JULY 2013 2012 NOVEMBER Visit us now online at
www.NJPhysician.org
Health Republic Insurance of New Jersey
A Healthcare CO-OP Established Through the Affordable Care Act Partners with the Qualcare Network to Offer An Innovative Option on the NJ Health Insurance Marketplace Also In This Issue: Lawmakers Want to Stop Fee-For-Service Medicare Payments Survey Shows Many Physicians Do Not Know if They are in Exchange Plans The Good News: Medicaid Applications Are On the Rise, and State’s Website Has Been Flawless New Statin Advice to Lower Cholesterol is Challenged
Princeton Insurance knows New Jersey, with the longest continuous market presence of any company offering medical professional liability coverage in the state. Now a Medical Protective/Berkshire Hathaway company, Princeton Insurance offers even more resources, strength and innovation to those we insure. • Measured either by Gross Written Premium or by number of policyholders, Princeton Insurance is New Jersey’s leading healthcare malpractice insurer. • Serving New Jersey continuously since 1976 and the country since 1899 – the longest track record in the state, the oldest healthcare malpractice insurer in the nation • More than 57,000 New Jersey medical malpractice claims handled • Industry-leading financial strength, with a rating of A+ (Superior) from independent rating agency A.M. Best • Calls handled personally, specialized legal representation, knowledgeable independent agents, 24-hour new business premium quote • Unmatched ability to innovate, create, develop and support new products
Publisher’s Letter Dear Readers,
Published by
Welcome to the November issue of New Jersey Physician. We are currently reaching over 30,000 physicians across the state and our readership continues to grow each month. Thank you for your support.
Montdor Medical Media, LLC
For the past two months, we have continually heard the providers and public discuss two things: the ACA and Medicare reimbursement. Will the ACA website get up to speed, and will the Medicare reimbursement schedule finally be solved with a long term plan, instead of it threatening physicians until the last moment before the cuts are rescinded? Your feedback on these matters is very welcome.
Co-Publisher and Managing Editors Iris and Michael Goldberg
Contributing Writers Iris Goldberg Michael Goldberg Andrew Kitchenman James Rowley
The cancellation of insurance policies that do not meet the requirements of the ACA has been pulled back for one year. Just how important this matter is, seems to be just more of the same political noise distracting people from what is important. Whether people will be better served keeping their current plans or switching to plans offered through the new federal health insurance marketplace can vary depending on the circumstances of each individual or family.
Virgil Dickson
How Medicare pays doctors is being actively debated. The U.S. House Ways and Means and the Senate Finance Committees want to phase out our current system. In order to convince physicians to go along with changes, they are proposing to eliminate the yearly threat of reduced reimbursement along with financial incentives. Doctors would be encouraged to use shared-savings programs and to bundle medical services through a single team. Doctors would get a 5% bonus each year from 2016 through 2021 if a “significant share of their revenues” comes from these alternatives. Other options being discussed include capping Medicaid spending and raising the age for Medicare.
Mark Manigan
Some good news: In New Jersey, Medicaid applications are on the rise, and the state website is functioning flawlessly.
Tel: 973.994.0068
This month we are offering something different than our usual practice profile as our feature story. Health Republic Insurance of New Jersey, a healthcare CO-OP established through the ACA and partnering with the Qualcare Network offers an innovative option to those seeking to take advantage of the federal program. This non-profit Consumer Operated and Oriented Plan joins a total of 23 other CO-OPs nationally that have been awarded loans through the ACA. Competing with two established insurers on the marketplace, HRINJ’s mission is to offer cost-effective, comprehensive healthcare coverage to individuals and small businesses throughout the state. It’s partnership with Qualcare ensures that HRINJ will be up and running on Day One. With warm regards,
Michael Goldberg
Maureen McKinney Joseph M. Gorrell Debra C. Lienhardt Keith J. Roberts Kevin M. Lastorino John D. Fanburg
Dan Goldberg Dan Ivers
Layout and Design - Nick Justus
New Jersey Physician is published monthly by Montdor Medical Media, LLC., PO Box 257 Livingston NJ 07039
F ax: 973.994.2063 For Information on Advertising in New Jersey Physician, please contact Iris Goldberg at 973.994.0068 or at igoldberg@NJPhysician.org Send Press Releases and all other information related to this publication to igoldberg@NJPhysician.org Although every precaution is taken to ensure accuracy of published materials, New Jersey Physician cannot be held responsible for opinions expressed or facts supplied by its authors. All rights reserved, Reproduction in whole or in part without written permission is prohibited. No part of this publication may be reproduced or transmitted in any form or by any means without the written permission from Montdor Medical Media. Copyright 2010.
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Co-Publisher
New Jersey Physician magazine is an independent
New Jersey Physician Magazine
publication for the medical community of our state and is not a publication of NJ Physicians Association
Contents
Health Republic Insurance of New Jersey
HRINJ
4
A Healthcare CO-OP Established Through the Affordable Care Act Partners with the Qualcare Network to Offer An Innovative Option on the NJ Health Insurance Marketplace On the Cover:
The HRINJ Executive Team, From left, Joel VandeVusse, CFO, Cynthia Jay, Director of Marketing and Strategic Outreach, James A. Martin, Executive Director, Catherine Ann Sauner, COO, and Gregory Muller, CIO
CONTENTS
9 11 12
Insurers Weigh Whether to Rescind Cancellations As Obama Eases Restrictions Medicare Reimbursement Medicare
17
Medical News
18
Statehouse
19
The Good News
20
New Statin Advice To Lower Cholesterol Is Challenged
13
Affordable Care Act
14
Health Law Update
22
Practice News
16
ACOs
22
Insurance Fraud
2 New Jersey Physician
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www.Bollinger.com/pro Coverage is subject to meeting eligibility requirements and company approval.
Cover Story
Health Republic Insurance of New Jersey
A Healthcare CO-OP Established Through the Affordable Care Act Partners with the Qualcare Network to Offer An Innovative Option on the NJ Health Insurance Marketplace photography by Michael Goldberg
By Iris Goldberg Despite problems with the federal government’s website that have delayed an on-schedule (Oct.1st) enrollment process for millions of uninsured Americans, including about 900,000 eligible New Jerseyans, the Affordable Care Act (ACA) is a reality with the difficulties to be eliminated by mid to late November, according to current projections. Here in our state, those shopping on the health insurance marketplace can choose from three different options to determine the company and plan most suitable for their particular situation. Of the three providers, Health Republic Insurance of New Jersey (HRINJ), established through the ACA, is the only non-profit Consumer Operated and Oriented Plan (CO-OP). The concept of starting an insurance CO-OP in New Jersey was originally suggested by the
Freelancers Union of New York, which assisted with the application for funding. Receiving $107 million in federal loans, HRINJ joins a total of 23 CO-OPs, nationally, that have been awarded loans through the ACA. Each will be governed by consumer-led Boards of Directors. In fact, 51% of the HIRNJ board will consist of plan members. Most notably, as a non-profit insurer, HRINJ does not have private shareholders amongst which surplus revenues will be distributed. Instead, those will be reserved to possibly reduce premiums, improve benefits and fund innovative programs that provide the highest quality of care. As the “new kid on the block,” and up against two well-established commercial companies (AmeriHealth NJ and Horizon Blue Cross Blue Shield
of New Jersey), HRINJ’s mission is to offer cost-effective, comprehensive healthcare coverage to individuals and small businesses throughout the state with innovative plans that will serve as attractive alternative options. For example, HRINJ plan choices will prioritize enhancing patient engagement by encouraging members to actively participate in their care through a “whole person” approach. This is demonstrated by health plan designs that promote preventive care and wellness. Also special programs have been implemented for controlling chronic health conditions such as hypertension and diabetes and to manage serious illnesses. Further, it is the goal of HIRNJ to target individuals and small businesses that have thus far been overlooked by the more traditional providers.
The HRINJ staff takes a moment to gather together for a photo.
4 New Jersey Physician
Executive Director, James A. Martin shares his excitement about the opportunity to come to HRINJ and guide the process of starting a health insurance CO-OP in New Jersey. As both a provider and manager of healthcare services during the course of his impressive career, Mr. Martin has served a diverse number of populations, each with unique needs. He brings his significant experience within the healthcare arena, specifically in all aspects of the delivery side of health services, to join with those on the HRINJ start-up team who are experts within the health insurance arena. His mission, as he explains it, is to integrate the two sides with the goal of advocating for yet another population, comprised of the working uninsured.
