Jersey for Healthcare Coalition has an improved website – CoverNJ.org – where people can find local assistance with the enrollment process and learn more about the ACA and enrollment in general. 2014 enrollment data For the 2014 open enrollment period, by April 19, 161,775 people had completed their enrollment in private plans through the New Jersey exchange. Private plan Obamacare enrollments in the New Jersey exchange were nearly 70 percent higher than HHS had predicted last year, prior to open enrollment (the projection was about 113,000 people in 2014). Every state saw a surge in enrollment in March and early April, but New Jersey’s was the seventh largest surge in the country. The carriers in New Jersey have been forthcoming with their enrollment numbers though. AmeriHealth had 130,000 enrollees as of early September (up from about 10,000 at the end of 2013), and Horizon BCBS had 140,000 by mid-August. Health Republic had enrolled roughly 4,000 new members. These totals are for the carriers’ full book of business, including both on and offexchange enrollments. But AmeriHealth reported that the majority of their new enrollments have been through the exchange. More health plans on the horizon? In mid-October, two NJ hospital systems – Hackensack University Health Network and Meridian Health – signed preliminary paperwork to begin a merger process, although the deal still has to be approved by regulators. If approved, Hackensack Meridian Health would become the largest hospital system in NJ, and would include nine acute-care hospitals, two children’s hospitals, and numerous doctor’s offices, rehab centers, skilled nursing facilities, and assisted living centers. Officials are predicting that if it goes forward, the merger will lead to the creation of new provider-managed health insurance plans, which could bring more competition to the NJ health insurance market. August 2015
9
ACA’s impact on the uninsured rate In addition to the people who have purchased private plans through the exchange, another 343,000 people had enrolled in New Jersey’s expanded Medicaid by mid-October. That means about 74 percent of the total Medicaid-eligible population in the state enrolled in the first year expanded Medicaid became available (Medicaid enrollment continues year-round). From December 2013 through October 2014, total Medicaid enrollment in New Jersey grew from 1.28 million to 1.65 million people. In September 2013, New Jersey’s uninsured rate was 21.2 percent. By June 2014, that rate had dropped to 11.5 percent, according to a study by the Robert Wood Johnson Foundation. In less than a year, the ACA has halved the uninsured rate in New Jersey. Congressional outreach and legislation In late February, 11 New Jersey lawmakers — all Democrats — partnered with Get Covered America to volunteer their time in helping NJ residents get enrolled in the exchange. The lawmakers’ staff members also helped with the enrollment effort, which was Get Covered America’s largest partnership with state lawmakers in the country. Their involvement was part of the reason for the extremely successful final couple of months of open enrollment in New Jersey. In mid-January, U.S. Rep Bill Pascrell (D, NJ) introduced a bill that would allow HHS to recoup ACA outreach funding that remains unused by Republican governors like Chris Christie who have refused to use the money in their states to promote the ACA and educate residents about its benefits. New Jersey officials were involved in lengthy discussions with HHS over the use of $7.67 million in federal funds that had been granted to NJ in 2012 to use for promoting the state’s health insurance exchange. The money was intended for outreach, advertising and general promotion of the ACA and the exchange, although NJ officials wanted to use it to staff a call center for the state’s expanded Medicaid program. But HHS had made it clear last year that such a use was not permitted. Ultimately, the state and HHS were not able to come to a compromise on the issue. New Jersey forfeited the money on February 20 when the deadline passed, and HHS officially rescinded the funds in early May. History of the New Jersey exchange The New Jersey Assembly passed two bills authorizing a state-run exchange in 2012, but both were vetoed by Gov. Christie. Those vetoes left the federal government to operate the health insurance marketplace in New Jersey. Governor Christie has taken a very hands-off approach to the ACA, and the state has done little to promote the HHS-run exchange, leaving most of the heavy lifting to brokers, navigators and HHS. The state did opt to expand Medicaid however, making health insurance available to hundreds of thousands of low-income residents.
