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Published Monday, California Healthfax is copyrighted by HealthLeaders Media, a division of BLR, 35 Village Road, Suite 200, Middleton, MA 01949 and is transmitted solely to the sub-scriber. Any unauthorized copying, duplication or transmission is strictly prohibited. Subscriptions are $179 for 48 issues. For group and bulk sub-scriptions, call 800-650-6787.
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December 5, 2016 | VOLUME 23 | NUMBER 46
T O P S T O R I E S
Covered California Braces for Changes to Affordable Care ActCurrent open enrollment period won’t be affectedThe policies of president-elect Donald Trump won’t affect the current enrollment period for Covered California , but future changes are likely to impact the health exchange in California.
Covered California officials discussed the potential effects of a Trump presi-dency at their monthly board meeting in Sacramento on November 18 and heard testimony from a number of health policy experts about potential changes to the Affordable Care Act (ACA) that would affect the exchange.
Despite the uncertainty, exchange officials are focused on the current open enrollment period that runs from November 1, 2016 to January 31, 2017, said Covered California Executive Director Peter V. Lee. “We’re here for the fore-seeable future and we’re the place to sign up,” said Lee. Covered California is projecting that 400,000 new members will enroll for coverage during the three-month open enrollment period.
Most analysts believe Trump is likely to follow through on earlier vows to “repeal and replace” the ACA, but it’s still unclear how far those changes will go and the impacts they will have on ACA funding.
“The debate is very much in flux and there’s a lot of uncertainty about what’s going to happen and about the timing,” said Larry Levitt, vice president of the Kaiser Family Foundation. “But the conventional wisdom is that the new Congress will attempt to repeal the ACA starting in 2017 through some type of reconciliation strategy.”
Levitt and other policy experts said they expect changes to the ACA to be incremental, unfolding over the course of two or three years.
Anthony Wright, executive director of Health Access California, said Republication majorities in both houses of Congress could expedite changes to the ACA. “Many of the changes could be passed through budget reconciliation, which only requires 51 votes in the Senate, a majority of the House, and the pres-ident’s signature,” said Wright.
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� Jordan Herget , FACHE ha s been named president and CEO of St. Louise Regional Hospital in Gilroy and O’Connor Hospital in San Jose. In his new role, Herget will also oversee De Paul Medical Center in Morgan Hill. According to a November 23 report in the Gilroy Dispatch , Herget most recently served as chief operating officer for Good Samaritan Hospital in San Jose and has 16 years of hospital executive experience. Both St. Louise Hospital and O’Connor Hospital are owned by Verity Health System . “My first priority will be to get to know the physicians, nurses, staff, and volunteers at each hospital,” said Herget. “Ultimately, my main goal is to identify ways in which we can work together to ensure that the hos-pitals continue to thrive for genera-tions to come.”
� Kaiser Permanente broke ground on a $50 million medical office build-ing in Santa Rosa. Construction on the 87,000-square-foot office building is scheduled to be complete in early 2018, according to a November 18 report in the North Bay Business Journal. The three-story structure will house offices for primary care physicians and special-ists along with a lab, pharmacy, and imaging services. “This medical office reflects what we want to do within the community in the West Sonoma County area to get the best quality of care,” said Judy Coffey, senior vice president
I N B R I E F T O P S T O R I E S CONTINUED FROM PAGE 1
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Changes to ACA cont.
Reduced funding for federal subsidies could also play a major part in weakening the ACA in the state. Covered California estimates that 90% of the 1.4 million people who have enrolled for coverage through the exchange are receiving federal subsi-dies to help pay for premiums. California Insurance Commissioner Dave Jones said recently that the state does not have “the financial capacity to backfill the proposed federal cuts to health insurance subsidies or the cuts proposed for public plans.”
Analyst Micah Weinberg, president of the Bay Area Council Economic Institute, estimates the state is receiving about $5 billion per year in federal funds for subsidies and more than $15 billion to fund Medicaid expansion. The impact on California depends on “how much of that $20 billion federal spigot will be turned off,” Weinberg said last month.