Executive Director James A. Martin
Fig. 1
HRINJ Hospital Network 1
Saint Clare’s Health System
2
Saint Clare’s Hospital - Denville Saint Clare’s Hospital - Dover
St.Joseph’s Healthcare System
4
HackensackUMC
8
Hackettstown Regional Medical Center *
5
HackensackUMC Moutainside
Bergen Regiona l Medical Center
9
12 C h i l t o n H o s p i t a l
13 S t . M a r y ’ s H o s p i t a l
2
8
MORRIS
Rahway
14
HUNTERDON
28
29 28
SOMERSET 20
Capital Health Regional Medical Center Capital Health Medical Center - Hopewell Campus 22
33
30
Toms River
3 37
32 Cooper University Hospital*
37
32 38
BURLINGTON
37 34
38
CAMDEN
GLOUCESTER
Morristown Medical Center * Overlook Medical Center Newton Medical Center
31 Raritan Bay Medical Center
40
Perth Amboy
3
Old Bridge
33 Meridian Health Jersey Shore University Medical Center* Southern Ocean Medical Center Bayshore Community Hospital Riverview Medical Center Ocean Medical Center
28 38
33
SALEM
42
35 Shore Medical Center
ATLANTIC 34
35
42
37 Virtua
CUMBERLAND
Kennedy University Hospital - Stratford Kennedy University Hospital - Cherry Hill Kennedy University Hospital - Washington Township
27 A t l a n t i c H e a l t h S y s t e m
29 J F K M e d i c a l C e n t e r
34
36
Medical Center
33
OCEAN
37
34 Inspira Health Network
Health System
25 Englewood Hospital & 33
33
MONMOUTH
24 24
21 East Orange General Hospital
23 Trinitas Regional Medical Center
3
MERCER 20
30 CentraState Medical Center
38 Kennedy
39
26
28 Children’s Specialized Hospital
Hospital of Salem County
31
Center
N
O DS HU
31
41
MIDDLESEX
26 Saint Peter’s University Hospital*
36 The Memorial
23
15 17
UNION
18
16
24 Capital Health System
Inspira Medical Center Woodbury Inspira Medical Center Vineland Inspira Medical Center Elmer
21
20
of Princeton at Plainsboro
New Brunswick
3
3 27
11
Jersey City Medical Center
25
19 Saint Michael’s Medical
ESSEX19 27
22 University Medical Center
10
3
5
17 LibertyHealth
6
BERGEN
2
1
University Hospital
4
9
13
1
WARREN
20 Robert Wood Johnson Hamilton
7
PASSAIC
12
18 Somerset Medical Center
Berlin 43
Marlton
Voorhees
Memorial
39 T h e U n i v e r s i t y H o s p i t a l
CAPE MAY
40 Deborah Heart and Lung Center
41 T h e C a n c e r I n s t i t u t e o f N J 43 C a p e R e g i o n a l M e d i c a l C e n t e r
42 AtlantiCare Regional Medical Center City Division
10 Holy Name Medical Center
15 Palisades Medical Center
27
SUSSEX
16 Hunterdon Medical Center
Mountainside
7 The Valley Hospital
Manhatten
14 St. Luke’s Warren Hospital
New Brunswick*
Saint Barnabas Medical Center Clara Maass Medical Center Newark Beth Israel Medical Center * Kimball Medical Center Monmouth Medical Center Community Medical Center
Hackensack Pascack Valley
6
11 Memorial Sloan-Kettering Cancer Center Basking Ridge
Barnabas Health
3
St. Joseph’s Regional Medical Center * St. Joseph’s Wayne Hospital
Mainland Division
* Designated NJDSS children’s specialty acute care hospital.
**Our Lady of Lourdes Medical Center contracted for inclusion 2014. QC07-13
Ensuring that it will “hit the ground running” come January, HRINJ has partnered with QualCare, one of New Jersey’s leading healthcare coverage providers. Being linked with QualCare’s already-existing, impressive provider network and operating systems in place saves significant time and expense for HRINJ, which translates into lower costs. This is also good news for the more than 25,000 physicians and virtually all of the major hospital systems throughout the state in the QualCare provider network that will now serve HRINJ members as well. Of course, HRINJ enrollees are the greatest beneficiaries, having access to a comprehensive and far-reaching range of highly- skilled specialists and premier healthcare facilities statewide (see Fig.1).
OUT OF STATE REGIONS ON BACK PAGE NEW YORK
PENNSYLVANIA
“We firmly believe there is a need to insure the entire population,” Mr. Martin states. “We are targeting the individual population of those who are working and do not have insurance through their employer. It is our hope, through our engagement within the community, to create awareness about the value of this product. The whole focus of this is to help people see that having insurance is an opportunity to improve their health,” he emphasizes, referring to the many in our society who ignore important health issues because they lack coverage. “Our job is to demonstrate to our members that we will have affordable costs and better access to care – thus the expansive QualCare network,” Mr. Martin continues. “Also as a not-forprofit and as a CO-OP, our consumer members will actually be voting on
DELAWARE how the proceeds from the product’s sale will be utilized. So those things that are valued by the members to improve wellness are what we will be investing in,” he relates. “My hope is not only to grow an insurance company but that the insurance company will be the vehicle for improving the health of the community.”
Cynthia Jay is HRINJ’s Director of Marketing and Strategic Outreach. Ms. Jay has amassed experience in managed care, the pharmaceutical and biotech industries, a diagnostic laboratory and a health promotion institute, providing her with an understanding of both business principles and non-profit ideals. She discusses a major difference between HRINJ and its competitors. “We’re the only carrier that gives full network coverage to any kind of plan November 2013
5
an individual buys. We’re not tiered,” Ms. Jay informs. “So, for example, all 68 hospitals in New Jersey in the QualCare network are approved for all of our members to use.” she adds. “We’re the only carrier that gives full network coverage to any kind of plan an individual buys. We’re not tiered,” Ms. Jay informs. “So, for example, all 68 hospitals in New Jersey in the QualCare network are approved for all of our members to use.” she adds. Essential Benefits coverage for all HRINJ members will also include:
Jersey shopper who has become more knowledgeable by carefully investigating each plan and comparing costs as they apply in her particular case. She is not choosing the least expensive plan amongst the three because she learned that a plan offered by HRINJ with a higher premium covers a drug she takes daily for only $30 each month. The plan with the lowest premium requires her to meet a deductible first and then would cover only half of the $300 monthly cost. Therefore, the cheapest plan is not necessarily the most affordable.
• Ambulatory patient services, such as doctor visits and outpatient services
“It’s also important for physicians and their office administrators to know that come 2016, those folks that have bought our plans may be on the Board of Directors and will be helping to guide what those plans are going to look like in the future,” informs Ms. Sauner. Perhaps having input from members will serve to eliminate some of the frustrating encounters experienced by office staff members when trying to intercede with the insurance company on behalf of patients.
• Emergency services and hospitalization • Preventive and wellness services • Chronic disease management • Maternity and newborn care • Pediatric services, including oral and vision care • Mental health and substance abuse services, including behavioral health treatment • Rehabilitative devices
services
and
• Prescription drugs and laboratory services Additionally, Ms. Jay points out the importance of educating insurance shoppers about hidden costs so that they look beyond the price of the premium in order to ascertain the real affordability of each of the plans offered on the marketplace. This is discussed in an article that appeared in the Star Ledger on October 27th, where the author reveals that many people shopping on the marketplace, especially those who are purchasing health insurance for the first time may not fully understand their options: “Most people shopping on the online marketplace created by the Affordable Care Act are likely to look first at what they must spend each month, but there is so much more than premiums to consider when picking a plan from the marketplace, insurance experts warn.” To exemplify this point, the article shares the situation of one New
6 New Jersey Physician
“From the perspective of the providers, we want them to know that we are going to be very innovative and also extremely member and patient-centered. We are going to be reaching out, proactively, from the get-go, to make sure that new members understand the plan they bought,” Ms. Sauner assures. She goes on to explain that especially for those that might not have purchased healthcare services in the past, it is crucial for those members to be guided through all of the terminology and processes in order for them to not only understand but to properly utilize the services they are entitled to.
Joiel Ray-Alexander, HRINJ Membership and Outreach Associate with Daniel Rivera, Jersey City Councilman at Large HRINJ COO, Catherine Ann Sauner, with more than 20 years of experience in health insurance and managed care, takes this point even further. “I have noticed that our competitors on the marketplace have offered less costly plans but with a tiered network,” Ms. Sauner shares. This refers, for example, to making it more cost-effective for a patient to go a preferred hospital within the tiered network, rather than allowing that patient to choose the best hospital for his or her particular needs without additional out-ofpocket expense. Patients who choose HRINJ will have access to the entire QualCare network of hospital providers as is shown in Fig. 1, without any subsequent financial outlay. Again, a lower premium does not translate to a less costly plan over-all, when patients’ choices are restricted.