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Insurance
Insurer, N.J. medical associations seek solution to surprise out-of-network medical bills By LINDY WASHBURN The state’s largest health insurance company and organizations representing doctors and hospitals have held private discussions over the summer about legislation to protect consumers from surprise medical bills. They haven’t hammered out a compromise yet over the toughest issue — how to determine how much to pay a provider who isn’t part of an insurance network — but one participant expressed optimism. “We’ve had conversations with many key stakeholders, including the Medical Society of New Jersey and the New Jersey Hospital Association,” said Robert Marino, chairman and CEO of Horizon Blue Cross Blue Shield of New Jersey, which covers about half of the state’s insured population, “and I’m hopeful based on how those conversations are going that we might be able to find middle ground.” A law to solve the vexing problem of high out-of-network bills has long eluded legislators. The Democratic sponsors of the most recent effort were frustrated when their proposal stalled in June. “I would hope that if we, the medical society and the hospital association can find some common middle ground, that the legislative process becomes a little easier,” Marino said. “I’m cautiously optimistic.” The proposed legislation aims to protect consumers and limit the fees insurers must pay when care is provided by a doctor or hospital that does not participate in an insurer’s network and demands more than the insurer pays. A Franklin Lakes woman who had an emergency cesarean section at The Valley Hospital in Ridgewood, for example, was billed $1,852 by the anesthesiologist after her insurer, Cigna, had already paid its standard fee for the care. She went to Valley because both the hospital and her obstetrician were in Cigna’s network, but none of the anesthesiologists affiliated with the hospital accepted Cigna. The anesthesiology practice sued the patient for payment in Bergen County Superior Court, and a decision is pending. Insurer’s tab Another situation addressed by the legislation is the cost to an insurance company for emergency care at a hospital that is not part of its network. Under state regulations, the patient can be billed no more than he would have paid at an in-network hospital. But the hospital can bill the patient’s insurance company whatever it wants, and charges at some New Jersey hospitals are among the highest in the nation. Friday was the deadline set by Assemblyman Craig Coughlin, D-Middlesex, chairman of the Assembly committee that oversees insurance, for comments from various interest groups about the draft legislation. Many comments were received, and they will be analyzed over the next week, said a staffer. Coughlin and the other sponsors — including state Sen. Joseph Vitale, a Woodbridge Democrat and chairman of the Senate Health Committee, and Assemblymen Gary Schaer of Passaic and Troy Singleton of Mount Laurel, both Democrats — are to meet during the week of Aug. 31 to discuss possible revisions in their bill, called “The Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act.” Last June, after months of hearings and meetings with various interest groups, the proposed law failed to make it out of committee because of strenuous opposition from doctors and hospitals that said its plan to settle disputed bills through binding arbitration would cause them economic harm. Marino said that an alternate method of resolving fee disputes — different than baseball arbitration, which the bill initially included — might receive the support of all three groups. In baseball arbitration, the arbitrator chooses one side’s final offer to resolve a claim. Marino recommended “balanced” binding arbitration instead, which would be based on the amount similar claims receive from Medicare and other insurance plans, both in-network and out-of-network. Mediation alternative The state medical society, however, said it favored non-binding mediation. “We prefer that claims be referred, and go through some kind of informed mediation by physicians who know the work — and not just have a lawyer and someone who’s not familiar with clinical medicine look at it,” said Lawrence Downs, the society’s CEO. Downs said the medical society has long had a voluntary resolution process, adding that professional societies want to help identify physicians whose fees are excessive and encourage them to be more reasonable. When patients face out-of-network bills, Downs said, the responsibility really lies with insurers who do not offer sufficient payments to doctors to persuade them to join their networks.
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“The reason we’re having such a problem fixing the out-of-network problem is that we’re not fixing the in-network problem,” he said. “It’s very difficult to address just this issue. That’s why it’s taking so long.” Doctors believe that state regulations already do enough to protect consumers, Downs said, and that the proposed legislation is aimed more at protecting insurance companies. A spokeswoman for the hospital association said the association was not yet prepared to comment on the latest version of the legislation.
HOSPITAL ROUNDS
Nearly all N.J. hospitals face Medicare readmission penalties By Andrew George According to new data released this week by the federal government, every New Jersey hospital except for one will receive penalties for having too many Medicare patients readmitted within a month of being discharged. Data compiled by Kaiser Health News shows that 63 New Jersey hospitals, some 97 percent of all hospitals in the state, will be penalized for the 2016 fiscal year, with an average Medicare funding cut of 0.73 percent. No other state had a higher percentage of penalized hospitals. Several hospitals received exemptions from the assessed penalties. The results largely mirror those from the previous fiscal year, when 98 percent of all New Jersey hospitals received fines. The Bergen Regional Medical Center in Paramus was the only institution not to be penalized. However, several hospitals, including Livingston’s Saint Barnabas and the Morristown Medical Center, received minimal cuts such as 0.01 percent and 0.02 percent, respectively. Nationally, 54 percent of all hospitals face penalties, with an average cut of 0.61 percent. The program, now in its fourth year under the Affordable Care Act, is designed to incentivize hospitals to maintain a high quality of care and keep readmission rates down.