The state has added more than 3.5 million new members to Medi-Cal under Medicaid expansion, according to Sandra R. Hernandez, MD, president and CEO of the California HealthCare Foundation (CHCF). Proposals to roll back or defund that program could have a major impact on the state, which now has more than 13 million Medi-Cal enrollees.
“If you undermine Medicaid in any way, it would really disrupt the [health-care] market,” said Hernandez. “You have literally half of the people in places like Fresno County covered by Medi-Cal, and changes to the program could have a major impact on the state.” A new report from the California Budget and Poli-cy Center estimates that Tulare County has the highest percentage of residents enrolled with Medi-Cal at 55.5% followed by Fresno County at 49.9%.
Levitt said Republicans have proposed a plan that would modify Medicaid using a block grant system that would potentially reduce funding for Medi-Cal. Other proposals call for rolling back or reducing spending for Medicaid expan-sion.—DOUG DESJARDINS
Anthem-Cigna Merger Trial Underway in Federal CourtCalifornia part of federal antitrust lawsuit to block mergerThe state of California is backing the U.S. Department of Justice (DOJ) as it seeks to block the proposed $45 billion merger between Anthem Inc. and Cigna Corp.
The DOJ filed an antitrust lawsuit against the merger in July and the trial began November 19 in U.S. District Court for the District of Columbia. Califor-nia Attorney General Kamala Harris said the merger “would drive up costs
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Anthem-Cigna Merger trial cont. T O P S T O R I E S CONTINUED FROM PAGE 2I N B R I E F Continued from page 2
and area manager of the Sonoma-Marin area for Kaiser Permanente.
� A planned three-day strike by more than 3,000 Sharp HealthCare nurs-es was cancelled on November 27, a day before it was to start. The Sharp Professional Nurses Network-United Nurses Associations of California and Sharp HealthCare agreed to restart contract negotia-tions to avert the planned walkout, according to a November 27 report in the San Diego Union-Tribune. “Sharp made some compromises and we made some compromises,” said union President Denise Duncan, RN. The contract dispute between the health system and the Sharp Professional Nurses Network centers on wages, retirement benefits, and work sched-ules. As part of the agreement, the union has agreed to not file another strike notice until January 1, 2017. Sharp HealthCare operates four acute care hospitals in San Diego County.
� Covered California has appoint-ed Doug McKeever as Chief Deputy Executive Director of Programs, effective January 3, 2017. McKeever comes to Covered California from the California Public Employees Retirement System (CalPERS), where he most recently served as Deputy Executive Officer of Benefit Programs Policy and Planning. In his new role, McKeever will oversee the Plan Management, Outreach, Sales and Marketing, Service Center, and Policy
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for consumers” when announcing in August that California would join 10 other states in supporting the DOJ lawsuit
Anthem and Cigna contend the merger would create a more efficient com-pany that would generate lower premiums. However, the DOJ alleges the merger would reduce competition and result in higher premiums for policyholders. “Effi-ciencies don’t count if the only way you get them is more market power,” said DOJ Attorney Jon Jacobs in his opening statements.
The California Medical Association (CMA) on November 20 reiterated its position that the merger would likely be bad for consumers because it would cre-ate a larger company with more power over the market. A CMA survey conduct-ed earlier this year found that 85% of its physician members oppose the merger.
“The California Medical Association has opposed the Anthem-Cigna mega-merger since day one because it will hurt patients and increase healthcare costs,” said Ruth E. Haskins, MD, president of the CMA. “Limiting market competition would compel insurers to contract with fewer physicians, resulting in higher pre-miums and longer wait times for referrals, not to mention forcing many patients to pay more to see out-of-network doctors.”
Healthcare policy expert Gerald Kominski, PhD, said there is little evidence to support claims that the merger would result in lower premiums. “There is no theoretical or empirical data that shows that consolidation leads to lower costs to consumers,” said Kominski, director of the UCLA Center for Health Policy Research. “Monopolistic power increases prices, it doesn’t decrease them.”