Ms. Sauner makes a point of mentioning the collaborative effort HRINJ shares with QualCare in terms of prioritizing the initiative to have physicians who are contracted and insured members working towards perpetuating patient wellness. “Our focus is not just about delivering healthcare services when you are sick. That’s part of it but it’s really making sure that the physicians and all the patients we cover are fully engaged and accountable and responsible for that whole member,” she emphatically states. This is a significant goal embraced by the Affordable Care Act as well and if realized, will dramatically reduce healthcare costs associated with treating conditions such as the epidemic of obesity and resulting diabetes and other debilitating complications. Tapping into those processes, policies and procedures that already exist at QualCare gives HRINJ a distinct advantage as a newcomer, especially from the perspective of physicians, as Ms. Sauner explains. Instead of having to adjust to the administrative organization of a new health insurer making its arrival on to the New Jersey healthcare arena, physicians are
familiar with the operating systems in place at QualCare. Further, QualCare’s impressive reputation for its efficient claims management and exemplary customer service, make it an ideal partner for HRINJ.
Qualcare CEO Annette Catino Annette Catino has been Qualcare’s CEO since its inception. She views the partnership with HRINJ as an exciting opportunity to include a segment of the population that has been under-served by providing the CO-OP with the tools
and QualCare’s significant expertise in administering health plans in order to facilitate a successful outcome. “For example, they didn’t have a network of providers in place that are contracted at extremely competitive rates,” Ms. Catino offers. “They also needed help in organizing the customer service component of running a health plan – how to be set up to answer the questions people have when they call. And they had to build in the care management tools to coordinate care, so that the overall costs of healthcare can be managed,” she adds. “So those are the tools that we brought to the table as well as helping them talk to their actuaries so that they could price and design their products in such a way that they could efficiently be administered and also meet the needs of the people who are out in the marketplace.”
for HRINJ to get to where it will start off come January 1st.
Vice President Insurance Operations at QualCare, Dawn L. Wright, points to perhaps, the most obvious advantage QualCare supplies for the HRINJ startup. “They can turn the key on Day One and have a product that is up and running,” she says. Both she and Ms. Catino agree that building from scratch, would take at least three years
“We have all the systems in place,” mentions Ms. Catino, alluding to everything from QualCare’s state-ofthe-art administrative hardware and software to a QualCare website filled with important health and wellness tools and information for members that can be accessed from the HRINJ website (see Fig. 2). “We’ve been
The Qualcare team, from left, Mary Kay Breitenbach, Senior Account Executive, John McSorley, CFO Qualcare Corp., and Dawn L. Wright, Vice President Insurance Operations
HRINJ
Fig. 2
EXPEDIENT CLAIMS MANAGEMENT
PATIENT INFORMATION TOOLS TO FOCUS ON HEALTH AND WELLNESS QUALCARE MULTI-LAYERED WEBSITE
MEMBER AND PROVIDER CALLS EXPERTLY HANDLED FROM
STATE-OF-THE-ART ADMINISTRATIVE HARDWARE AND SOFTWARE
EXPANSIVE NON-TIERED HOSPITAL NETWORK
HIGHLY-TRAINED CUSTOMER SERVICE TEAM
HMO NETWORK OF 25,000+ PHYSICIAN PROVIDERS
STATEWIDE NETWORK OF PHYSICIANS
68 HOSPITALS STATEWIDE
COST-EFFECTIVE, COMPREHENSIVE HEALTHCARE COVERAGE FOR INDIVIDUALS AND SMALL GROUPS
DAY ONE
November 2013
7
building all of this over years, adding and improving every year,” Ms. Catino points out. “Start-ups usually can’t have all of the toots and whistles in place for their membership that we are providing.” Also, offering enrollees QualCare’s full, comprehensive HMO network from the start distinguishes HRINJ from its competitors, who are arriving on the marketplace with networks that are narrower. As Ms. Wright shares, “I think the HRINJ plan will be the one that comes across as really offering the most bang for the buck.” This is a plus for the new members, of course but as Ms. Catino and Ms. Wright share, providers will benefit as well. “The message we want to send to our providers is that partnering with HRINJ gives us a product on the marketplace for the individual market that QualCare never had,” informs Ms. Catino. “This not only generates a new population of patients but providers can trust that and have confidence that we will pay them on a timely basis and as always, ensure they are treated fairly,” she states. In fact, all electronic claims submissions will be handled from the first day of HRINJ’s operation through access to QualCare’s portal. This is important for timely payment to providers and also saves the CO-OP substantial administrative costs, allowing more profits for reinvestment to improve benefits, lower premiums and fund wellness programs. Another key member of the HRINJ start-up team is CFO Joel VandeVusse. Mr. VandeVusse emphasizes the importance of having a third choice on the New Jersey marketplace. “We believe that the state will benefit from having more competition. Consumers will benefit and providers will benefit,” he confidently remarks. Mr. VandeVusse goes on to share his strong belief that providers and hospitals, especially, have become quite accustomed to the exemplary service associated with the QualCare name and can certainly expect the same from HRINJ. “We are not a national player who will come and go from New Jersey, depending upon the weather,” Mr. VandeVusse states. “We
8 New Jersey Physician
Zena Nelson, Exchange Manager and Adrian Sidarev, Vendor Relations Manager for HRINJ are here for the duration to really try to have a positive impact on the New Jersey healthcare marketplace. And we believe we will only be successful by working in partnership, not only with our members but also with the provider community,” he continues. “The future of healthcare is really about health insurers and providers finding new ways to work together in partnership,” Mr. VandeVusse offers. “And that’s what we believe here at Health Republic Insurance of New Jersey.” From a financial perspective, Mr. VandeVusse reiterates the value consumers will be getting by enrolling in HRINJ once co-pays, co-insurance, networks and pharmaceutical costs are factored in. “I think when consumers make those close comparisons, they will see that there really is a lot of value to our plans, which is a big part of our mission to provide,” he states. “And because we are ultimately a membergoverned plan, we will need to be very responsive to our membership in our pricing and also our plan design,” assures Mr. VandeVusse. Gregory Muller is HRINJ’s Chief Information Officer. He is confident that the problems currently associated with the government website, although challenging, will eventually be adequately rectified and the three plans on the New Jersey marketplace will be enrolling members who are eligible for government subsidies as well as those who are not, as is required by the ACA. As an I.T. specialist, Mr. Muller wants providers to know that HRINJ will be focused on tracking the quality
of patient care. “I.T. doesn’t provide better healthcare,” Mr. Muller asserts, “but it does tell you more about the healthcare that is being provided.” He refers to giving feedback to physicians on their own costs for treating patients and the overall productivity in their offices. “So one of our goals is to help doctors better understand their own businesses,” Mr. Muller shares. “In fact, we’re going to be working on providing feedback to everyone involved, including members,” he adds. “It’s the primary care physician, the specialist, the pharmaceuticals prescribed, all of these things all tie together and I think one of the original concepts of the Affordable Care Act is to set up more communication amongst these providers and services about each individual patient,” Mr. Muller explains. “This can and will be done in a secure and private manner,” he maintains. “And if done properly we can really bring down costs without sacrificing high quality patient care. This is definitely one of our top priorities.” In the months to come we will all be keeping a watchful eye on developments, cautiously optimistic that millions of Americans who do not presently have healthcare insurance will be able to shop and purchase affordable coverage to become active as of January, 2014. Here, in New Jersey, the insurance marketplace offers three choices. Although it is up against two established and formidable commercial competitors, a newly-formed CO-OP Health Republic Insurance of New Jersey, may be just what the doctor ordered.
