Sutherland insights healthcare news flash 16082013

HEALTHCARE NEWS FLASH 16th August 2013

Table of Contents Sales & Marketing ................................................................................................................. 3 Finance ............................................................................................................................... 10 Technology .......................................................................................................................... 18 Strategy .............................................................................................................................. 25

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Sales & Marketing Vanguard, Tufts launch CO-OP health plan 14 August, 2013 | Fierce Health Payer http://www.fiercehealthpayer.com/story/vanguard-tufts-launch-co-op-health-plan/2013-08-14 Vanguard Health System, Tufts Medical Center and its New England Quality Care Alliance physicians' group have formed a consumer operated and oriented plan (CO-OP) health plan with an $88.5 million loan from the Centers for Medicare & Medicaid Services, the Boston Business Journal reported.

Minuteman Health will begin open enrollment Oct. 1 through its website, insurance brokers and the state health insurance exchange, called Commonwealth Connector, the paper said. The company plans television, radio and outdoor advertising to spread awareness of its five coverage plans, which go into effect Jan. 1.

The 14 hospitals accepting Minuteman Health insurance include Tufts Medical Center, three Vanguard-owned hospitals, and hospitals owned by Lahey Health and Southcoast Health System, according to the Business Journal.

Under its CO-OP structure, Minuteman Health members will elect the board of directors, with a majority of the directors being plan members, the insurer said in an announcement.

Minuteman said it will provide "lower-cost, high-quality care with unprecedented transparency, as well as increased efficiency and satisfaction for physicians, patients and employers alike."

With its loan from CMS, the nonprofit becomes the first healthcare CO-OP in the state to be funded through the Affordable Care Act, Rep. Mike Capuano (D-Mass) said in a statement. "The ACA encourages innovation in the structure and governance of health plans, as hospitals and doctors seek to control cost and improve quality of care. I will watch Minuteman's progress with great interest."

The new CEO is Tom Policelli, former director of UnitedHealth Group's iPlan, according to the Business Journal. Rina Vertis, former chief actuary at Blue Cross Blue Shield of Massachusetts, is the chief financial officer.

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WellPoint, Blues plan to sponsor Spanish ads on Univision 9 August, 2013 | Fierce Health Payer http://www.fiercehealthpayer.com/story/wellpoint-blues-plans-sponsor-spanish-adsunivision/2013-08-09 In an effort to woo the coveted Hispanic consumer market, WellPoint and some Blue Cross Blue Shield plans will be Univision's exclusive health insurance sponsors of the TV network's health initiative Salud Es Vida (Health is Life), reported Kaiser Health News.

Roughly 10 million Hispanics could be eligible for coverage under the reform law. Since many of these consumers are young, they represent a key population for insurers--inexpensive and healthy.

However, a recent survey concluded that more than 50 percent of Hispanics have little or no understanding of the law, the Los Angeles Times reported.

That's why some WellPoint plans have contracted with Univision, for an undisclosed amount, in California, New York, Colorado and Georgia. Two other insurers--Horizon Blue Cross Blue Shield of New Jersey and Florida Blue--also have signed on to partner with Univision.

The Spanish-language media network's health initiative will include a special sponsored website that connects Hispanic consumers to health insurance exchanges as well as sponsored ads on TV, radio and newsletters. Univision also plans monthly town halls and meetings to reach out to the Hispanic community, according to Georgia Health News.

Blue Cross Blue Shield of Georgia, for example, is hoping to reach the state's 850,000 Hispanics who lack health insurance. "We are confident that the partnership with Univision will be a positive one for both parties and give Hispanic residents of Georgia affordable and effective options," Bert Kelly, a spokesman for the insurer, told GHN. Meanwhile, Florida Blue's agreement with Univision includes a website that explains in basic terms how health insurance works and will allow consumers to connect directly to a Spanish Florida Blue site, where they can buy policies.

"The initial concept that we had for the Univision health insurance center is for it to feel as though you're walking into a Florida Blue retail center," Steve Snell, vice president of enterprise marketing for Florida Blue, told KHN. "Our goal first and foremost is awareness. A lot of folks who are currently uninsured may never have signed up for insurance before."

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Global health IT outsourcing market to reach $50.4 billion by 2018 8 August, 2013 | Fierce Health IT http://www.fiercehealthit.com/story/global-health-it-outsourcing-market-reach-504-billion2018/2013-08-08 The U.S. and Canada lead in the global healthcare IT outsourcing market, with North America accounting for the largest share at 72 percent, according to a new report from RnRMarketResearch.com. The global market is expected to reach $50.4 billion by 2018 from $35 billion in 2013, with health insurance, healthcare systems and the pharmaceutical industry driving growth.

All three rely on outsourcing to reduce operational and maintenance costs, increase access to IT staff and quickly implement new technologies. Lack of in-house IT expertise, increasing need to integrate disparate systems, and growing pressure to meet Meaningful Use criteria and implement ICD-10 are among the factors at play, according to the report.

However, factors such as the fragmented nature of the business, growing concern for data security and cultural and language barriers restrain growth of the market.

IT hiring remains difficult in healthcare. In a recently published HIMSS Analytics survey, hospital respondents said they outsourced at least one IT function rather than hiring in-house. Ninety-three percent said they plan to outsource a function within the next year.

Health information exchanges, too, are relying on outsourcing for positions when they don't have the required skills in-house, HIMSS and the American Health Information Management Association (AHIMA) reported.

Despite pressure to measure and analyze data for quality reporting, a report published this week found budget woes and a skills gap holding back many healthcare organizations from fully harnessing the potential for analytics.

Blue Cross, Allina join forces on new plan 7 August, 2013 | Star Tribune http://www.startribune.com/business/218619801.html Two major players in Minnesota health care have teamed up on a new insurance plan they say removes obstacles that keep people from -getting the best care.

The plan that Allina Health and insurer Blue Cross and Blue Shield of Minnesota unveiled Tuesday offers a handful of free office visits plus full coverage of many prescription drugs and lab screenings.

It eliminates many co-pays.

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The two organizations say the offering is the result of extensive interviews with patients and employers in an attempt to find out what they don’t like about existing plans.

“We tried to strip everything out that got in the way of optimal patient care,” said Dr. Robert Wieland, executive vice president of Allina’s clinic and community division.

The partnership is an example of how health reform efforts and rising medical costs are pushing traditional adversaries to work together to -coordinate patient care.

Providers face declining reimbursements for their work and are having to take on more responsibility for keeping patients healthier. There’s greater incentive to use electronic medical records and claims data to avoid wasteful duplication of tests or to ensure that patients pick up their prescription drugs when they leave the clinic.

“It’s an evolutionary step in the market, but there’s a lot of merit to movement like this,” said Steve Parente, a health care economist and professor at the University of Minnesota. “I can see it working both in terms of consumer appeal as well as in the nuts and bolts of the actuarial parts of it.”

Known as “BluePrint,” the plan will be available for individuals and families as well as large and small employers in the 11-county Twin Cities metropolitan area. It will be sold on the state’s MNsure exchange starting in October as well as through brokers and Blue Cross.

The organizations say the price for the coverage will be lower than “open choice” plans Blue Cross offers because patients are limited to Allina hospitals, clinics and the 53 independent physician groups in its network.

