16 September 2010
California Edition
Calendar
September 19-21
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E-Mail
info@payersandproviders.com with
the details of your event, or call
(877) 248-2360, ext. 3. It will be
published in the Calendar section,
space permitting.
Enrollment Down, But Complaints Up
Year-to-year DMHC Grievances Up 9% For Big Plans
Despite a modest drop in the number of
Californians enrolled in HMOs, the number
of complaints filed with the Department of
Managed Health Care against large plans
rose 9% in 2009, a number some say could
rise further as components of federal
healthcare reform are implemented.
A total of 4,274 complaints were filed
in 2009, versus 3,864 in 2008. That’s
despite the fact that overall enrollment in
large plans – those with 400,000 or more
lives – dropped by 105,000 to 15.52
million.
Kaiser Foundation Health Plan
garnered the most complaints, 1,809, or
more than 40% of the total. That is up from
1,516 in 2008, an increase of 17.2%. At
the same time, its enrollment dropped
5.2%, to 5.65 million.
Blue Shield of California also saw a
considerable rise in complaints, from 675
in 2008 to 799 last year, up 15.6%. Its
enrollment was down 4.7%, to just over 2
million.
Anthem Blue Cross of California saw a
decrease in complaints, to 935 from 1,046,
down 10.7%. Its enrollment was down
9.2%.
Health Net and PacifiCare both saw
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modest decreases in complaints, although
PacifiCare’s enrollment dropped 23.2%.
Regarding specific complaints, those
involving coordination of care increased
22.7%, to 613, while most of the other
categories showed more modest rises.
Among plans with enrollment below
400,000, complaints dropped 42%, from
212 filed in 2008 to 123 last year. Total
enrollment dropped 22.6%, to 2.86
million.
Meanwhile, investigative medical
reviews dropped 15%, to 1,615,
compared with 1,900 in 2008.
A DMHC spokesperson did not
immediately respond to a request for
comment.
Health plan officials say that few
trends may be read into the numbers.
“We take each complaint seriously,
but it is normal to see some fluctuation
from year to year,” said Kaiser spokesman
Jim Anderson. He added that the increase
was the equivalent of one more complaint
being filed for every 1,000 members.
Kaiser’s complaints had dropped in
2008. It had 1,834 complaints in 2007,
similar to its 2009 numbers.
Continued on Next Page
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In Brief
CMA Sues Blue Shield
Over Physician Ratings
The California Medical Association
has filed a lawsuit against San
Francisco-based Blue Shield of
California, claiming its physician
rating system for enrollees is deeply
flawed.
The lawsuit, filed in Alameda
County Superior Court, claims Blue
Shield’s Blue Ribbon Recognition
Program physician rating system is
masquerading as “an economic
profiling scheme that inaccurately
and unfairly 'rates' the physician
plaintiffs and members of the
physician class through the use of
an inherently flawed methodology.”
The suit claims that the system,
which rates about 6,000 physicians
statewide, does not include
information on patient outcomes,
and does not allow physicians who
are rated to correct any erroneous
information.
The lawsuit demands an
injunction that would require Blue
Shield to pull its ratings system,
along with damages. The CMA
represents about 35,000 physicians
statewide.
Brown & Toland To Join
Sutter Network
The San Francisco-based Brown &
Toland Physicians IPA has agreed to
afliate with the Sutter Medical
Network of Northern California
Physicians.
The afliation adds Brown &
Toland’s 800 physicians to the
approximately 4,200 already
practicing in the Sutter network.
“When primary and specialty
physicians come together with a
common goal of creating the highest
quality experience based on best
medical practices, our patients and
communities benet,” said Jeff
Burnich, M.D., a Sutter Medical
Continued on Page 3
NEWS
Complaints (Continued from Page One)
Concurring with Anderson was
Nicole Kasabian Evans, spokesperson for
the California Association of Health
Plans, the state’s leading trade group.
“The numbers change from year to
year,” she said. “There’s been a lot
happening regarding healthcare over the
past year, and I don’t know how that’s
impacting people and their interactions
with their health plans.”
Evans’ reference to healthcare reform
was echoed by Anthony Wright,
executive director of Health Access, a
Sacramento-based patient advocacy
group. He believes that as major federal
health plan reforms are implemented
For Counties, A Coverage Struggle
Study Shows Differences In Recession-Based Losses
Californians have suffered enormous losses of
healthcare insurance coverage during the
Great Recession, but some counties have fared
far worse than others, according to UCLA
researchers.