For more information, please visit www.newjersey.healthrepublic.us
Insurers Weigh Whether to Rescind Cancellations As Obama Eases Restrictions Andrew Kitchenman
NJ coverage providers scramble to determine whether and if they will rescind cancellation notices The options that New Jersey residents who buy their own insurance will have next year may have expanded yesterday, when President Barack Obama announced that current individual health plans wouldn’t have to meet new federal regulations in 2014. Whether these people will be better served keeping their current plans or switching to plans offered through the new federal health insurance marketplace, also known as the exchange, can vary depending on the circumstances of each individual or family. It’s not yet clear whether insurers in New Jersey, in light of Obama’s announcement, will reconsider their decisions to discontinue a number of their current individual plans next year or whether state regulators would permit them to rescind those decisions. In addition, it’s not clear how continuing to offer these plans would affect their premiums, as well as the premiums of the new marketplace plans. The insurers that offer individual and family plans this year and through the marketplace –- AmeriHealth New Jersey and Horizon Blue Cross Blue Shield of New Jersey -- had decided against seeking to “grandfather” their plans from new ACA regulations. This led to thousands of New Jersey individual insurance customers receiving notices that they must enroll in new plans. This became part of a national outcry as doubt was cast on Obama’s statements that people who liked their current insurance would be able to keep those plans. The president responded yesterday by saying that no ACA regulations would apply in 2014 to any existing plans for current customers of those plans. Horizon spokesman Thomas Vincz said company officials have to evaluate how the company could offer current plans next year “in such a short period of time,” while AmeriHealth spokeswoman Jill Roman said company officials were “moving quickly” to understand the implications of Obama’s announcement and working with state officials to determine the “the most prudent way to assure that our customers have health care coverage and affordable options. We want to make this as easy as possible for our customers.” State Department of Banking and Insurance spokesman Marshall McKnight said the department was reviewing information that the federal Centers for Medicare and Medicaid Services provided regarding Obama’s announcement yesterday. National insurance industry representatives responded to Obama’s announcement by cautioning that allowing young, healthy people to keep their current individual insurance plans would lead to higher premiums for the remaining consumers in the marketplace. Federal officials responded by saying they would make regulatory changes to offset the impact on premiums. The open enrollment period for marketplace insurance, which began on October 1 and will last until March 31, 2014, has been hobbled so far by the technical flaws of its website, healthcare.gov. While federal officials have said that the marketplace website’s performance is improving, federal data released on Wednesday for the exchange’s first month showed exactly how slow enrollment in New Jersey has gone. Only 741 New Jersey residents enrolled in health plans through November 2, which is just over one-tenth of 1 percent of the estimated 628,000 residents eligible for insurance through the marketplace. While there is much uncertainty about the next step for insurers, what is becoming clearer is how current insurance customers would be affected by the changes that were in place before Obama’s announcement. A comparison of the plans that are currently offered with those that are being offered through the marketplace shows that many people would receive both more extensive benefits and lower costs in the form of premiums and out-of-pocket expenses. However some people , such as young men, would see substantially higher premiums. One example is provided in the changes occurring for customers of AmeriHealth, which is one of three companies selling individual and family health insurance through the marketplace, along with Horizon and Health Republic Insurance of New Jersey. Insurance offered through the marketplace will begin on January 1, 2014. The difference in costs is stark between young men and women for the most popular current individual plan and the most similar plan in the marketplace. A 27-year-old man currently pays $218 per month for an individual plan that requires $30 copayments for visits to primary care doctors, while a plan with the same copayments through the marketplace would cost $379 per month. But a woman of the same age would benefit from a provision of the 2010 Affordable Care Act that prohibits using a person’s sex to November 2013
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determine premium rates. A 27-year-old would currently pay $476 per month but would pay the same $379 rate as a man in 2014. Both sets of plans require patients to pay $100 for emergency room visits and the plans all offer similar networks of healthcare providers from which patients can choose. But the differences between the current and future plans are extensive, and premiums describe only a small part of those differences. There are some advantages to the current plan. For example, visits to specialists have $30 copayments, compared with $50 copayments in the new plan. But overwhelmingly, the benefits are more extensive in the marketplace plans due to the ACA’s requirements. For example, the most popular current plan does not cover prescription drugs, ambulance fees, chemotherapy, durable medical equipment, chiropractic care and hospice care, while the most similar marketplace plan does provide at least some coverage for these services. In addition, the most popular current plans limit insurance payments for specialists to $700 annually – or roughly 23 visits. There is no similar limit for plans under the ACA. The difference between the amounts paid for hospital stays would depend on how many hospitalizations a patient requires. Patients in the most popular current plan pay a $500 copayment per hospital stay, while patients in the most similar marketplace plan must pay a deductible of $1,500 for hospital fees, then 30 percent of additional healthcare costs until they reach an annual maximum out-of-pocket expense of $2,500. There is no maximum on annual expenses under the current plan. Another difference regards how pre-existing conditions are handled. Under the most popular current plan, patients who have had a break in their insurance coverage have to wait a year before the insurer will pay for treatment of pre-existing conditions, while treatment of pre-existing conditions is paid for under the marketplace plans. “It’s hard to draw a direct comparison between these, because they’re so vastly different, but it’s fair to say that you’re getting more coverage,” said Mike Munoz, AmeriHealth’s senior vice president of sales and marketing. Munoz also noted that the company is offering new sets of plans that offer lower premiums and more limited networks of providers than existing plans. These include plans that offer less expensive care at “Tier 1” hospitals and at Cooper University Health Care-affiliated providers. For AmeriHealth, the design of the marketplace plans was “a matter or providing options and multiple price points and that’s what we’ve tried to do,” Munoz said. Consumers who select more limited local networks will pay 10 percent less than customers that choose the most extensive AmeriHealth plan, while those that choose a plan with only Tier 1 hospitals will pay 18 percent less and those who choose the Cooper plan will pay 20 percent less. Obama said yesterday that when he said people would be able to keep their plans, he expected they would be covered by plans “grandfathered” by insurers. He also said that he expects more people who currently would prefer to keep their current plans to eventually see the value of the marketplace plans, as they seek medical care and protections provided by the ACA.
10 New Jersey Physician
Medicare Reimbursment
Lawmakers Want to Stop Fee-for-Service Medicare Payments
By James Rowley
The chairmen of the U.S. House Ways and Means and the Senate Finance committees want to phase out the way Medicare pays doctors for their services. They’re proposing a gradual change to a new system along with a pay freeze and incentives to give up fee-for-service billing. “Enough with the quick fixes. Our proposal is for a new physician payment system that rewards value over volume,” Senator Max Baucus of Montana said in a statement. “It will go a long way in improving the efficiency and quality of care for America’s seniors.” The proposal by Democrat Baucus and his Republican counterpart, Representative Dave Camp of Michigan, would freeze physician payment rates for 10 years and give doctors bonuses for agreeing to accept certain percentages of Medicare revenue through the alternative payment methods. Doctors would be encouraged to use shared-savings programs and to bundle medical services through a single team, Bloomberg BNA reported. Doctors would get a 5 percent bonus each year from 2016 through 2021 if “a significant share of their revenues” comes from these alternatives, according to a discussion draft distributed by the committees. After 2023, doctors who opt for alternative payment systems would get a 2 percent increase in reimbursement each year, according to the draft. Doctors who opt to continue to be paid according to Medicare’s fee-for-service system would get a 1 percent annual increase in reimbursement. Seeking Value “It’s looking for better value, less emphasis on volume, more emphasis on quality, which is good,” Senator Jay Rockefeller, a West Virginia Democrat, said after a Senate briefing on the Baucus-Camp plan. The chairmen have asked medical groups to provide their comments on the proposal by Nov. 12, according to the Bloomberg BNA report. Coming after partisan disagreements so great that the U.S. government was partially shut down earlier this month, the cross-party cooperation by the two chairmen increases the prospects of the plan’s success. Their goal is to replace the Sustainable Growth Rate (SGR), a formula enacted as part of the Balanced Budget Act of 1997 to curb the growth in health-care costs. That formula has led Congress to vote each year since 2003 -- and sometimes more than annually -- on a “doc fix” that has prevented decreases in Medicare’s physician reimbursements, which would discourage doctors from participation. Medicare is the government’s health-care program for people 65 and older and for people under 65 with certain disabilities. No Freeze Earlier this year, a different House committee put together its own proposal for breaking the “doc fix” cycle. Instead of freezing payments, that legislation, H.R. 2810, would allow annual increases of 0.5 percent over five years, according to the Bloomberg BNA report. The Congressional Budget Office estimated in February that it would cost $138 billion in the next 10 years to keep reimbursement rates at the current level. Lower health-care costs have reduced the agency’s 10-year estimate, which was $245 billion last year -- one reason that permanently fixing the formula has become more popular. Under the SGR, Medicare’s reimbursements for medical care are scheduled to be reduced by more than 24 percent on Jan. 1, 2014, according to the Department of Health and Human Services. There were 215,919 primary-care physicians in the U.S. treating Medicare fee-for-service patients in 2012, according to the Centers for Medicare and Medicaid Services, which is part of HHS. The average primary-care physician got about 25 percent of his or her revenue from Medicare patients in 2012, according to the American Academy of Family Physicians. Camp and Baucus aren’t including in their proposal any additional mechanism to offset additional government costs, lawmakers said.