A focus on chronic diseases Although the plan will be open to anyone, it targets those with diabetes, hypertension and high cholesterol — three chronic conditions that can be costly for patients and -providers if people wind up in the hospital.

Parente said working together is sound business strategy in an environment in which the newly merged HealthPartners insurance company and Park Nicollet system of hospitals and clinics are trying to lower costs by having everything under one roof.

An alignment of Blue Cross, the state’s largest insurer, and Allina Health, a major health care system, to focus on chronic diseases has the same goal.

“If you can get these folks in, manage them by having them in your electronic health record system, make sure they get access to their medications, and manage to keep costs down, everybody wins,” Parente said.

“The patient wins because they’re going to be insured, the plan and providers win because they’re going to capture some of this market and they’re going to have demonstrated that they can keep costs relatively low.”

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Blue Cross led focus groups with doctors, as well as patients and employers, to try to figure out how to help people feel less overwhelmed and take a more active role in staying on top of their health.

The plan will incorporate a souped-up website where enrollees don’t just fill out a health assessment form, but someone on the medical side evaluates the results and works with patients to help them achieve better health. Patients get discounts for participating in workshops.

“It’s a big leap for us,” said Garrett Black, senior vice president of health management at Blue Cross and Blue Shield of Minnesota. “In the past, we have created products without talking to people who deliver the care.”

The result is something built from the ground up, Black said, rather than “taking an existing product and network and just bolting them together.”

Well-known insurers could lose competitive edge in exchanges 2 August, 2013 | Fierce Health Payer http://www.fiercehealthpayer.com/story/medicaid-insurers-could-have-competitive-edgeexchanges/2013-08-02 The big-name players in the private insurance industry shouldn't let their guards down as they enter the homestretch before the health insurance exchanges begin open enrollment in October.

Sure, name recognition for companies like Aetna, Cigna, UnitedHealth and WellPoint could help boost their sales. But among the many unique characteristics of this new consumer group shopping for coverage through online marketplaces is that they haven't had insurance for a long time, if ever.

In other words, mainstream insurers won't be able to easily sway some people by name alone. They don't care if you're the industry behemoth or a newcomer.

That's good news for small companies, especially those specializing in Medicaid plans. Although they'll be entering new territory by selling policies on the exchanges, Medicaid-based insurers have many advantages that will let them successfully compete with big-name commercial insurers.

"There has never been a better time to be a Medicaid health plan with the opportunities in front of us," Lisa Rubino, president of Molina Healthcare of California, told AIS Health, including "the exchanges and the expansion of Medicaid."

Several Medicaid insurers participating in exchanges say they'll focus on uninsured individuals with low incomes plus the parents of children who already have Medicaid coverage. "They're already tapped into those family units, so this is a way to bring the whole family together. [Medicaid carriers] really do see exchanges as an opportunity," said Jeremy Palmer, a principal and consulting actuary with Milliman, AIS Health noted.

Massachusetts-based Network Health is one such Medicaid insurer forging ahead with plans to compete and vie for consumers on the exchanges despite--or perhaps because of--its smaller size.

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Network Health and other Medicaid-based insurers will have some key competitive advantages like experience with a sicker population, making them better prepared for consumers shopping on exchanges who likely will have multiple chronic conditions. They also will have brand recognition among the low-income population. "They feel like their brand among the lower-income population is very strong," Palmer said.

Plus, Medicaid insurers have leaner margins since they're used to operating with lower profit margins. "We are very frugal in how we spend the government's money," Rubino said. And they have existing relationships with essential community providers as required by the reform law. "We didn't have to go out and forge new relationships like many commercial carriers," she said, adding that Molina maintains a culturally sensitive staff.

With the opening of exchanges this fall, the healthcare industry is ushering in an entirely new way of doing business. No longer will insurers operate primarily within the business-to-business market, where they make deals with big employers to obtain several hundred new members, for example.

The online marketplaces officially introduce the business-to-consumer market, forcing insurers to reach out directly to individual people to obtain their business. The very newness of this market puts every company on even footing.

Who will become the new big players in this fresh market? Only time will tell. But I would venture to guess if a company can work hard, market to the right audience and offer competitive prices, it's anyone's ballgame.

Highmark success could push insurers to enter provider business 2 August, 2013 | Fierce Health Payer http://www.fiercehealthpayer.com/story/highmarks-success-could-encourage-insurers-enterprovider-business/2013-08-02 As hospitals make inroads into the health insurance business, insurers are getting more interested in crossing over to the provider side of the industry. The leader, so far, is Pittsburgh-based Highmark, which has invested $1.1 billion into the purchase of West Penn Allegheny Health System.

Some insurers believe buying hospitals and other providers can help diversify their business, better manage risk, control costs and meet quality measures. That's why many insurance companies throughout the country are looking to Highmark as it navigates the ins and outs of operating both an insurance company and several hospitals, reported the Pittsburgh Tribune-Review.

"Every insurer and Blue Cross plan in the country is taking a close look" at Highmark's experience, Ted Schwab, partner at the health and life sciences practice of Oliver Wyman, told the newspaper.

"If this one is successful, you're going to see activity at an unprecedented level."

Highmark chose to buy the West Penn system partly to help transform healthcare in the Pittsburgh market. "There has to be a better way, a better model that allows care to be delivered more

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affordably," Highmark CEO William Winkenwerder told the Tribune-Review.

"It gives us a real unique opportunity to offer lower costs, high quality and great service," Winkenwerder said. "I do believe that we are on the leading edge of change here in Pittsburgh." *Other insurers following in Highmark's footsteps, albeit on a much smaller scale, include Humana, which purchased urgent care clinic operator Concentra in 2010 and WellPoint, which bought clinic owner CareMore in 2011, FierceHealthPayer previously reported.

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Finance The Challenge of Helping the Uninsured Find Coverage 14 August, 2013 | The New York Times http://www.nytimes.com/2013/08/15/us/politics/the-challenge-of-helping-the-uninsured-findcoverage.html?emc=edit_tnt_20130814&tntemail0=y&_r=0 Cyndy Dailey held a job fair at her nonprofit agency here last weekend, with a major caveat: she did not yet know if she could hire.

Like many organizations across the country, Ms. Daily’s agency, Northern Virginia Family Service, is hoping to win a federal grant to help uninsured people in the state sign up for coverage under President Obama’s health care law. With the money, she hopes to hire at least a handful of “navigators” — a new category of worker created under the law to educate consumers about new health insurance options and, starting in October, to walk them through the enrollment process.

Navigators are seen as crucial to the success of the law. As the Jan. 1 deadline approaches when most Americans will be required to have health coverage or pay a fine, navigators are supposed to explain away confusion and fear among the legions of uninsured, helping them understand how new health insurance markets will work and whether they will qualify for subsidies to help with the cost of coverage.

But as the navigator effort gets under way across the country, it is clear that their impact will vary from state to state, with wide discrepancies in how much will be spent to hire and train navigators and how many people they will be able to reach. Many will be operating on shoestring budgets, with extremely tight time frames and hostile political climates.