A study issued last month by the UCLA
Center for Health Policy Research indicates
every county in California saw its rates of
uninsured go up. Some counties saw the
percentages of their population uninsured for
all or most of a year increase by 30% or more.
Most of those were rural counties, but urban
counties, most notably those in the Bay Area,
were also hit hard.
“These huge jumps are astronomical,”
said Shana Alex Lavarreda, UCLA’s director of
health insurance studies and the lead
researcher for the county-based data.
Alameda County saw its uninsured rate
jump from a modest 10.6% in 2007 to 15%, a
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Page 2
incrementally between this Sept. 23 and
2014, consumers may become more
demanding.
Among the changes to take effect next
week are the lifting of lifetime annual caps
on coverage; a loosening of age
restrictions for children to remain on their
parents’ policies, and mandated coverage
for preventative care. That last rule mostly
applies to recent and future health plan
enrollees.
“As we had we head next week into
range of new patient protections, that will
only create some new expectations for
insurers,” Wright said.
jump of about 40%. Solano County saw a
similar jump, from 14.9% to 20.3%.
Placer County, the only county in
California with an uninsured rate below 10%
in 2007, saw its rate increase from 9.6% to
15%. That’s more than 50% jump and the
biggest percentage-wise increase in California.
Los Angeles County, by far the state’s most
populous county, lost the most insured, its
uninsured rate rising from 22.9% to 28.9%.
That means about 600,000 people in the
county lost coverage in less than two years.
“There are a lot of low-income workers
and immigrants in the county who had job-
based coverage that they lost,” said Jim Lott,
executive vice president of the Hospital
Association of Southern California. Those
who lost that coverage likely could not afford
Continued On Next Page
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In Brief
Network senior vice president.
The Sutter group now has 18
afliated physician groups covering 24
Northern California counties.
Coye Named To UCLA
Health System Post
Molly J. Coye, M.D., has been
named chief innovation officer of
the UCLA Health System.
Coye will oversee UCLA-
based initiatives to try and improve
healthcare delivery, particularly as
it relates to federal healthcare
reform.
Coye, who was previously
with the Public Health Institute in
Oakland, was previously director
of the former California
Department of Health Services and
as commissioner of the New Jersey
Department of Health.
“Dr. Coye’s remarkable
background makes her just the
right person to work with our
Health System’s clinical and
administrative leadership,” said A.
Eugene Washington, UCLA’s vice
chancellor of health sciences.
Coye will assume her new post
later this month.
UCI Wins
Anesthesiologist
Training Grant
UC Irvine’s anesthesiology and
perioperative care department has
won a Picker Institute/Gold
Foundation Grant to change the
way anesthesiologists are trained. It
will implement a 19-week program
to teach more compassionate
patient care..
"Few, if any, anesthesia
residency programs focus on the
patient experience," said Zeev N.
Kain, chair of UCI's department of
anesthesiology & perioperative
care.
NEWS
Counties (Continued from Page Two)
to continue coverage under COBRA, Lott
added.
Only 10 counties still had rates of
uninsured below 20% of the total population,
versus 24 in 2007. Shasta County had the
highest uninsured rate of 32.7%, up from
27.4% in 2007. San Mateo County had the
lowest uninsured rate at 14.3%, up from
10.8% in 2007.
Lavarreda does not believe the rates of
job-based coverage will begin seeing
Medi-Cal Hospital Fee Approved
Legislation SIgned Into Law; CMS Approval Near
Gov. Arnold Schwarzenegger signed AB
1653 into law last week, among the nal
steps toward a self-imposed fee on the state’s
hospitals that is expected to draw down
billions of dollars in additional funds from
the Medi-Cal program.
The lengthy piece of technical legislation
sets the ground rules for how the fee may be
imposed on and paid by the hospitals, and
which ones would benet from the extra
Medi-Cal payments. The plan is now pending
approval by the Centers for Medicare and
Medicaid Services, which is negotiating with
the California Department of Health Care
Services, which administers Medi-Cal. A
DHCS spokesperson indicated that an
announcement would likely occur later this
week.
“We’re hoping that CMS signs off on this
soon,” said Jan Emerson, vice president of
external affairs for the California Hospital
Association. “This bill addresses all the
concerns that they had.”