Visit us now online at
www.NJPhysician.org November 2013
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Medicare
Capping Medicaid spending, raising age for Medicare among options explored in CBO report By Virgil Dickson Capping federal Medicaid spending, raising the eligibility age for Medicare, and bundling Medicare payments to healthcare providers are some of the federal spending reduction possibilities included in a report by the Congressional Budget Office (PDF) released Wednesday. The release of the 316-page document came the same day the joint House and Senate budget conference committee resumed deliberations on fiscal issues with the goal of reaching a broader agreement on spending and taxes to avoid another government shutdown and threat of debt default. The report was unsolicited by Congress and is meant to inform lawmakers about the budgetary implications of various ways to reduce spending or increase revenues, the budgeting agency said. Non-healthcare related proposals included reducing social security benefits for new beneficiaries by 15%, increasing federal insurance premiums for private pension plans, and reducing or eliminating subsidized loans for undergraduate students. The government is currently operating under legislation that provides funding until Jan. 15 and suspends the borrowing limit until Feb. 7. CBO Director Douglas Elmendorf testified at the panel and said the report could help lawmakers during their budget deliberations. The option to cap federal Medicaid contributions to the states comes as federal spending on the program has risen at an average rate of about 6% a year for the last two decades because of general growth in healthcare costs, mandatory and optional expansions of program eligibility and covered services and states' efforts to increase federal payments for the program. Last year, the federal government sent $251 billion in Medicaid funding to the states, according to the CBO. The annual rate of spending growth is expected to increase to 8% per year as states expand Medicaid coverage to adults with incomes up to 138% of the federal poverty level as part of the Patient Protection and Affordable Care Act.
The CBO report offers several approaches for capping federal contributions. One is to give states fixed block grants that generally would not increase if states' costs rose or decrease if states' costs fell. Another is to base caps on average federal spending per enrollee for each of the four principal categories of those eligible for Medicaid: the elderly, the blind or disabled, children and poor nonelderly, nondisabled adults. The government could determine the spending limit for each category by counting the number of enrollees in a category and multiplying it by the specified per-enrollee spending amount for that category. A Medicaid spending cap could save $280 billion to $610 billion between 2016 and 2023, depending on various implementation factors, according to the CBO. The risk is that states would have to make up the shortfall if their Medicaid programs experienced cost growth beyond the spending cap, or else they would have to cut eligibility, benefits, or provider payments, the CBO said. For Medicare, Congress could consider bundling payments to healthcare providers. This would mean one payment for all or most of the services that patients receive from various providers related to a particular disease or incident. The CBO estimated that Medicare spent more than $170 billion in fiscal 2013 on services provided during a hospital stay or within 90 days of discharge. That's half of all nondrug spending in Medicare's fee-for-service program. The CBO acknowledged that it's difficult to predict how bundling would affect providers. But it presented the possibility of hospitals and physicians collaborating to reduce costs by consolidating purchases of medical devices or other equipment and seeking volume discounts from their manufacturers. Or they could reduce the quantity and intensity of post-acute care that their patients received and economize on the use of physicians' services during a hospital stay. Raising the Medicare eligibility age from 65 to 67 would reduce the federal budget deficit by a total of $19 billion between 2016 and 2023—far less in savings than previously projected by the CBO due to the slowdown in Medicare spending growth. The CBO acknowledged that raising the eligibility age would shift costs from Medicare to beneficiaries, employers and Medicaid, and could leave many people in that age group uninsured.
12 New Jersey Physician
Affordable Care Act
AFFORDABLE CARE ACT Many Physicians do not know if they are in exchange plans, survey shows
By Maureen McKinney Physicians in New York, Texas and other states are scratching their heads about whether they are actually participating in the health plans offered on their state's insurance exchange and if so, how much they can expect to be paid for providing care. A recent survey by the Medical Society of the State of New York (PDF) found that one-third of responding physicians did not know if they were included in an exchange plan. Two-thirds said they had not received information about payment, said Moe Auster, the society's vice president of legislative and regulatory affairs, and the survey's creator. The confusion comes as many are expressing concern about the narrowness of many exchange-plan networks and the potential exclusion of many hospitals and physicians from the plans. “Many physicians don't know if an insurance carrier has included them in plans or not,” said Lee Spangler, vice president of medical economics at the Texas Medical Association, which has pushed for major changes in the Patient Protection and Affordable Care Act. He said the association was regularly fielding calls from physicians trying to determine their plan participation. Contracts between physicians and insurers often contain an all-products clause, which requires a provider to participate in all of the plans an insurer offers unless the insurer decides to exclude the provider. Many Texas physicians operating under such agreements have been left scrambling, Spangler said. “Some are trying to do provider searches,” he said, referring to the online search tools featured on many insurers' websites. “We tell physicians which carriers are operating in their counties and we encourage them to contact those companies themselves.” Nearly three-quarters of Texas's 254 counties have only one or two insurers offering plans on the federal exchange serving Texas and 35 other states. So physicians in those Texas counties will only have to make a few phone calls, Spangler added. But in urban areas, physicians will have to contact as many as six insurance companies. The association also has heard physician concerns about potential interruptions in patients' continuity of care because of provider network changes, and about the adequacy of reimbursement under exchange plans. Some doctors report that exchange plans are offering reimbursement rates close to Medicaid rates, though there are no definitive data on what plans are paying doctors. “They're worried if they can afford to take patients from an exchange plan that has a different fee schedule,” Spangler said. Dr. Stephen Brotherton, an orthopedic surgeon who serves as the Texas Medical Association's president, said neither he nor any of the other physicians in his Fort Worth-based practice intend to accept exchange plans. “We can't keep the doors open with those kinds of rates,” Brotherton said. He added that exchange plans are reimbursing at rates similar to Medicaid. “I think you'll see pretty low acceptance rates across the state.” MSSNY President Dr. Sam Unterricht said that of his association's members who have received rate information from exchange plans, a significant majority indicated that the reimbursement generally was well below what the insurer pays in other contracts. Of the more than 1,000 physician practices surveyed by the Medical Group Management Association in September, 40.2% said they are still evaluating whether they will participate in exchange health plans, 29.2% said they plan on participating (with 26.8% of those reporting they have an “all-products” contract clause requiring them to participate), 16.2% said they just don't know, and 14.4% said they will not be participating.
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Higher nurse staffing rates may mean fewer readmissions penalties, study shows Hospitals with higher nurse staffing rates were less likely to be penalized under the federal government's Hospital Readmissions Reduction Program than hospitals that staff nurses at lower levels, according to a study in Health Affairs. Launched in October 2012, the federal government's readmissions program docks Medicare payments for hospitals with high readmission rates for heart attack, heart failure and pneumonia. On Oct. 1, the maximum penalty jumped from 1% to 2% for 2014. For the study, University of Pennsylvania researchers examined staffing data and publicly available readmission rates for more than 2,800 hospitals, covering fiscal 2013. Hospitals with high staffing levels—an average of eight registered-nurse hours per adjusted patient day—were 25% less likely to be penalized than low-staffing hospitals, which staffed at an average level of 5.1 RN hours per patient day. “Our findings point to management of nurse staffing levels and workloads as a potential system-level intervention through which hospitals can respond to the new regulatory environment,” they wrote in the study.
Survey analyzes consumer experiences during open enrollment The Commonwealth Fund released a survey analyzing consumer experiences during the health insurance exchanges' rocky first month of open enrollment. Of those potentially eligible for coverage, 60% said they were aware of the exchanges and 17% reported visiting them. Just over 20% of those who visited said they enrolled in a plan, while others reported technical difficulties and uncertainty about affordability.