“There’s definitely going to be a tremendous difference, not only in navigators but also in marketing funds,” said Andy Hyman, senior program officer at the Robert Wood Johnson Foundation. “So what we’re going to have to see in states with fewer funds is a lot more ingenuity.”

Maryland is spending $24 million on a program that will soon dispatch 325 navigators and assisters around the state. Colorado is investing $17 million on 400 “coverage guides,” and New York is spending $27 million on a similar effort.

But in states like Virginia, which declined to build their own insurance markets under the law and ceded the task to the federal government, navigators will not have much money to get the word out.

The Obama administration has promised up to $54 million for navigators in the 34 states where the federal government is setting up all or part of the markets. The grants are to be awarded Thursday.

In Virginia, up to $1.4 million will be distributed to navigator groups, which may include nonprofit community organizations, trade groups, chambers of commerce, unions and other public and private entities.

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“It is what it is,” Ms. Dailey said about the comparatively tiny budget for navigators in her state. “All we can do is make our best effort.”

Her agency has asked for $495,000, about a third of the total navigator funds allocated for Virginia.

That would cover the equivalent of seven and a half full-time navigators (some may end up working part-time), computers and other equipment for them to do their jobs, informational materials, marketing, and continuing outreach events in five counties.

The federal government did not anticipate having to cover the cost of running the insurance markets in 34 states, which is why it has only $54 million — transferred from a fund for public health prevention programs — for navigators in those states. The health care law set aside much more money for states that built their own markets, assuming that most would do so.

To fill in the gaps, other organizations will also be working to get the word out and helping people sign up for health plans through the new markets. About 1,200 community health centers around the country, which provide medical care for the uninsured, have received a total of $150 million in federal money to help with outreach and enrollment. Virginia’s health centers received $2.5 million.

In addition, many groups that did not apply for navigator funds will nonetheless help educate the uninsured about their options, connect them with navigators or point them toward the new insurance markets.

Insurance agents or brokers may also help people sign up for coverage through the markets; insurance companies selling plans through the markets will also play a role. Northern Virginia Family Service plans to enlist a network of partner organizations, many of whom already work with the uninsured, to help with outreach and enrollment or provide space and other resources.

“Other local groups may have funding or be in a position to get volunteers to do some of this work,” said Christine Barber, a senior policy analyst at Community Catalyst, a consumer advocacy group.

“Everyone is anxious to know who the navigators are so that other groups can partner with them, know who to refer people to, know how to flesh out their coalitions and their outreach.”

Navigators, who will also help small businesses and their employees learn about and enroll in health plans offered through the new markets, cannot recommend any particular health plan or receive compensation from an insurance company. They will get at least 20 hours of training and take a certification test.

Opponents of the health care law have nonetheless questioned whether navigators will know enough to help consumers understand the complexities of insurance coverage, and whether they can be trusted with the personal data that consumers will include in applications for coverage.

Ms. Dailey said her agency planned to run background checks on navigators and have them sign off on ethics policies, adding, “We will do a good job because we have all these protocols in place.”

Once the federal grants are awarded, recipients will have to move quickly to hire and train navigators and set their outreach plans in motion. Judy Robinson, whose small nonprofit group in Charlottesville, Va., hopes to win a grant to hire three navigators who would team up with at least a

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dozen volunteers, said she was excited about the possibility despite the pressure.

Ms. Robinson said her group, the Jefferson Area Board for Aging, was already getting calls from uninsured residents seeking information about the new insurance market.

“I’m a planner, I like to anticipate things, so it is a little hard for me,” she said. “But I’m just going to try to let go, go with the flow of it and not be upset not to have it all in place.”

Ms. Dailey said her “contingent-upon-award” job fair for navigators last weekend drew about 20 people, including retirees, recent college graduates and people with compelling personal stories about health care and insurance.

“My hope would certainly be that we could do fast-track interviews,” she said. “I think I have a good pool of folks.”

New Laws and Rising Costs Create a Surge of Supersizing Hospitals 12 August, 2013 | The New York Times http://www.nytimes.com/2013/08/13/business/bigger-hospitals-may-lead-to-bigger-bills-forpatients.html Hospitals across the nation are being swept up in the biggest wave of mergers since the 1990s, a development that is creating giant hospital systems that could one day dominate American health care and drive up costs.

The consolidations are being driven by a confluence of powerful forces, not least of which is President Obama’s signature health care law, the Affordable Care Act. That law, many experts say, is transforming the economics of health care and pushing a growing number of hospitals into the arms of suitors.

The changes are unfolding with remarkable speed. Two big for-profit hospital chains, Community Health Systems of Tennessee and Health Management Associates of Florida, are combining in a $7.6 billion deal.

In New York City, Mount Sinai Medical Center, which is one of the country’s oldest and largest private nonprofit hospitals, is buying the parent of Beth Israel Medical Center and St. Luke’s and Roosevelt Hospitals. Tenet Healthcare of Dallas, which operates in 10 states, is buying Vanguard Health Systems of Nashville, a network of 28 hospitals and facilities that includes Detroit Medical Center.

In fact, Booz & Company, a consulting firm, predicts that 1,000 of the nation’s roughly 5,000 hospitals could seek out mergers in the next five to seven years.

“There’s immense logic for them to become large super-regional systems, even some national systems,” said David W. Johnson, a managing director for BMO Capital Markets, which advises

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nonprofit health systems. Some chains are merging to increase their size and their negotiating clout with insurers, while others are trying to reduce costs and improve care, he said.

Some economists and health insurance companies worry that the trend could raise health care costs.

“The rhetoric is all about efficiency,” said Karen Ignagni, the chief executive of America’s Health Insurance Plans, a trade group that represents insurers. “The reality is all about higher prices.”

Whatever the outcome, hospitals are merging faster and in greater numbers than they have in years.

After holding steady through much of the 2000s, the number of deals doubled to 105 in 2012 from 50 in 2009, according to Irving Levin Associates, a health care research firm. That is still less than half the annual peak during the last merger wave, in the late 1990s, but Booz and others say this is only the beginning.

Hospital executives say they have little choice but to combine given the coming changes in the industry. Many hospitals are struggling with lower payments from the federal government and declining patient admissions. They are also being confronted with fundamental changes in how they are paid under the Affordable Care Act and by private insurers.

Instead of being paid on volume, rewarded for filling beds and performing more tests and procedures, hospitals are becoming responsible for more of the total cost of a patient’s care. As a result, they have an incentive to keep patients healthy — and out of their facilities.

By combining, hospitals can reduce costs in back-office activities like billing and devote more financial resources to investing in expensive electronic medical records systems and physician practices to better follow patients outside the hospital. Under the new state exchanges created by the federal health care law, consumers will be able to tell the difference in hospital prices between markets that have consolidated and those that have not, Ms. Ignagni said.

The plans have similar designs, but a policy offered by the same insurer in, for instance, Northern California, where hospitals have merged, will be more expensive than one offered in Southern California, where the systems are smaller, she said.

Federal regulators are concerned that the growing number of mergers could lead to anticompetitive practices. The Federal Trade Commission has increased its examination of the deals and has blocked a handful of transactions.