California Insurance Commissioner Dave Jones is also opposed to the merg-er, which he said would give Anthem a market share of more than 50% in 28 counties in the state and a 40%-or-higher share in 39 counties. “When it comes to the Anthem and Cigna merger, bigger is not better for California consumers or the health insurance market,” said Jones.
The Anthem-Cigna merger could have a major impact on the California market, because the two insurers have a combined total of 8.2 million members. According to data from the California HealthCare Foundation, Anthem has approximately 6.1 million members in the state and Cigna has nearly 2.1 million members.
A second proposed mega-merger, involving insurers Aetna and Humana and worth $37 billion, is also opposed by the CMA and the state Department of Insur-ance. However, this merger would impact California to a lesser degree. Aetna cur-rently has about 1.3 million members in the state and Humana has an estimated 513,000 members. The DOJ also filed an antitrust suit against the proposed Aetna-Humana merger and that trial is expected to begin this month.—DOUG DESJARDINS
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T O P S T O R I E S I N B R I E F Continued from page 3
divisions. “Doug McKeever brings a wonderful background, experience, and perspective that will help Covered California as we move into the future,” said Covered California Executive Director Peter V. Lee. “He is a great fit for us.” Prior to joining CalPERS, McKeever worked with the California Department of Corrections and Rehabilitation. His salary with Covered California will be $230,000 per year, according to a Covered California press release.
� San Joaquin Community Hos- pital has named Sharlet Briggs as its president and CEO. Briggs assumed the role on November 21. According to a November 21 ABC News 23 Bakersfield report, Briggs had been serving a dual role as interim CEO and chief operating officer since September. “Over the past few months, I have been working collaboratively with the governing board [of San Joaquin Community Hospital] and key part-ners to identify and prioritize the attri-butes we value,” said Beth Zachary, Southern California regional president for Adventist Health, which owns San Joaquin Community Hospital, a 254-bed facility in Bakersfield. “I have no doubt Sharlet is the right person to lead us forward.” Briggs has been with San Joaquin General since 2012 and was appointed chief operating officer in 2015.
� Sutter Health has partnered with Velano Vascular to test a needle-free
Capitation Is on the Decline in California Commercial MarketErosion of HMO market linked to lower incidence of capitationA recent study found the use of capitation in the California commercial insurance market is declining and could impact medical groups and independent physician associations (IPAs) in the future.
The study was commissioned by the California HealthCare Foundation and titled “As Commercial Capitation Sinks, Can California’s Physician Organiza-tion’s Stay Afloat?” The study noted that the use of capitation—a fixed prepay-ment for care—has declined steadily among both commercial insurers and public plans since the 1990s.
“Capitation was the form of payment for around 18% of visits for private HMO patients in 2013 and just over 8% of visits for Medicaid HMO patients in the same year compared to 35% and 25%, respectively, in 1996,” lead author Laura Tollen wrote.
The study linked the reduced rate of capitation to a steady decline in the commercial HMO market in California (excluding Kaiser Permanente’s inte-grated HMO patient network) and estimates the number of HMO members in California dropped from 6.3 million in 2004 to 3.6 million in 2015. The study cited several potential causes for the decline, including the 2008 recession, which prompted employers to transition employees to PPOs, and a lack of transparency in a capitated system that does not provide the detailed data on claims and utili-zation that payers now expect.
Tollen speculated that capitation could experience growth in some areas to offset losses in others. She cited the Medi-Cal managed care market as a poten-tial growth area, where enrollment has increased from 4.7 million in 2004 to 10.3 million in 2015.
“Networks based on community clinics and public providers are already becoming more prominent in managed care markets,” Tollen wrote. “Today, over 22% of medical groups in California accepting risk contracts from HMOs are community clinics, county groups, or University of California providers.”