Health Law Update
Bill Reopening Federal Government Contains Two Changes to ACA On October 17, 2013, President Obama signed into law H.R. 2775, reopening the federal government by funding the government until January 15, 2014 and extending the federal government’s borrowing authority until February 7, 2014. Also contained in the new law are two provisions relating to the Affordable Care Act (ACA). Health Exchanges must now verify the income of individuals applying for premium tax credits or a reduction in cost-sharing obligations to ensure that their income levels meet the eligibility requirements for such tax credits or reductions. The Secretary of the U.S. Department of Health & Human Services (HHS) must submit a report to Congress by January 1, 2014, setting forth the procedure for Health Exchanges to follow in order to verify eligibility for credits and cost sharing reductions. The law also requires the Inspector General of HHS to submit a report to Congress by July 1, 2014 regarding the effectiveness of the procedures and safeguards under the ACA for preventing the submission of inaccurate or fraudulent information by applicants enrolling in qualified health plans through Health Exchanges. For more information, contact: Joseph M. Gorrell | 973.403.3112 | jgorrell@bracheichler.com Debra C. Lienhardt¦ | 973.364.5203 | dlienhardt@bracheichler.com
OIG Reports CMS Overpaid for Sleep Studies in 2011 by $17 Million Last month, the Department of Health and Human Services Office of Inspector General (OIG) issued a report (OEI-05-12-00340) entitled “Questionable Billing for Polysomnography Services.” According to the OIG, “increased Medicare spending on polysomnography (a type of sleep study), along with growing concerns about fraud and abuse, prompted OIG to conduct this study.” OIG reported that, from 2005 to 2011, Medicare spending for polysomnography services rose from $407 million to $565 million, an increase of 39%. In addition, OIG noted particular fraud and abuse vulnerabilities related to billing for these studies. Through its analysis of Medicare payments for 2011, OIG concluded that Medicare paid almost $17 million for polysomnography services that did not meet one or more of three Medicare requirements, with the majority of the problem related to inappropriate diagnosis codes. OIG noted that the majority of inappropriate diagnosis codes came from hospital outpatient departments. In addition, OIG noted a pattern of questionable billing related to the studies, including overpayment issues so rampant that in some instances providers were paid for rendering two sleep studies for the same patient in one day, which is highly unlikely given the time required to complete one of the studies. OIG is recommending that Centers for Medicare & Medicaid Services (CMS) implement or improve claims processing edits and consider using measures of questionable billing from the study to identify providers for further investigation. OIG also recommends that CMS take appropriate action regarding inappropriate payments and providers that exhibited patterns of questionable billing. For more information, contact: Keith J. Roberts | 973.364.5201 | kroberts@bracheichler.com Joseph M. Gorrell | 973.403.3112 | jgorrell@bracheichler.com
14 New Jersey Physician
NJ Bill to Protect Elderly in Continuing Care Communities Signed into Law Last month, Governor Christie signed “Angelini’s Bill of Rights” (S2052) into law. Immediately effective, the law establishes a bill of rights for elderly residents living in continuing care retirement communities (CCRCs). The law requires CCRCs to provide a disclosure statement to prospective residents before they sign longterm care agreements and provide an explanation of the rights and responsibilities of residents in clear and plain language. Prospective residents then have 30 days to review the documents before executing the agreements. Residents may also cancel the agreements within 30 days after signing and receive a full refund, except for the application fee. Additional rights provided in Angelini’s Bill of Rights include: (i) determinations that a resident can no longer function independently, with or without the assistance of an aide, must be made by the director of medical services of the facility and satisfy certain other requirements; (ii) residents are entitled to privacy in their units and to be treated with respect courtesy, consideration and dignity; (iii) residents can view their own medical records, participate in medical decisions, refuse treatments and determine life support options; (iv) residents can file a complaint with an appropriate agency without fear of reprisal from the facility; (v) residents are entitled to 30 days’ advance written notice of an increase in any fees; and (vi) residents are entitled to have guests and visitors at the facility and leave and return to their individual units at will, subject to certain conditions. For more information, contact: Kevin M. Lastorino | 973.403.3129 | klastorino@bracheichler.com Debra C. Lienhardt¦ | 973.364.5203 | dlienhardt@bracheichler.com
NJ Bills May Impact Health Care Providers A732, initially introduced in January of 2012, was signed into law on October 16, 2013. The bill makes it a crime of the third degree to practice or represent oneself to others concerning certain licensed or certified health care related professions. Specifically, the bill criminalizes the unauthorized practice of psychology, chiropractic and social work. S2999, introduced on September 30, 2013, would provide an alternative pathway for individuals seeking licensure to practice orthotics or prosthetics in New Jersey. The bill, among other things, permits individuals seeking licensure to practice orthotics or prosthetics to satisfactorily complete 1900 hours of work experience. Previously, individuals seeking licensure needed 1900 hours of clinical experience. For more information, contact: John D. Fanburg | 973.403.3107 | jfanburg@bracheichler.com Mark Manigan | 973.403.3132 | mmanigan@bracheichler.com November 2013
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ACOs
Accountable Care Organizations
Reshape Healthcare Delivery Andrew Kitchenman
Advocates say patients benefit from emphasis on cost-cutting and efficiency Accountable care organizations (ACOs) have been a rising force in how healthcare is organized and delivered, both in New Jersey and nationally. They seek to reduce the growth in healthcare costs while improving the quality of care that patients receive. They are similar in some ways to health maintenance organizations (HMOs), the major health insurance trend of the 1980s and 1990s, which ultimately proved unpopular – but there are significant differences. Bringing providers together: ACOs are groups of providers who agree to be held accountable for the cost and quality of care they provide to a group of patients. They generally do this by having a portion of their payments depend on how they perform. For example, in Medicare Shared Savings ACOs, providers are paid more if they are able to keep costs down while meeting agreed-upon standards for providing quality care. How this is done: The central feature of ACOs is a focus on greater coordination of care. ACOs generally employ care coordinators, such as a registered nurse, who is responsible for ensuring that patients receive appropriate care from a range of specialists. They do this both by helping patients to schedule appointments and by following up with patients to make sure that they are taking the right medications. This can be particularly important for patients with a high-risk of readmission to hospitals, such as patients with diabetes who have difficulty managing their blood-sugar levels. Cost-cutting incentives: While there are variations in how providers are compensated in ACOs, in the Medicare Shared Savings model , for example, doctors, hospitals and other providers receive a portion of their payments through a fee-for-service model and a portion based on whether they achieve savings compared with their projected costs. After the first three years, providers face penalties if the care they provide is more expensive than projected. The government is using a variety of measurements to ensure that providers don’t achieve the savings by reducing the quality of care. Coordinating and communicating: The focus on care coordination is intended to address one of the chief problems with the U.S. healthcare system: the inefficiencies caused by poor communication between various providers and patients, leading to unnecessary tests and hospital stays, as well as an inability in some cases to manage chronic conditions. The range of ACO programs: Both private and government insurance programs are contracting with providers to form ACOs. Medicare ACO programs were included in the 2010 Affordable Care Act, in one of the provisions of the law that focused on how healthcare is delivered rather than on expanding access to health insurance. Federal officials have been authorizing a growing number of Medicare ACOs in the state, including a recent agreement between Barnabas Health, which is the state’s largest healthcare system, and Horizon Blue Cross Blue Shield of New Jersey, its largest insurer. Private insurers also have been working to increase the number of providers in ACOs. What about New Jersey? New Jersey plans plans to launch a Medicaid ACO pilot program next year. It will involve a high proportion of all providers in geographic areas with large numbers of low-income residents. Healthcare experts, including Dr. Jeffrey Brenner of Camden, have said the state program could become a national model if it’s successful. Similarities and differences with HMOs: Health maintenance organizations were the first great experiment with shifting from the healthcare system’s traditional reliance on paying fees for each service that providers give. In an HMO, providers agreed to receive payments for each patient they served rather than for the services they provided, which was known as capitation. While ACOs also include capitation, there are some major differences with HMOs. Unlike HMOs, ACOs do not require patients to stay within the ACO’s network of providers. In addition, advances have been made in how to measure the quality of care that patients receive, which in turn have been incorporated in ACO payment systems. What’s next? The portion of New Jerseyans whose healthcare providers are in ACOs has been rising steadily. Nationally, 14 percent of patients Americans were served by ACOs as of February, according to management consulting firm Oliver Wyman. The focus on better care coordination has also increased pressure on doctors to join their practices with larger groups or hospital systems. That change is rapidly remaking how many New Jerseyans receive healthcare.
16 New Jersey Physician
MEDICAL NEWS
Medical News
NJ Home Health Care program uses telehealth monitoring to improve the quality of care for patients with chronic illnesses. The Visiting Nurse Association of Somerset Hills has received national recognition for an innovative health care program that studied the impact of using telehealth monitoring to improve the quality of care and outcomes for patients with chronic illnesses. Featured in the recently published Visiting Nurses Association of America case study compendium, the study was developed in partnership with Summit Medical Group, the largest and oldest physician-owned multispecialty practice in New Jersey. The year-long program resulted in a zero percent 30-day hospital readmission rate and high level of satisfaction for patients with congestive heart failure or chronic obstructive pulmonary disease. Services provided to patients included daily remote vital sign monitoring using technologically advanced equipment, customized care plans and education modules to improve selfmanagement of their conditions. “ By coordinating communication between the VNA and SMG to ensure early intervention for potential problems, patients experienced a reduced risk for hospital and emergency room visits. In addition to helping patients with serious chronic conditions maintain an independent and active lifestyle, the program offers an opportunity for significant health care cost savings,” said Ann Painter, VNA of Somerset Hills President & CEO. The VNAA Case Study Compendium: Innovative Models for the Evolving Home Health and Hospice Industry, is a collection of ten VNAA member case studies highlighting successful programs and techniques nonprofit home health and hospice providers have developed to adapt to changes in the healthcare landscape.