Last year, two hospital chains in Illinois, OSF Healthcare System of Illinois and Rockford Health System, abandoned plans to merge after the F.T.C. challenged the deal on the expectation that the combined hospitals would control 64 percent of acute-care inpatient services. That, regulators said, would allow the combined entity to raise rates and “impose a financial burden on local employers and employees,” through higher insurance premiums, co-pays and out-of-pocket expenses.

For the most part, however, the mergers continue unchallenged among for-profit systems as well as nonprofit hospitals.

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Roman Catholic-sponsored systems have formed some of the first national nonprofit chains, and some worry that Catholic hospitals’ growth and acquisitions of non-Catholic hospitals could limit patient access to services like birth control.

In May, for example, Trinity Health and Catholic Health East joined forces to create an 82-hospital system in 21 states. Ascension Health, the largest Catholic nonprofit health system, added 35 hospitals to its network of 78 this year when it closed a deal to acquire a hospital system based in Tulsa, Okla. Ascension has teamed with Oak Hill Capital Partners, a private investment firm, to help finance some of its purchases in the future.

“There isn’t an independent hospital out there that is not thinking about this,” said Gary Ahlquist, a senior partner at Booz, the consulting firm, referring to the mergers. “At the top of the list is the question, Who should I merge with?”

The last wave of mergers took place in the mid-1990s as hospitals joined forces to combat the potential threat from managed care and a giant for-profit chain now called HCA Healthcare. As those threats receded, mergers slowed.

“Today, the motivations for mergers are a lot broader,” said Paul Ginsburg, the president of the Center for Studying Health System Change.

“These independents, or smaller hospitals, are very worried about their ability to do well in the future,” he said.

Analysts say there is not a one-size-fits-all model for this merger wave. While some systems are fanning out across the country, others appear to be focusing on a certain state or region.

But as the hospital merger boom continues, hospitals fiercely holding onto their independence may find it more difficult to compete against bigger, leaner organizations, say analysts.

“There are hospitals out there that have been independent for 80 years and they’re saying, ‘We’re going to be independent for the next 100 years,’ ” said Lisa Goldstein, an analyst of nonprofit hospitals at Moody’s Investors Service. “That’s going to be a tall order. As other hospitals consolidate and grow around you, whatever niche you had will vaporize.”

Employee engagement saved UnitedHealth $107M 7 August, 2013 | Fierce Health Payer http://www.fiercehealthpayer.com/story/employee-engagement-saved-unitedhealth107m/2013-08-07 UnitedHealth saved $107 million in health costs over three years by engaging its employees, including motivating them to maintain healthy lifestyles and lose weight, according to a new report published in the journal Health Affairs.

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In only one year, UnitedHealth's "Rewards for Health" program led to 76 percent of its employees decreasing their premiums, with 27 percent cutting rates by $1,200. Employees are rewarded with premium cuts by meeting certain health goals, including getting screenings for cancer or diabetes or reducing their body mass indexes.

"Our own experience with our 133,000 employees shows that rewarding healthy behavior works.

Implementing patient-engagement strategies more broadly could have a profound impact on consumer health, help achieve wide-scale cost reductions and advance a higher-performing health system," report author Lewis Sandy, UnitedHealth's senior vice president for clinical advancement, said Monday in a statement.

Moreover, UnitedHealth found in only two years the program resulted in particularly large increases in employees' wellness visits and office-based screenings, colorectal cancer screenings and retinal eye exams for workers with diabetes.

"I think we are seeing greater and greater interest in aligning interests in healthcare, to offer consumers incentives to actually do what it is that will improve their health," Sandy told Bloomberg.

Portage Health inks definitive agreement to form joint venture with LifePoint Hospitals 6 August, 2013 | News Medical http://www.news-medical.net/news/20130806/Portage-Health-inks-definitive-agreement-toform-joint-venture-with-LifePoint-Hospitals.aspx The Portage Health Board of Directors has signed a definitive agreement to form a joint venture with LifePoint Hospitals速 (NASDAQ:LPNT). The agreement, which includes $60 million in capital investments over the next 10 years by the new joint venture, would allow Portage Health to expand and enhance its services to better meet the healthcare needs of its communities.

"We are delighted to take the next step in our potential joint venture with LifePoint," said Steve Zutter, chairman of the Portage Health board. "As we have explored this partnership, our board has become even more excited about the benefits that becoming part of LifePoint will bring our communities. This joint venture offers Portage Health opportunities not only to expand and enhance the care we provide, but transform healthcare provided throughout the region."

Under the terms of the definitive agreement, Portage Health and LifePoint would jointly own and operate Portage Health and its affiliated assets. LifePoint would own 80 percent of the joint venture, while Portage Health would have a 20 percent ownership stake. In addition to the $60 million in capital investments by the joint venture, approximately $40 million would be used to create a locally governed charitable foundation to fund organizations that support crucial community needs.

"LifePoint is very pleased to have reached this important milestone in our proposed partnership with Portage Health," said LifePoint Hospital's Chairman and Chief Executive Officer William F. Carpenter

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III. "We have enjoyed working with the Portage Health team and learning more about the hospital and the important role it plays in the U.P. We are excited at the prospect of becoming part of this community and working with Portage Health to find ways to make the Western Upper Peninsula healthier."

As part of the agreement, governance of Portage Health would be equally shared between Portage Health and LifePoint to ensure that the community has an active and ongoing voice in the strategic direction of the hospital. An eight-member governing board with equal representation from Portage Health and LifePoint would be established.

"This joint venture has exciting potential for Portage Health, our physicians, employees and patients," said Jim Bogan, Portage Health President and CEO. "LifePoint has a strong track record of partnering with hospitals across the nation to improve healthcare in their communities. Through this joint venture, we have great opportunities not only to make Portage Health an even better place to work and receive quality care, but to strengthen and shape the future of healthcare in the Western Upper Peninsula."

The definitive agreement is subject to review by the Attorney General of Michigan before being finalized.

Aviv REIT acquires post-acute and long-term care skilled nursing facility in Kentucky 2 August, 2013 | News Medical http://www.news-medical.net/news/20130802/Aviv-REIT-acquires-post-acute-and-long-termcare-skilled-nursing-facility-in-Kentucky.aspx Aviv REIT, Inc. ("Aviv" or the "Company") (NYSE: AVIV) announced today it has acquired a post-acute and long-term care skilled nursing facility ("SNF") in Kentucky for $9.3 million. The property is triplenet leased to existing Aviv tenant Diversicare Healthcare Services ("Diversicare"). Diversicare is an operator of SNFs with 54 facilities in 9 states. The triple-net lease has an initial cash yield of 10.25%, initial lease term of 15 years and an annual compounded escalator based on CPI. "We began our relationship with Diversicare in 2012 and we are pleased to continue to grow our relationship with them," said Craig M. Bernfield, Chairman and Chief Executive Officer of Aviv. "We have closed on $46 million of investments year-to-date and we are continuing to work on other opportunities in our pipeline."

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CEO: Humana to sell plans on 14 exchanges 2 August, 2013 | Fierce Health Payer http://www.fiercehealthpayer.com/story/ceo-humana-sell-plans-14-exchanges/2013-08-02 Humana will be participating in health insurance exchanges in 14 states, up from the company's previous prediction of 10 online marketplaces, CEO Bruce Broussard said Wednesday.