The study also suggested the capitated market could continue to decline and eventually vanish if current trends continue. “It is unclear whether there will be any capitated business left for these groups in the near future, given the diffi-culties they report in contracting with Medi-Cal managed care organizations and the shrinking, non-Kaiser commercial HMO market.”—DOUG DESJARDINS
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T O P S T O R I E SBlue Shield to Appeal State Decision
to Revoke Not-for-Profit Status
Insurer says appeals process could take two years
Blue Shield of California plans to appeal a state decision to rescind its tax-
exempt status in California as a not-for-profit insurer.
The ruling by the California Franchise Tax Board
Shield to pay millions of dollars in retroactive state taxes. Blue Shield vice president
of corporate communications Steve Shivinsky
decision. “We have filed a protest against the FTB ruling and this will take up to
two years to decide,” said Shivinsky. “Blue Shield as a company and a management
team firm believes it is fulfilling its not-for-profit mission and commitment to the
community. We are, and will remain, a not-for-profit company…”
Shivinsky noted that the decision only pertains to Blue Shield’s status in the
state. “Blue Shield has paid federal taxes since 1986,” said Shivinsky. “Blue Shield
of California’s e�ective tax rate on pre-tax profits exceeds 45% annually …” Blue
Shield of California and other Blue Cross and Blue Shield plans in the U.S. lost their
federal tax-exempt status under reforms to the federal tax code approved in 1986.
O¢cials for the Franchise Tax Board declined to comment on the ruling or
what prompted the state audit that led to its decision issued in August 2014. The
FTB added Blue Shield to a list of companies that had their tax-exempt status
revoked and posted the information on its website but did not comment on it at
the time. The decision will also require Blue Shield to file tax returns dating back
to 2013. While state and federal laws regarding not-for-profits have changed over
the years, the action taken against Blue Shield is unusual. “I am not aware of any
nonprofit health insurer that has been stripped of its tax-exempt status prior
to Blue Shield,” said Gerald Kominski, a professor of health policy at the
Fielding School of Public Health and director of the
Policy Research.
Kominski said Blue Shield has the option of converting to a for-profit insurer
but that it’s more likely to negotiate a settlement with state o¢cials if its appeal of
the Franchise Tax Board decision fails. “I imagine that Blue Shield will try to reach
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E V E N T SI N B R I E F Continued from page 4
Dec. 7–9. CAPH/SNI Annual Con-ference. Langham Hotel, Pasadena. A gathering for public healthcare sys-tem leaders and safety-net providers in California. Sponsored by the California Association of Public Hospitals and the Safety Net Institute. To register, please visit http://caph.org/aboutcaph/annual-conference/
Dec. 12. CME Essentials Workshop. San Mateo County Medical Association, San Mateo. A workshop for healthcare professionals interested in establish-ing or improving a continuing medical education program. Sponsored by the Institute for Medical Quality. To register, please visit http://www.imq.org/continu-ing-medical-education/education-and-resources-for-cme-accreditation.aspx
Jan. 11–14. 40th Annual Emergency Medicine Conference. Ahwahnee Hotel, Yosemite National Park. An edu-cational conference for emergency medical personnel and administrators. Co-sponsored by the California chapter of the American College of Emergency Physicians. To register, please visit http://www.yosemitemef.org
Jan. 23–25. Personalized Medicine World Conference. Computer History Museum, Mountain View. An annual educational conference for personalized medicine that brings together leaders in government, business, and research. To register, please visit http://www. pmwcintl.com/2017sv/location/
blood draw system. Velano’s PIVO device uses a patient’s peripheral IV line for blood draws, reducing reliance on needle sticks and central line access. “It’s im-portant for us at Sutter Health to continually research and explore new ways of enhancing quality of care and how we deliver that care,” said Sutter Health Chief Nursing Officer Anna Kiger, DNP, RN. “By removing the needle from the equation using the PIVO device, we aim to create a more positive patient-practitioner rela-tionship to deliver safer care.”