The fee, which would apply retroactively
from the spring of 2009 and expire at the end
of this year, is expected to help draw down
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Page 3
dramatic improvement for at least a couple of
years. However, she does believe that an
impending expansion of the Medi-Cal
program through a special waiver and the
federal healthcare reform – which mandates
consumers may purchase coverage without
preexisting conditions – will make a difference
in the rates of uninsured.
But even with those initiatives, Lavarreda
cautitoned “that a quarter of the state’s
uninsured will still be left out.”
an additional $2.6 billion in Medi-Cal
matching funds from the federal government.
Some hospitals are in desperate need of a
boost in Medi-Cal revenues, as the rates paid
in California are among the lowest in the
nation. The fee also takes advantage of last
year’s $700 billion stimulus program, which
temporarily altered the matching funds
formula to the advantage of providers.
However, according to a formula that was
negotiated by the federal government, 19
hospitals and two hospital systems – about
10% of the state’s total acute care facilities –
would not reap benets from paying the fee.
Emerson noted that most of those
hospitals, such as Eisenhower Medical Center
in Rancho Mirage, serve wealthy communities
and see few Medi-Cal patients. One of the
systems is Kaiser Permanente, which only
treats Medi-Cal patients who might appear in
the emergency rooms of its individual
hospitals.
In addition to providing the money for the
hospitals, about $500 million will be set aside
for Healthy Families, the state’s health
insurance program for moderate-income
children.
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Payers & Providers
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OPINION
“Healthier” Doesn’t Mean Drudgery
A Program to Improve Lifestyles Also Emphasizes Fun
According to the U.S. Centers for Disease
Control and Prevention, the prevalence of
obesity among adults aged 20 and over
has increased from 19.4 percent in 1997
to 28 percent in
2009.!The
Congressional Budget
Office estimates that
providing healthcare to
an obese individual is
about 38% more costlier
than for their thinner
counterparts.
Employers have
noticed these trends,
and are seeking ways to
balance their need for
healthy workers without
creating programs that
may be shunned
because of their
administrative
complexity or
joylessness.
! To answer that need, my firm By Henry employers are finding that they are
has created the “Thinner
Loubet
Winners” program. It is
specifically designed to create a
fun and informative way to encourage
individuals and their families to develop
healthy lifestyle patterns and habits.
“Thinner Winners” focuses its resources
on a series of short-term events to help
maintain strong participation. Because
such a program must be coordinated by
staff members who are not necessarily
expert in wellness, the program is also
easy to plan, implement and to operate
within a small budget.
To kick off the “Thinner Winners”
program and fine-tune its delivery, Keenan
conducted a weight loss contest for its
own employees. Such contests create a
community-like spirit that encourages a
greater level of participation among
employees.
Approximately 25% of Keenan
employees, including senior management,
dove in. They achieved a total weight loss
of slightly more than a ton (2,263
pounds), with some top executives losing
up to 40 pounds. The program was
effectively administered by a human
resources professional who did not have
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Page 4
significant training in wellness. This allowed
the company to gauge the practicality of
transferring the program to an organization
that did not have a wellness specialist on
staff.!
The San Bernardino Community
College District recently
conducted a “Thinner Winners”
challenge of its own. It came out
of the experience with an
employee base now 521 pounds
lighter. The competition was
managed by Keenan and the
district’s benefits committee and
human resources department.!
The competitors were split into
17 teams, each with four to six
members. The winning team was
financially incentivized, and
split their earnings with a
campus cause of their choice.!
The impact of these programs,
although relatively small, does
add up over time. Some
paying off in the form of fewer sick days
taken. Eventually, this should translate
into a reduction in medical claims.!
Now offered as a value-added wellness
program for its school, public agency and
healthcare organization clients, the “Thinner
Winners” program guide provides
recommended procedures, along with flier
and email templates to help organizations run
a successful challenge.!
The guide includes information on
program preparation, rules and protocols, a
four-week pre-launch period, and a detailed
implementation process.!
Further details on the Keenan “Thinner
Winners” program can be obtained by
contacting LaShai Payne, at 310-212-0363
ext.3206 or lpayne@keenan.com.
Henry Loubet is the Chief Strategy Officer for
Keenan. He is a member of the Payers &
Providers editorial board.
Op-ed submissions of up to 600 words are
welcomed. Please e-mail proposals to
editor@payersandproviders.com, or call (877)
248-2360, ext. 3.
Payers & Providers MARKETPLACE/EMPLOYMENT Page 5

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Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

The Camden Group has been providing business advisory and management services to the healthcare industry exclusively since
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