"We expect the exchange products to include primarily HMO offerings, with select market presence with each of the 14 states, ensuring we are offering a competitive and cost-effective value," Broussard said, according to Business First.

Although he only identified Mississippi as one of the states where Humana would sell plans on an exchange, Broussard said the insurer is prepared to enter the 14 exchanges. "Tactical plans for sales, enrollment and retention (related to the plans) are well into the implementation phase," he said.

But Broussard added Humana is keeping a cautious outlook regarding the exchanges, having already created contingency plans in case of technology issues during the initial rollout, Reuters reported.

Broussard announced the exchange plans while releasing Humana's second-quarter earnings report.

The insurer's net income grew 18 percent to $420 million from $356 million in last year's second quarter, while revenue rose 6.4 percent to $10.3 billion.

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Technology Talking Scales And Telemedicine: ACO Tools To Keep Patients Out Of The Hospital 15 August, 2013 | Kaiser Health News http://www.kaiserhealthnews.org/Stories/2013/August/15/Minnesota-ACO-accountable-careorganizations.aspx When Bill Hill prepares to weigh himself each morning, a mechanical voice speaks to him from a small box on his nightstand that is connected to the scale on the floor.

"Ready for Health Check?" the voice asks. "Do you want to check your weight? Please step on the scale."

As Hill, 75, steps on the scale, his weight appears 24 miles away on a computer monitor at Essentia Health in the northwestern Minnesota town of Duluth. There, registered nurse Denise Buxbaum monitors his health as part of a program that aims to keep about 300 heart failure patients out of the hospital.

For Hill, who was diagnosed with heart failure more than seven years ago, the morning weigh-in has become as routine as putting on his shoes. Like countless other patients nationwide, he's becoming more involved in his healthcare.

That's a major goal of the federal health care overhaul. Essentia Health has been taking care of patients like Hill with telehealth tools like the special scale since 1998. And now it is an Accountable Care Organization, or ACO. That means it takes responsibility for the health of a population of Medicare beneficiaries and can share any savings created by keeping people like Hill out of the hospital.

Taking care of people with congestive heart failure gave Essentia “both competence and confidence to move forward as an Accountable Care Organization,” says Essentia Health’s Chief Operations Officer John Smylie.

Data is key to making ACOs work. Armed with information, patients can alert doctors to potential problems early and prevent complications. If Hill's weight goes up, a nurse or nurse practitioner will call him because heart failure patients gaining just one extra pound can signal a problem.

Something as simple as eating salt the day before can boost his weight, as it makes him retain water.

Because a heart failure patient's heart is already weakened, it can't handle the extra fluid, which eventually can back up into the lungs.

When that occurs, a nurse practitioner can prescribe a diuretic for one day to pull water out of the body. Sometimes that's enough; other times it's not.

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Although the scale provides a daily link to caregivers a half hour away, they can detect only so much.

Follow up with the patient is still necessary. "They're not a treatment; they're a tool," said Linda Wick, nurse practitioner manager of Essentia's heart failure program.

"The bigger picture is the nurses are talking to them, they're finding out what's going on," Wick said.

"They're assessing, 'hey, maybe they ran out of their medications because they couldn't afford them'....so the nurses can pull in resources to help them get their medications.�

Nurses also can gauge whether a heart failure patient is is suffering from depression, which can make heart disease worse.

When nurses detect symptoms that indicate patients could be depressed, the nurses will make appointments for them to see their primary care doctors. They do the same for patients being treated for other illnesses, such as diabetes.

Essentia's heart failure program, which began in 1998, has evolved over time. Wick said no more than 2 percent of the heart failure patients in Essentia's program need to be readmitted to the hospital within 30 days. That's a fraction of the national average of about 25 percent.

Essentia rents the scales from a company based in Chanhassen, Minn. Essentia wouldn't divulge what it pays, only that it receives a discount for what would cost between $60 and $100 per patient per month.

Wick said an average hospitalization for heart failure at Essentia Health-St. Mary's Medical Center costs between $6,000 and $11,000. If the patient needs to be readmitted, she said, the cost is more.

Keeping heart failure patients out of the hospital is not only good for patients, it's also good for medical centers' bottom lines, particularly now. Last year, as part of the federal health care law, Medicare started penalizing hospitals that had too many heart failure readmissions.

Such readmissions are expensive and put patients at risk, said Susan Mende, a senior program officer for the nonprofit, nonpartisan Robert Wood Johnson Foundation, which focuses on improving the health system. "Unnecessary readmissions really negatively affect people's health, and they put a huge burden on patients and their families, and they cost our country billions of unnecessary dollars," Mende said. "So I think we're seeing more and more strategies for better home management."

Mende said it's likely there will be more strategies to connect health providers with patients in their homes.

For Hill, stepping on a scale once a day means that he and his wife can tend four horses on their hobby farm.

"I ride [a] four-wheeler," he said. "I got a diesel tractor out there that I clean horse biscuits out of the pasture with and dump on a manure pile, and I don't work real hard. I don't beat myself to death but I stay active."

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That activity not only keeps Hill healthy, but also keeps him out of the hospital -- and saves the health care system money.

Patients Can Pay A High Price For ER Convenience 13 August, 2013 | NPR http://www.npr.org/blogs/health/2013/08/15/211411828/patients-can-pay-a-high-price-for-erconvenience Medical entrepreneurs are remaking the emergency room experience. They're pulling the emergency room out of the hospital and planting it in the strip mall.

It's called a "free-standing ER," and some 400 of them have opened across the country in the past four years.

The trend is hot around Houston, where there are already 41 free-standing ERs and 10 more in the works.

"I think these emergency medical centers are springing up like Texas wildflowers in the springtime," says Vivian Ho, a health economist at Rice University in Houston. "It's really amazing."

Some of the new facilities are owned by hospitals, but the majority are owned by for-profit companies. Ho says they may offer excellent care, but they're also chasing profits.

"They are usually set up in places where there are high-income patients who are well-insured and who want to see someone quickly," says Ho. They're not being built in poor neighborhoods, rural communities or areas with lots of uninsured people.

Patients like Lisa Boncler love how accessible they are. She came to the Texas Emergency Center in the affluent Houston suburb of Atascocita to get stitches on her scalp after she gashed her head on a gate handle.

"This is not the first time I've been in here," says Boncler, who has a choice of six different ERs, two based at hospitals and four free-standing, like Texas Emergency Center. "It's always fast [and] I don't feel like I'm picking up 1,000 germs."

The waiting room, furnished with brown leather armchairs and a coffee station worthy of a spa, is empty because patients are usually seen right away.

But Texas Emergency Center is a real emergency room. It's licensed by the state and staffed around the clock by a doctor and a nurse.

"We're a service to the community. We give them back the most valuable thing: time," says Terri Hardy, who is chief of clinical operations for Texas Emergency Center. "They come here and we see them immediately. We perform the same labs, the same X-rays, the same CAT scans, the same

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ultrasounds. ... It's convenience."