� A study that used health records from Kaiser Permanente health facili-ties found no link between autism and women who received a flu vaccine during pregnancy. The study, published November 28 in JAMA Pediatrics, examined the health records of 196,929 children born at Kaiser Permanente facilities in Northern California from 2000 to 2010 and found that 3,101—or 1.6%—had been diagnosed with autism as of June 2015. The study found that 23% of women had received a flu shot while they were pregnant but found no correlation between flu shots and higher rates of autism. “We feel it should be reassuring for prospective mothers,” Lisa Croen, PhD, a lead author of the study, told NPR.
� Healthcare workers at Queen of the Valley Medical Center in Napa have voted to join the National Union of Healthcare Workers (NUHW). According to a November 22 report in the Napa Valley Register, nearly two-thirds of service and technical workers at the hospital voted to join the NUHW. “This election vic-tory shows us what we can accomplish when we stand together and how we will finally have a seat at the table and a voice in patient care,” said Queen of the Valley radiology technician Ray Herrera in a press release from the NUHW. In an email, Queen of the Valley interim CEO Larry Coomes, FACHE, encouraged employees to “continue to respect each other’s views, creating a healing environment for not only our patients but ourselves.” The NUHW said the next step for employees is to select a union bargaining committee and to survey workers to select their bargain-ing priorities.
� UC San Diego Health opened Jacobs Medical Center in La Jolla on November 20. The 10-story hospital features 245 private patient rooms, 15 operating suites, and a 52-bed neonatal intensive care unit. It is named after Irwin and Joan Jac-obs, who donated more than $100 million toward construction of the $953 million hospital. The hospital will include three specialty centers: the Rady Pavilion for Women and Infants, the Pauline and Stanley Foster Pavilion for Cancer Care, and the Vassiliadis Family Pavilion for Advanced Surgery. All patient rooms will be equipped with iPads and Apple TV. “Jacobs Medical Center represents a tremendous investment in the future and will transform healthcare for our region,” said UCSD Chancellor Pradeep K. Khosla.
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transmission is strictly prohibited. Annual sub-
scriptions are $179. For group and bulk subscrip-
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To submit an item for consideration, con-
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By e-mail: [email protected]
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By phone: 978-624-4594. « CONTINUED ON PAGE 2 »
March 31, 2014 | VOLUME 30 | NUMBER 12
T O P S T O R I E S
Number of Physicians in State has
Increased 39% Since 1993
Many areas still have shortage of physicians
A new study from the California HealthCare Foundation (CHCF) shows the
number of physicians in California has increased 39% over the last two decades but
that not all regions of the state are benefiting from the increase.
The study titled California Physicians: Surplus or Scarcity? estimates that
the number of physicians in the state increased 39% from 66,151 in 1993 to 91,775
in 2011, a percentage that’s nearly double the state’s 20% increase in population
during that period. But despite that increase, the report shows many regions of the
state still have a shortage of physicians.
The federal government recommends that communities have between 60 and
80 primary care physicians for every 100,000 residents to ensure adequate access
to care and between 85 and 100 medical specialists for every 100,000 residents.
In 2011, California met that requirement statewide with 64 primary care physi-
cians for every 100,000 residents and exceeded it with 130 specialists for every
100,000 residents.
But the study showed sharp disparities in physician supply by region. The San
Francisco Bay Area had 86 primary care physicians and 175 specialists for every
100,000 residents in 2011, well above the state average. On the flip side, the San
Joaquin Valley had only 48 primary care physicians and 80 specialists for every
100,000 residents. The Inland Empire, a region in Southern California made up of
Riverside and San Bernardino counties, had only 43 primary care physicians and
77 specialists for every 100,000 residents.
“There are efforts underway to get more physicians to practice in those
areas,” said Robbin Gaines, a senior program officer for the CHCF. “But it’s going
to take a while.” One program provides doctors who recently graduated from medi-
cal school with up to $105,000 in student loan payments in return for practicing in
an underserved area of California for three years.