Saint Michael’s hospital files for Ch. 11; hopes move will hasten sale to Prime By Joshua Burd Saint Michael's Medical Center in Newark has filed for Chapter 11 bankruptcy protection, in a move that it hopes will expedite the long-awaited sale of the facility to Prime Healthcare. Executives announced the filing Monday, calling it “a prudent and necessary action to preserve the medical center’s financial viability and the jobs of more than 1,400 employees, as well as a continued choice of health care for the greater Newark community.” In a conference call, David A. Ricci, chief executive officer and president of Saint Michael’s, said, “We decided that, in order to move forward, we would use the federal courts to help us with telling the story in a very public way to get to a conclusion that we hope is the sale to Prime.” The 357-bed hospital said it has sufficient liquidity to remain fully operational during the reorganization process, and patients will see no disruption in services. Ricci emphasized during the conference call that the hospital has no plans to close or conduct mass layoffs, although it must legally acknowledge the possibility. The filing comes as Prime Healthcare, a for-profit operator, awaits state approval to acquire Saint Michael’s. The two entities since February 2013 have had an asset purchase agreement, which was recently amended to facilitate a sale to Prime. In a conference call, Ricci expressed frustration with the lengthy approval process. “Now, after two and a half years, it would appear that we’re no further than where we were when we started,” he said. “It’s very difficult to keep the organization’s morale and the commitment to the community going, and provide the kind of care that we would like with the shroud of uncertainty being cast over us.” Under the Chapter 11 filing, Prime would serve as the “stalking horse” bidder, setting the standard that would have to be exceeded by any rival bidders. August 2015
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Saint Michael’s officials said they were not aware of any other potential bidders at this time. “We recognize the urgency of completing this transaction with Saint Michael’s,” Luis Leon, president of operations for Prime Healthcare, said in a prepared statement. “We are hopeful that after hearing from the community and the employees at Saint Michael’s, and in light of this most recent development, the state will act quickly to approve the sale and preserve this vital Newark institution.” Meantime, Saint Michael’s has had to contend with the recommendations of a state-commissioned study, which found that it and two other Newark-area hospitals should cease to operate as an acute care facilities and instead be converted into modern ambulatory centers to relieve an oversupply of hospital beds. Saint Michael’s has come out against those findings. In Monday’s announcement, Saint Michael’s said it will file a series of motions with the court to ensure the continuation of normal operations including, but not limited to, meeting all employee payroll and benefit obligations, and maintaining physician privileges. The hospital said it had distributed so-called “WARN” notices — as required under for the federal Worker Adjustment and Retraining Notification Act — prior to the filing because a sale outcome is not guaranteed. "We have responded to the numerous rounds of questions submitted by New Jersey’s Department of Health,” Ricci said in a statement with the announcement. “We are asking for the Department of Health and the attorney general to act expeditiously to allow the sale of Saint Michael's to Prime Healthcare, so that Saint Michael’s, under the ownership of Prime, can emerge as a financially viable, strong institution, maintain jobs and continue to ensure healthcare choice for those we serve.” Cole Schotz P.C. is serving as Saint Michael’s legal adviser and EisnerAmper LLP as financial adviser.
Prime takeover of Saint Clare’s delayed until later in 2015 By Eric Strauss The for-profit Prime Healthcare Services chain's takeover of the Saint Clare's Health System has encountered a slight delay, the two parties said last week. In a news release, Prime and Catholic Health Initiatives — the owner of Saint Clare’s — said the transaction has closed, but will not be effective until late summer or early fall, rather than the earlier announced date of July 31. “Prime Healthcare looks forward to expanding its presence in the Garden State and partnering with the Saint Clare’s community of dedicated physicians, nurses and employees,” Dr. Prem Reddy, Prime’s chairman, chief executive officer and president, said in a prepared statement. “We are committed to providing the best quality care in each and every community we serve, and the addition of Saint Clare’s to the Prime Healthcare family will allow us to continue that tradition.”