Free-standing ERs can make a lot of money because they charge ER prices. A visit that might have cost $200 at an urgent-care center can cost four or five times as much at an ER. Bills are just like at the hospital ER — you pay for the treatment, the doctor's fee and something called a facility fee. That fee is for all the overhead, including expensive equipment like the CAT scanner and the lab.

Patients are sometimes shocked when they get the bill.

Steve Henderson, 41, lives in Spring, a suburb north of Houston. He woke up one morning in March with back spasms so bad he could barely walk. He dragged himself to his car and drove to what he thought was an urgent-care facility.

The sign did say emergency, but it just didn't look like an ER. "My idea of an emergency room is attached to a hospital with crash carts and cardiac arrest and car wreck victims and all that stuff," he says. He says the place he went looked like "your friendly neighborhood doc-in-a-box" in a shopping center with a doughnut shop across the street.

Henderson got a shot in his back, a prescription and, later, a bill for $1,200 — $900 of that for the facility fee.

"I knew there'd be some kind of fee for this place. But $900 for just walking in the door is outrageous," says Henderson, who is insured but hadn't met his deductible. He was on the hook for the whole fee.

Similar consumer complaints can be found online and on file at the Better Business Bureau.

Insurance companies are also pushing back. By law, they must cover emergency room visits, even if the ER isn't in their network.

"For these free-standing ERs, we've seen our dollars and visits just about double over the past year," says Shara McClure, a vice president for Blue Cross Blue Shield of Texas. "While ER is a choice, it's a high-cost choice and it's one that can cost five to seven times more than a typical office visit."

But standalone-ER executives emphasize they treat real emergencies all the time.

"The problem with urgent care is if you're having something serious, you go there [and] they either call 911 or they send you to the emergency department," says Brian Orsak, co-founder of St. Michael's Emergency Rooms, which has three locations in Houston. "We're equipped basically to handle anything."

But that level of care has a price to the entire health care system, says economist Ho, at a time when the government — and insurers — are trying to control those costs

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Some states have tougher regulations for free-standing ERs, like requiring them to be part of a hospital system.

And some insurance companies have sued over the facility fees or persuaded the ERs to sign contracts and accept lower payments.

For now, it's up to the medical consumer to figure out where to go for the right level of care at the right price.

HealthcarePays creates virtual card processing solution for healthcare providers 9 August, 2013 | News Medical http://www.news-medical.net/news/20130809/HealthcarePays-creates-virtual-card-processingsolution-for-healthcare-providers.aspx HealthcarePays (HCP) has created a virtual card processing solution to ensure compliance, reconciliation of remittance information with payments, and detection of waste and fraud for healthcare providers throughout the United States. MasterCard will supply the connection between banks and providers to ensure speed and convenience in the payment process.

"We are using our expertise to help transform healthcare payments to new, efficient and paperless systems before January 2014," said Michael Cyr, group executive, MasterCard. "HealthcarePays offers a straightforward, transparent system for U.S. providers that reduces payment processing time and allows providers to receive payments for services faster."

With the new virtual card, healthcare providers process payments completely electronically and easily download reconciled information from commercial and government payers within the HCP network. HCP's unique industry-owned network reconciles remittance data with payments and systematically distributes Electronic Remittance Advice (ERAs) and Electronic Payments.

HCP employs a novel approach to healthcare payment processing that is all-inclusive, yet industrystandardized and fully compliant with the Affordable Health Care Act (ACA) and all state and federal laws. Every participant in the healthcare payment ecosystem – providers, employers, private and government payers, intermediaries, clearinghouses and banks – can own and use the secure network to access the data they require to complete healthcare payment transactions.

"Our goal is to eliminate paper from the healthcare payment system once and for all. The MasterCard virtual card and HCP network work together to eliminate paper processes and significantly reduce waste and fraud in healthcare, which is siphoning an estimated $600 billion from our healthcare system annually," says HealthcarePays Chief Executive Officer Dave Adams. "The strength of the HCP network is that it works with all the players within the healthcare payment system on one universal platform, creating an efficient, cost-saving network that reduces costs for the entire healthcare industry."

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TruClinic signs new partnership with University of Utah Hospital's Department of Telemedicine 8 August, 2013 | News Medical http://www.news-medical.net/news/20130808/TruClinic-signs-new-partnership-with-Universityof-Utah-Hospitals-Department-of-Telemedicine.aspx Today TruClinic™ announced a new partnership with University of Utah Hospital's Department of Telemedicine, which will enable patients and practitioners to have video-based online visits and consultations with simply a computing device, Internet connection and a webcam.

University of Utah Health Care (UUHC) is the Intermountain West's only academic health care system, combining excellence in patient care, the latest in medical research and teaching to provide leading-edge medicine in a caring and personal setting. The system provides care for Utahans and residents of five surrounding states in a referral area encompassing more than 10 percent of the continental United States.

UUHC has more than 1,100 board-certified physicians who staff four University hospitals (University Hospital, Huntsman Cancer Hospital, University Orthopedic Center, and the University Neuropsychiatric Institute); 10 community clinics; and several specialty centers including the John A. Moran Eye Center, the Clinical Neurosciences Center and the Utah Diabetes Center.

TruClinic™ is a cloud based telehealth portal that enables health systems, provider groups and specialty practices to offer online, clinically meaningful consultations to their patients through video, secure messaging, and VOIP. The TruClinic™ platform is helping the University of Utah remove the barriers of location, allowing more patients to access high quality health care. Justin Kahn, CEO of TruClinic™, comments, "We are very excited to be working with such a world class organization.

TruClinic's solution is enabling the University of Utah Health Care network to expand its reach and deliver convenient, much-needed care to households outside of its geographic footprint."

TruClinic™ and UUHC have been in a pilot phase for three months, serving a small subset of patients with much success. The relationship that has been formalized includes aggressive plans to make the service available system-wide where appropriate. Nathan Gladwell, Administrative Director of Telehealth for the University of Utah Hospitals and Clinics says, "University of Utah Health Care is committed to providing care that local and regional patients need in the communities we serve.

Telemedicine offers our physicians a solution for connecting with their patients that live in all communities. Our efforts are geared toward removing any barriers in the way of the all-important patient - physician relationship."

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Telemedicine improves pediatric care in rural Ers 8 August, 2013 | Fierce Health IT http://www.fiercehealthit.com/story/telemedicine-improves-pediatric-care-rural-ers/2013-08-09 Care quality for pediatric patients in rural emergency rooms improved "significantly" when delivered via telemedicine consultations, according to a study published online this week in the journal Critical Care Medicine.

For the study, researchers from the University of California Davis Children's Hospital examined ER cases for 320 seriously ill or injured patients 17 years old and younger between 2003 and 2007. The patients all were treated at hospitals in Northern California outfitted with videoconferencing units.

ER physicians used the tools to work with pediatric critical-care specialists at UC Davis Children's Hospital.

The researchers also determined parent satisfaction with care delivered to their children via telemedicine to be higher than consultations provided via telephone. Rural ER physicians were more apt to adjust diagnoses and treatments for such patients following the telemedicine consultations.

"This research is important because it is one of the first published studies that has evaluated the value of telemedicine against the current standards of care from three different viewpoints: the emergency room physician; the parents of the patients; and the actual quality of care and patient outcome," lead author Madan Dharmar, an assistant research professor in the pediatric telemedicine program at UC Davis, said in a statement.