One trend in California’s favor is the percentage of medical school graduates
who choose to remain in California after they graduate. The study showed that
62% of students who attended medical school in California remained in the state
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Find out why others commit to work for PIH Health:
PIH HealthRecruitment 562.698.0811 Ext. 12788
Submit Resumes to [email protected]
A county organized health system, CalOptima provides publicly funded health care coverage for low-income children, adults, seniors and people with disabilities in Orange County, California. CalOptima’s mission is to provide members with access to quality health care services delivered in a cost-effective and compassionate manner. In total, CalOptima serves more than 780,000 members with a network of more than 7,000
primary care doctors and specialists, as well as 30 hospitals.
CalOptima is accepting applications for candidates with public agency and managed care experience:
Executive Director, Clinical Operations - Code #14107-080416
Executive Director, Human Resources - Code #14067-062916
Executive Director, Operations - Code #14026-061516
Executive Director, Network Operations - Code #13114-052716
Director, Long Term Support Services - Code #02586-091616
Staff Attorney (2 Openings) - Code #17023/17024-072216
Medical Director- Code #96264-031516
For a complete job description and to apply online, please go to www.caloptima.org. Questions can be directed to
Debbie Neal, Senior Recruiter for CalOptima at 657-235-6981 or [email protected].
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PAGE 8 November 7, 2016
TO PLACE A LISTING, PLEASE CALL 978-624-4594
E M P L O Y M E N T O P P O R T U N I T I E S
WE HAVE THE FOLLOWING OPPORTUNITIES AVAILABLE:
Chief Medical Officer – Orange, CA
Great opportunity for an MD or DO licensed in the state of California. The CMO is responsible for the leadership of clinical programs and performance of Prospect Medical Systems in 6 states including CA. Minimum of 5 years medical director, medical leadership or equivalent executive/administrative experience in an IPA, Medical Group, or Health Plan.
Director of Outpatient Clinical Operations- Orange, CA
Unrestricted, licensed Registered Nurse with minimum of 5 years of high level management (Manager or Director) experience in Medical Group, Health Plan and IPA arenas to include Utilization management, Quality Improvement, Inpatient/Outpatient Case Management Programs, Health Plan Incentive programs to include P4P/HCC.
• Director of New Markets Performance Programs – Orange, CA
• Director of Strategic Projects – Orange, CA• Executive Director, MSO Client Relations and
Operations – Orange, CA• Healthcare Project Manager – Orange, CA• Healthcare Business Analyst – Orange, CA• UM /Medical Management Compliance Manager –
Orange, C
Join a company that is committed to a long-term, integrated, coordinated care strategy, and growing nationwide.
• Physician networks in 6 states (CA, TX, RI, NJ, CT, PA)• 4 Regions in Southern CA• 300,000 Enrollees• 20 IPAs• 20 Hospitals • 4 - 5 STAR Medicare Advantage rating• ‘Elite’ status in CAPG’s Standards of Excellence for 5
consecutive years
If you want to be part of an innovative health care system dedicated to coordinated and integrated care, send your resume to [email protected].
NEXT GENERATION HEALTHCARE SYSTEM NEW OPPORTUNITIES, NEW
CHALLENGES
Please apply through our career page at www.sfhp.org/careers
INPATIENT UTILIZATION MANAGEMENT NURSEMust be a California Registered Nurse who is passionate about making a difference in the lives of individual members and improving our system of healthcare in San Francisco. Should be skilled team player, detail oriented, innovative and committed to belief that managing care and utilization can be a tool to improve quality and promote sustainability of our safety net.
Responsibilities: Collect patient information and utilize clinical assessment skills to make decisions regarding medical necessity of services. Determine which cases should be referred to the Medical Director for evaluation. Apply clinical criteria and guidelines to ensure appropriate administration of benefits and optimum medical outcomes based on the use of relevant SFHP policies, InterQual criteria and Medicaid/Medicare guidelines. Works closely with hospital case managers to repatriate members back to member’s designated home hospital and with hospital staff to ensure appropriate discharge planning for our members at hospitals and skilled nursing facilities. Collaboration with Medical Directors to ensure quality and cost-effective care.