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
November 2013
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NEW JERSEY Statehouse
STATEHOUSE Bill Would Make It Easier For Women to Receive In-Vitro Fertilization
Andrew Kitchenman
Weinberg decries invasive requirements in current law, but insurers and employers question added mandate When and how women should be considered eligible for fertility treatments for insurance purposes is an issue before the state Legislature. Senate Democratic Majority Leader Loretta Weinberg says the current law is too restrictive in ascertaining eligibility and is invasive in how infertility is determined. Weinberg is sponsoring a measure that she says addresses those issues. S-2867/A-4347 would expand access to in-vitro fertilization (IVF) to lesbian couples and women without partners. It would also change how infertility is defined in a way that the bill’s sponsors say would make the process less invasive. But opponents of the measure say it amounts to a mandate that would increase the healthcare costs of both private insurers and the state. Insurance companies, business groups, and social-conservative organizations oppose it. IVF involves joining a woman’s egg and a man’s sperm in a laboratory dish and transferring the resulting embryo to the woman’s womb. Women undergoing the process must first take a series of fertility drugs to boost their egg production. Weinberg (D-Bergen) said she was shocked by language in the current state law that governs insurance requirements for IVF. The law’s definition of infertility includes women who are unable to “conceive after two years of unprotected intercourse if the female partner is under 35 years of age, or one year of unprotected intercourse if the female partner is 35 years of age or older.” Weinberg said it was wrong to require a woman to demonstrate this for an insurance benefit “she paid for through her premium. And now she would be forced to produce a chart or a log of her sexual activity. What if she didn’t keep a log, like most people don’t? What if she’s a lesbian?” The bill would remove that language from the law and replace it with a provision allowing a woman’s doctor to determine whether the woman is infertile. “Ask yourself this one question,” Weinberg told the Senate Commerce Committee at a November 7 hearing. “If a woman could conceive without medical intervention, wouldn’t they? This bill respects all people and respects a woman’s right to manage her own body.” But the bill would have implications beyond eliminating intrusive language, according to its opponents. It would also expand the health insurance mandate beyond the 2001 law requiring the IVF benefit for plans that cover at least 50 people. New Jersey Association of Health Plans Vice President Sarah McLallen said the law’s infertility definition requires that a doctor’s diagnosis of infertility be based on “medical circumstances.” Changing the definition would undermine this requirement, she said. She added that altering the provision is a significant departure from the more modest goal of expanding IVF coverage to women in same-sex relationships or who don’t have a partner. McLallen also said that if the bill were to move forward, it should be amended so that only board-certified providers who specialize in the treatment of infertility -- and not just any doctor -- would be allowed to diagnose infertility. McLallen focused on the cost implications of making it easier to have IVFs, noting that each process generally costs $10,000 to $15,000. The bill “would expand the IVF mandate to new populations, but it also eliminates an important cost-control process that’s in place today for all people, heterosexuals included, who are seeking IVF,” McLallen said.
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Christine Stearns, vice president of health and legal affairs for the New Jersey Business & Industry Association, voiced a separate concern about the bill. She noted that the 2010 Affordable Care Act requires that state’s that add insurance mandates beyond what the ACA defines as essential health benefits have to pay for those mandates. “That is a concern that is important and something for the Legislature to be mindful of,” Stearns said. Weinberg said she felt that the mandate is already in place and that the law’s current language is “extremely objectionable.” “What we’re doing in this bill is removing the requirement that you have to somehow prove you’ve had two years of unprotected sex,” Weinberg said. Sen. Raymond J. Lesniak (D-Union), who supports the bill, emphasized that IVF is not something that women would impose on themselves due to the potential side effects that women face when they take fertility drugs. “No one is going to ask for this treatment if they don’t need it,” Lesniak said. The New Jersey Food Council, League of American Families, and New Jersey Family First also oppose the bill. The Commerce Committee released the bill on a 4-1 vote, with all four committee Democrats voting in favor, Sen. Gerald Cardinale (R-Bergen and Passaic) voting against it and Sen. Thomas H. Kean (R-Morris, Somerset and Union) abstaining. Sen. Nia H. Gill (D-Essex and Passaic) also sponsored the Senate bill, while the Assembly version is sponsored by Assembly members Pamela R. Lampitt (D-Burlington and Camden), Valerie Vainieri Huttle (D-Bergen), former Assemblywoman Connie Wagner (D-Bergen and Passaic) and Reed Gusciora (D-Hunterdon and Mercer). The Senate bill was referred to Senate Budget and Appropriations Committee, which could require an assessment of the fiscal impact of the bill on the state. The Assembly bill has been referred to the Assembly Financial Institutions and Insurance Committee.
The Good News
The Good News: Medicaid Applications Are On The Rise, And State's Website Has Been Flawless By Dan Goldberg While many New Jerseyans struggle to purchase private health insurance from the government's glitch-prone website, a group of local nonprofits reported last week that at least one part of the Affordable Care Act is working as intended. New Jersey — like many other states — is seeing an uptick in Medicaid applications, thanks to the new law, also known as Obamacare. The Affordable Care Act expands Medicaid in several ways, most notably by increasing the amount of money one can earn and still qualify for the program, which is primarily meant to insure the poor. An individual is now Medicaid eligible if he or she earns less than $15,282 and a family of four is eligible if they earn less than $31,322. Adults without dependent children are now also eligible for Medicaid because ofthenewlaw. Ray Castro, a senior policy analyst at the left-leaning New Jersey Policy Perspective, said highlighting Medciaid's expansion is "good for the state's health and good for the state's economy. "Medicaid is a great deal for struggling, low-income, uninsured New Jerseyans because there is no cost to them and the benefits are very comprehensive," he said. The Supreme Court ruled in 2012 that states could choose whether to expand their Medicaid program. New Jersey is one of 25 states along with the District of Columbia that have done so, and the Rutgers Center for State Health Policy estimates that nearly 250,000 residents will enroll. The federal government will pay all the costs for states that expand Medicaid through 2016 and 90 percent of the extra expense to 2020. States like Washington, New York, Kentucky and Colorado have already reported surges in their Medicaid rolls. A spokeswoman for New Jersey's State Department of Human Services, which oversees the program, said it only tracks enrollment, not ap- plications. Because coverage won't begin until Jan. 1, no official tally is available and likely won't be until February. Maura Collinsgru, health policy advocate with New Jersey Citizen Action, said many nonprofit groups that help people enroll are seeing a "steady stream" of applicants. She said she might be able to provide more concrete numbers later this month. The reason Medicaid signups have been so much more successful is because those applications are processed through the state of New Jersey, according Collinsgru. "The process of applying through the NJ Family Care website has been seamless," said Quynh Tran, Health Program Manager for BPSOS, a Vietnamese community based organization with an office in Pennsauken. "Since beginning to use the site two weeks ago, we have had no problem completing applications for members of our community." November 2013
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It's not just the website. The Medicaid population is often easier to reach because they tpyically rely on nonprofits for other services. Those who earn too much to qualify for Medicaid but still want to purchase federally subsidized private health insurance must apply through the federal government, which has struggled to process applications because of the problems with the website, healthcare.gov Collinsgru said enrollment is about more than just a website. "We've not been sitting idly by waiting for fixes," she said. "We are urging consumers to utilize to the maximum extent possible the NJ Family Care website, which is working." Applications for Medicaid can be completed online at NJFamilyCare.org or by calling 1-800-701-0710.