Added study senior author James Marcin, director of the hospital's telemedicine program, "The bottom line is that this readily available technology can and should be used to improve the quality of care delivered to critically ill children when there are no pediatric specialists available in their own communities."

The study is a continuation of research published last month by in the journal Telemedicine and eHealth. In that study, the same team of researchers found that hospitals that used telemedicine technology and referred patients to children's facilities saw their revenue nearly double. For that study, the researchers examined billing information for patients transferred from 16 hospitals that used telemedicine, comparing information before and after the implementation of telemedicine tools from July 2003 through December 2010.

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Strategy Pueblo Surgery Center in Colorado Forms Partnership With St. Mary-Corwin Medical Center 13 August, 2013 | Becker's ASC Review http://www.beckersasc.com/asc-transactions-and-valuation-issues/pueblo-surgery-center-incolorado-forms-partnership-with-st-mary-corwin-medical-center.html St. Mary-Corwin Medical Center announced today a partnership with Pueblo Surgery Center. It will provide a convenient option for surgeries performed on an outpatient basis that do not require a hospital setting, such as colonoscopies, ENT, orthopedics, gynecology, podiatry and more.

The surgery center's leadership will remain intact with Dr. Ben Massey, medical director; Gala Hendricks, RN, director of nursing; and Jennifer Arellano, administrator. The surgery center will continue to operate as Pueblo Surgery Center, and will be managed by Surgical Care Affiliates.

Pueblo Surgery Center has been a preferred multispecialty, outpatient surgery center for patients and physicians in the Pueblo area since 1992 with a commitment to provide safe, high quality care to patients of all ages in the most cost effective manner. The Pueblo Surgery Center partnership provides patients with a choice for many same day surgery needs. The facility features five operating rooms, pre- and postoperative areas including overnight rooms for patients requiring additional recovery time. The center is intimate and comfortable, providing individualized care for patients, family and physicians.

ProMedica and Cleveland Clinic collaborate to develop health system affiliation 9 August, 2013 | News Medical http://www.news-medical.net/news/20130809/ProMedica-and-Cleveland-Clinic-collaborate-todevelop-health-system-affiliation.aspx ProMedica and Cleveland Clinic have signed a Memorandum of Understanding to develop a health system affiliation that will better position both organizations to anticipate and proactively respond to the evolving healthcare landscape.

As a result of this relationship, Cleveland Clinic and ProMedica will work together to create a clinically aligned network that will provide high-quality, cost-effective and technologically advanced clinical services in a framework of comprehensive population management.

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"Through this affiliation, ProMedica and Cleveland Clinic will collaborate to address current and emerging national issues in healthcare while maintaining their caring missions to their local communities," says Randy Oostra, DM, FACHE, president and CEO of ProMedica. "Who better to transform healthcare than healthcare. This alliance represents an inside-out approach to healthcare transformation."

Initial opportunities for collaboration include: the Cleveland Clinic's Quality Alliance, shared services, clinical and operational standardization, and supply chain efficiencies, as well as patient access and information technology.

As the two organizations move forward with their health system affiliation, groundwork will be laid for further integration in the future.

"In this transformational time in healthcare, a new level of collaboration is required and health systems are integrating in unique ways," said Toby M. Cosgrove, M. D., President and Chief Executive Officer, Cleveland Clinic. "This affiliation will allow Cleveland Clinic and ProMedica to work together to improve efficiency, reduce costs, and drive quality and value to patients."

The formal health system affiliation between the two organizations is a natural evolution of the Innovation Alliance ProMedica and Cleveland Clinic formed last year to help develop and commercialize medical innovation.

Nationally, healthcare organizations are moving from a hospital-centric model to a more populationcentric model. What that means is: Organizations are looking for new and innovative ways to collaborate to provide access to coordinated care across large populations; health systems will network to increase standardization of care and reduce care variation; and for these organizations there will be increased focus on providing care at the right place, the right time and at reduced cost.

"Increasingly, healthcare organizations from across larger geographic regions will network to improve care in local communities as well as for broader populations," says Stephen H. Staelin, chairman, ProMedica Board of Trustees. "What's being expected are new, sophisticated capabilities to deliver value-based care. We can build these capabilities together, along with economies of scale and skill."

The first step in the health system affiliation is the establishment of an Affiliation Steering Committee to be co-chaired by representatives from Cleveland Clinic and ProMedica, with equal representation from both parties. The steering committee will be responsible for oversight, guidance, and development of the relationship.

"This is an important step in the new healthcare realm, which will integrate Cleveland Clinic and ProMedica in deeper ways to enhance healthcare delivery and strengthen our ability to jointly explore additional clinical and functional collaborations," said Robert E. Rich, Chairman, Cleveland Clinic Board of Directors.

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Minn. Blues partners with provider for new narrow network plan 9 August, 2013 | Fierce Health Payer http://www.fiercehealthpayer.com/story/minn-blues-partners-provider-new-narrow-networkplan/2013-08-09 Blue Cross Blue Shield of Minnesota has partnered with Allina Health, one of the state's largest provider systems, to create a new health plan based on interviews with patients and employers about which aspects they don't like in their current coverage.

The result is BluePrint, a plan that aims to eliminate any financial barriers to members receiving medical care, including skipping co-pays and deductibles for some office visits, reported Minneapolis Public Radio.

"We tried to strip everything out that got in the way of optimal patient care," Robert Wieland, executive vice president of Allina's clinic and community division, told the Minneapolis Star-Tribune.

The BluePrint plan, which will be available on the state's health insurance exchange, is geared for consumers with three chronic conditions--diabetes, hypertension and high cholesterol--although the plan is open to anyone. Members will receive two free office visits, including primary care, specialty or behavioral health, while those with chronic conditions will have an extra free office visit.

And since it's a narrow network plan, members will have to seek care at one of Allina's hospitals and clinics as well as doctors working at 52 independently-owned physician practices. When consumers sign up for BluePrint, they will take a health assessment, after which Allina will contact them to help better manage their health, the Minneapolis/St. Paul Business Journal reported.

Wieland thinks such collaborations will continue to appear throughout healthcare markets. "I think health plans have areas of expertise that provider organizations don't, on the marketing side, in product development, and sales," he said. "Provider organizations have clinical data, clinical expertise, and I think a large ability to manage populations more effectively than a health plan does."

California exchange signs up 12 insurers, loses Ventura County plan 7 August, 2013 | Los Angeles Times http://www.latimes.com/business/money/la-fi-mo-california-health-exchange-ventura20130807,0,4028569.story California signed contracts with 12 health insurers for its new state-run marketplace, but the Ventura County Health Care Plan unexpectedly dropped out.

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Covered California, which is implementing the federal healthcare law in the state, said it supported Ventura County's decision to opt out next year and that it welcomes a subsequent bid for 2015.

The exchange said it will now provide three health plans -- Kaiser Permanente, Anthem Blue Cross and Blue Shield of California -- to Ventura County residents.

In contrast, the exchange will offer six health plans in Los Angeles County.