Princeton Medicine group gets ‘Patient-Centered Medical Home’ designation By Eric Strauss Princeton Medicine, a group of health care practitioners in Mercer and Middlesex counties, announced recently that a team of its doctors and nurses has received Patient-Centered Medical Home status. The status, conveyed by the National Committee for Quality Assurance, covers 13 physicians and advanced practice nurses working at four of Princeton Medicine’s locations: Dayton, Monroe, Plainsboro and Princeton. Patient-centered medical homes are a new model of care that combines teamwork and information technology to improve care and patient experience, as well as reduce costs. Patient care is overseen by clinician-led teams that coordinate treatment across the practice or system. “There is a concept called the Triple Aim, which states that providers should pursue a three-part goal to increase patient satisfaction, improve health and reduce costs,” Dr. Tobe M. Fisch of Princeton Medicine, said in a prepared statement. “As an example, when we help people better manage a chronic condition, we can reduce hospitalizations. That avoids unnecessary expense and, even more importantly, our patients will be healthier and enjoy a better quality of life.” Princeton Medicine, which has about 70 practitioners in eight offices, is part of Princeton HealthCare System.
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N.J. health care organizations get $2M in funding through two programs By Eric Strauss A number of health care organizations in New Jersey are receiving an influx of cash, as two initiatives pump more than $2 million into the state to bolster treatment of so-called “vulnerable” populations. First, The Nicholson Foundation announced Tuesday that it is working with nine organizations on a nearly $1 million initiative aimed at bolstering health care innovation.
In addition, the U.S. Department of Health and Human Services awarded 18 organizations a total of just over $1 million to recognize their achievements in providing care. The Nicholson Foundation’s project, dubbed the New Jersey Innovation Catalyst Initiative, will help groups serving vulnerable populations improve how they deliver care to their constituents. The initiative will be led by the Center for Care Innovations, a California nonprofit that designs programs that transform the health care safety net, the foundation said in a news release. Participants in the initiative will receive training on patient-centered design techniques, an approach to care that solves problems while keeping the patient’s needs foremost in mind. It will focus on three areas: improving access to care, increasing patient engagement and addressing social factors in health. “Across the country, the rate of funding for health care innovation is growing rapidly,” Barbara Kang, senior health care program officer for the foundation, said in a statement. “However, funding for projects to improve care for vulnerable populations has been underrepresented in this upsurge. This initiative will help address this imbalance by injecting energy, renewed excitement and funding to stimulate a culture of health care innovation in New Jersey.” The nine groups chosen for the initiative after what the foundation called a “robust application process” include:
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CompleteCare Health Network;
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Henry J. Austin Health Center;
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Hospital Alliance of New Jersey;
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New Jersey Primary Care Association;
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Newark Beth Israel Medical Center;
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Robert Wood Johnson University Hospital;
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St. Joseph’s Regional Medical Center;
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Trinitas Regional Medical Center;
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Visiting Nurse Association Health Group Inc. August 2015
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The nine teams involved submitted challenges for which they hope to develop innovative solutions, such as vegetable prescription programs, group care sessions and the use of EMTs and paramedics in continuous contact with high-risk patients. “If we want to improve outcomes and reduce costs, organizations that care for vulnerable populations must be given the tools to take risks, think differently and be innovative as they seek to improve care delivery,” Joan Randell, chief operating officer of the foundation, said in a prepared statement.
Meanwhile, 18 health centers around the state received a combined $1.021 million in Affordable Care Act grant funding for providing high-quality care to vulnerable populations. They will be able to use the funds to grow their quality improvement systems and infrastructure, as well as improve primary care service delivery, the government said Tuesday in a news release. “Today’s funding rewards those health centers that are achieving the highest levels of clinical quality performance and improvement,” Jim Macrae, Health Resources and Services Administration acting administrator, said in a prepared statement. “The awards will help health centers continue to provide comprehensive primary care to the nation’s most vulnerable communities.” The 18 include:
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AtlantiCare Health Services Inc., $24,832;
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CAMcare Health Corporation, $77,380;
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Community Health Care Inc., $53,546;
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Horizon Health Center Inc., $72,066;
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Jewish Renaissance Medical Center, $16,591;
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Lakewood Resource and Referral Center Inc., $127,999;
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Metropolitan Family Health Network Inc., $15,652;
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Monmouth Family Health Center, $14,888;
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Newark Community Health Centers Inc., $103,357;
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City of Newark, $20,584;
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North Hudson Community Action Corporation, $174,469;
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Ocean Health Initiatives Inc., $38,383;
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Paterson Community Health Center Inc., $42,445;
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Project Hope, $20,409;
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Rutgers University, $36,698;
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Southern Jersey Family Medical Centers Inc., $79,016;
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Visiting Nurse Association of Central Jersey Community Health Center, $20,672;
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Zufall Health Center Inc., $82,919.
Nationwide, more than 1,150 health centers received more than $63.3 million in funding.
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