Medical News
New Statin Advice to lower cholesterol is challenged Last week, the nation’s leading heart organizations released a sweeping new set of guidelines for lowering cholesterol, along with an online calculator meant to help doctors assess risks and treatment options. But, in a major embarrassment to the health groups, the calculator appears to greatly overestimate risk, so much so that it could mistakenly suggest that millions more people are candidates for statin drugs. The apparent problem prompted one leading cardiologist, a past president of the American College of Cardiology, to call on Sunday for a halt to the implementation of the new guidelines. “It’s stunning,” said the cardiologist, Dr. Steven Nissen, chief of cardiovascular medicine at the Cleveland Clinic. “We need a pause to further evaluate this approach before it is implemented on a widespread basis.” The controversy set off turmoil at the annual meeting of the American Heart Association, which started this weekend in Dallas. After an emergency session on Saturday night, the two heart organizations that published the guidelines — the American Heart Association and the American College of Cardiology — said that while the calculator was not perfect, it was a major step forward, and that patients and doctors should discuss treatment options rather than blindly following a calculator. Dr. Sidney Smith, the executive chairman of the guideline committee, said the associations would examine the flaws found in the calculator and determine if changes were needed. “We need to see if the concerns raised are substantive,” he said Sunday. “Do there need to be changes?” Problems seen earlier The problems were identified by two Harvard Medical School professors whose findings will be published Tuesday in a commentary in The Lancet, a major medical journal. The professors, Dr. Paul Ridker and Dr. Nancy Cook, had pointed out the problems a year earlier when the National Institutes of Health’s National Heart, Lung, and Blood Institute, which originally was developing the guidelines, sent a draft to each professor independently to review. Both reported back that the calculator was not working among the populations that it was tested on by the guideline makers. That was unfortunate because the committee thought the researchers had been given the professors’ responses, said Dr. Donald Lloyd-Jones, co-chairman of the guidelines task force and chairman of the department of preventative medicine at Northwestern University. Ridker and Cook saw the final guidelines and risk calculator on Tuesday at 4 p.m., when a news embargo was lifted, and discovered that the problems remained. On Saturday night, members of the association and the college of cardiology held a hastily called closed-door meeting with Ridker, who directs the center for cardiovascular disease prevention at Brigham and Women’s Hospital in Boston. He showed them his data and pointed out the problem. On Sunday, officials from the organizations struggled with how to respond. People have changed Other experts said there has not been a real appreciation of the difficulties with this and other risk calculators. “I don’t think people have a good idea of what needs to be done,” said Dr. Michael Blaha, director of clinical research at the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University, who was not associated with forming the new guidelines. Blaha said the problem might have stemmed from the fact that the calculator uses as reference points the results from various studies conducted more than a decade ago, when more people smoked and had strokes and heart attacks earlier in life. For example, the guideline makers used data from studies in the 1990s to determine how various risk factors like cholesterol levels and blood pressure led to actual heart attacks and strokes over a decade of observation.
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But people have changed in the past few decades, Blaha said. Among other things, there is no longer such a big gap between women’s risks and those of men at a given age. And people get heart attacks and strokes at older ages. “The cohorts were from a different era,” Blaha said. ‘Best efforts’ Ridker and Cook evaluated the risk calculator using three large studies that involved thousands of people and continued for at least a decade. They knew the subjects’ characteristics at the start — their ages, whether they smoked, their cholesterol levels, their blood pressures. Then they asked how many had heart attacks or strokes in the next 10 years and how many would the risk calculator predict. The answer was that the calculator over-predicted risk by 75 to 150 percent, depending on the population. A man whose risk was 4 percent, for example, might show up as having an 8 percent risk. With a 4 percent risk, he would not warrant treatment — the guidelines say treatment is advised for those with at least a 7.5 percent risk and that treatment can be considered for those whose risk is 5 percent. “Miscalibration to this extent should be reconciled and addressed before these new prediction models are widely implemented,” Ridker and Cook wrote in The Lancet. “If real, such systematic overestimation of risk will lead to considerable over-prescription.” In a response on Sunday, Smith, the chairman of the guidelines committee, said the concerns raised by Cook and Ridker “merit attention.” But, he continued, “a lot of people put a lot of thought into how can we identify people who can benefit from therapy.” Further, said Smith, who is also a professor of medicine at the University of North Carolina and a past president of the American Heart Association, “what we have come forward with represents the best efforts of people who have been working for five years.” Asked to comment on the situation Sunday, some doctors said they worried that, with many people already leery of statins, the public would lose its trust in guidelines or the heart associations. “We’re surrounded by a real disaster in terms of credibility,” said Dr. Peter Libby, chairman of the department of cardiovascular medicine at Brigham and Women’s Hospital. What now? What are patients and doctors to do? On Sunday, there seemed to be no firm answers, except that those at the highest risk, like people who have had a heart attack or have diabetes, should take statins. The guideline developers said they were not totally surprised by the problems with the calculator. “We recognize a potential for overestimates, especially at the high end of risk,” said Dr. David Goff, dean of the University of Colorado School of Public Health and co-chairman of the guidelines’ risk assessment working group. Not long after receiving the assessments from Ridker and Cook, the National Heart, Lung and Blood Institute removed itself from the development of the guidelines, saying that was not its mission. The institute handed responsibility to the American Heart Association and the American College of Cardiology. Dr. Michael Lauer, the director of the division of cardiovascular sciences at the institute, said Sunday that it had received many reviews and sent them to the other groups, together with the responses of the guidelines’ authors. “We left it to them to take it through their vetting process,” Lauer said. And the groups did make changes in response to Ridker and Cook’s comments, Lloyd-Jones said. Miscalculations Some doctors who tested the calculator with hypothetical patients wondered if they should trust the results. Nissen, of the Cleveland Clinic, entered the figures for a 60-year-old black man with no risk factors — total cholesterol of 150, HDL (the good cholesterol) of 45, systolic blood pressure of 125 — who was not diabetic or a smoker. He ended up with a 10-year risk of 7.5 percent, meaning he should be taking cholesterol-lowering statins despite being in a seemingly low-risk group. Dr. Nissen also calculated the figures for a healthy white man, age 60, and also got a risk factor of 7.5 percent. “Something is terribly wrong,” Dr. Nissen said. Using the calculator’s results, he said, “your average healthy Joe gets treated, virtually every African-American man over 65 gets treated.”
Visit us now online at www.NJPhysician.org November 2013
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PRACTICE NEWS
Practice News
Reproductive Medicine Associates of New Jersey (RMANJ), one of the nation’s leading fertility clinics, is doing just that. In 2012, RMANJ established the Helping Heroes Build Families program to help New Jersey-based active duty Military personnel and their spouses overcome the problem of infertility and realize the dream of parenthood. Since its introduction, Helping Heroes has provided over $150,000 dollars’ worth of free services to New Jersey-based active duty military personnel and has helped approximately 30 patients through this program. The program was conceived by two former military physicians, currently practicing together at RMANJ, who are intimately familiar with the sacrifices our military make on a daily basis and developed this program to give back to our honored service men and women. This year, in honor of Veteran’s Day on November 11, RMANJ is extending its program to provide complimentary in vitro fertilization (IVF) cycles to qualifying New Jersey-based service members and their spouses. Until the Women Veterans and Other Health Care Improvement Act (designed to improve access to reproductive assistance services for military personnel who do not have coverage for infertility treatments under their current medical benefits) is passed by Congress, programs like Helping Heroes are the only option for those who are unable to afford the treatment and hope to ever have a biological child. For example, military couple Myesha and Sgt. Lyzander Jones, based in Maguire Air Force Base in Fort Dix, NJ, tried for several years to get pregnant to no avail – and hard as they tried to save, everyday expenses kept the couple from being able to afford IVF. The Helping Heroes program donated a free IVF cycle to the couple, which led to Myseha getting pregnant with twins! Maxwell and London were born on March 19, 2013 and thrilled mother, Myesha, noted that, “having these twins has changed everything. They are beautiful, amazing.”
Insurance Fraud
Closter cardiologist gets six years for record $19M healthcare scam By Dan Ivers A prominent cardiologist from Closter will spend more than six years in prison for pulling off what authorities say was one of the largest healthcare fraud scheme in history. Dr. Jose Katz, 69, founded two companies — Cardo-Med Services LLC and Comprehensive Healthcare & Medical Services. As the companies treated patients, Katz intentionally subjected them to various unnecessary tests and procedures, which he billed to Medicare, Medicaid, Aetna, and other agencies for reimbursement, according to U.S. Attorney Paul Fishman. In all, the scheme brought Katz over $19 million - which authorities say is the largest such fraud ever committed in New Jersey, New York or Connecticut. "Katz prized illegal profits over patients to a staggering degree, committing record- breaking fraud and compromising care,” said Fishman. “Prison is an appropriate consequence for ripping off the government and insurance companies through the shocking exposure of patients to unneeded or untrained treatment.” Authorities say Katz helped fuel his profits by spending millions on advertisements on Spanish-language radio and television stations, which helped keep a steady flow of patients in his offices located in West New York, Paterson, Union City, Manhattan and Queens. Employees were then ordered to perform a battery of tests, many of them unnecessary, and then diagnose them with conditions such as coronary artery disease or angina. Those patients often underwent procedures that could be dangerous, "therefore subjecting those patients to a substantial risk of serious injury or death", Fishman said. As part of a plea deal with federal prosecutors, Katz also admitted engineering a scheme that allowed him to collect $263,000 in Social Security benefits by keeping him on the payroll at Cardio-Med, despite the fact that he worked very little, if at all. Katz had pleaded guilty to Social Security fraud and conspiracy to commit health care fraud during a previous appearance at U.S. District Court in Newark. In addition to 78 months in prison, he will be ordered to pay $19 million in restitution and be subject to three years of supervised release.
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