Officials said about 95,000 residents in Ventura County may be eligible for federal premium subsidies under the Affordable Care Act. Enrollment is expected to start Oct. 1 for policies that take effect in January.

"Covered California remains partners with Ventura County Health Care Plan and will lay the groundwork for negotiations next year," said Peter Lee, executive director of the state exchange.

The state noted that Anthem and Blue Shield will provide access to Ventura County Medical Center, Santa Paula Hospital and other area clinics.

Ventura County Health Care Plan, a government-sponsored HMO established in 1993, primarily covers county employees, their dependents and enrollees of Healthy Families. It has about 24,000 members.

A spokeswoman there didn't have an immediate comment on the state announcement.

The state's four largest health insurers are all participating in the state exchange for individual consumers. They are Kaiser Permanente, Blue Shield, Health Net Inc. and Anthem, a unit of WellPoint Inc. Six of the 12 companies overall will also sell policies in a separate exchange for small businesses.

However, Anthem opted against participating in the small-employer exchange.

PeaceHealth inks contract to serve Sterling Medicare SELECT policyholders 6 August, 2013 | News Medical http://www.news-medical.net/news/20130806/PeaceHealth-inks-contract-to-serve-SterlingMedicare-SELECT-policyholders.aspx In an effort to better serve the Medicare population in our community, PeaceHealth Medical Group in Oregon has contracted with Sterling Insurance to become a network hospital serving Sterling Medicare SELECT policyholders. Sterling Medicare SELECT, underwritten by Sterling Life Insurance Company, is a Medicare Supplement insurance plan offering lower premiums to policyholders in exchange for using a network hospital when hospital care is needed.

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According to Sterling's Vice President of Product Development, Gerald Reilly, this is a win-win situation for everyone. "Our health insurance policyholders enjoy favorable premiums with access to the local hospital they know and trust." Reilly went on to explain, "In the unlikely event PeaceHealth cannot provide the service needed, Sterling policyholders are free to go to a hospital that does. And, if the policyholder is traveling and needs emergency care, they can go to any hospital." Reilly added, "PeaceHealth is to be commended for taking this step. Not only will they be able to serve the needs of Medicare beneficiaries, the contract with Sterling may help save the Medicare beneficiary valuable premium dollars."

In addition to affordable premiums, Sterling Medicare SELECT policyholders have access to "Real People" customer service, automated claims processing, and knowledgeable agents that will assist them in making a well-informed choice for their health insurance needs.

Aetna pulls health plans from state insurance exchange 2 August, 2013 | The Baltimore Sun http://www.baltimoresun.com/health/bs-hs-aetna-maryland-exchange20130802,0,6211024.story Insurer says Md.-approved rates weren't feasible as it scrutinizes its offerings across the country Aetna Inc. said Friday it canceled plans to sell insurance on Maryland's new health insurance exchange, set to open Oct. 1 as part of the federal health care reform law, after regulators cut the rates it could charge consumers for its plans.

Aetna was one of several carriers poised to sell on the state's exchange, along with Coventry Health Care, which Aetna acquired this spring. But Aetna told Maryland Insurance Commissioner Therese M. Goldsmith in a letter this week that cuts regulators made to the rates the companies had proposed "would not allow us to collect enough premiums to cover the cost of the plans."

The decision leaves the exchange with fewer choices for consumers who need to buy insurance, as required by the law, because they don't have it now or can't get it from their employer. But state officials said they don't expect the loss of Aetna and Coventry to significantly reduce consumers' options.

Officials hope the exchange will keep the cost of health insurance low for consumers with competition among the insurance carriers. And as more people enroll, costs are expected to decline.

"This is not a step that we take lightly," Aetna said in a statement. "We believe it is critical that our plans not only be competitive, but also financially viable, allowing Aetna and Coventry to meet the long-term needs of the Exchanges in which we choose to participate."

Aetna and Coventry combined insure 13,000 individual members in Maryland and 620,000 individuals nationwide. The decision does not affect coverage the insurers offer in the state through employers.

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Aetna had filed a proposal with state insurance regulators to raise its rates 25.4 percent, the highest of any carrier. The rate the state approved July 26 was 29 percent lower than what Aetna sought, while other carriers saw their proposals cut back by as much as 33 percent.

State health officials estimate that 180,000 people will buy individual insurance policies from the exchange for 2014. They will largely come from the 146,078 Marylanders who currently buy in the individual market and from the estimated 740,000 uninsured people in the state.

Top state health insurance officials, including Goldsmith and Rebecca Pearce, executive director of the state exchange, Maryland Health Connection, said they were confident in the range of options that will be available on the exchange when it opens this fall. Coverage through the exchange becomes effective Jan. 1.

"Notwithstanding Aetna's business decision not to offer products in Maryland's individual insurance market, consumers will continue to have many choices among health insurance carriers and plan options when open enrollment begins in October," Goldsmith said in a statement.

Pearce added that the carriers' departure does not affect an analysis showing rates on Maryland's exchange to be competitive nationally.

"The rates are still the lowest in the country," Pearce said in an interview. "I believe the plans will be competitively priced and people will find something that's right for them."

Insurance officials do not expect any other carriers whose rates were approved to follow Aetna.

Aetna's decision came days after it pulled its and Coventry's plans from Georgia's exchange, and as its CEO expressed hesitation about participating in other exchanges around the country. The company pulled out of California's individual insurance market earlier this year.

In a quarterly earnings conference call, Aetna CEO Mark Bertolini said the company was cautious about the rollout of the exchanges and was considering whether to cut back on its participation in them in 14 states. The company, meanwhile, plans to participate in private exchanges being run by benefits companies and is working on launching its own exchange for Aetna products.

"We are continuing to evaluate where Aetna and Coventry have submitted bids and are in the process of rationalizing our combined exchange participation," Bertolini said.

Also Friday, Coventry pulled a dental plan to be offered on Maryland's exchange. That plan's rates had been approved without modification.

One other insurer, a new cooperative model, said it remains committed to Maryland's exchange.

"We are very much devoted to staying on the exchange. That's the mission for our entire insurance company in the first place," said Dr. Peter Beilenson, president and CEO of Evergreen Health Cooperative Inc., which formed in November and plans to offer two types of plans on the exchange.

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Other insurers, including CareFirst BlueCross BlueShield and Kaiser Foundation Health Plan of the Mid-Atlantic States Inc., could not be reached for comment late Friday. Nine carriers in all had proposed plans for sale on the exchange, though they were represented by five owners.

Beilenson, the former health commissioner for Baltimore and more recently for Howard County, said it was unfortunate that Aetna decided to drop out. The point of the health care law is to increase competition so consumers have more choices and more affordable care, he said.

On the other hand, he noted, Aetna's action also means his new insurance company will have less competition.

Vincent DeMarco, president of the advocacy group Maryland Citizens Health Initiative, said Marylanders still will have plenty of choice within the exchange even without Aetna.

"There are seven carriers left providing a broad range of services, which we think are at reasonable rates, especially with the subsidy that the federal government is providing," he said. "Marylanders will be well-served."

DeMarco said he thought the commissioner did the right thing on setting rates.

"We wish as many as possible would have stayed," he said. "The point is the rates have to be fair for consumers. The commissioner came up with some fair rates."

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