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1w w w. He a l t h c a r e R e f o r m Ma g a z i n e . c o m

National Healthcare Reform Magazine

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w w w. He a l t h c a r e R e f o r m Ma g a z i n e . c o m

C O N T E N T S04

Headaches, Heartburn and Healthcare Reformby Cammie Scott

10 Health IT: The ACO Backboneby Deepak Padmanabhan

26 Market Based Patient Careby Ralph Weber

Copyright © 2011 Healthcare Reform. All rights reserved. Healthcare Reform Magazine is published monthly by. Material in this publication may not be reproduced in any way without express permission from Healthcare Reform Magazine. Requests for permission may be directed to [email protected]. Healthcare Reform Magazine is in no way responsible for the content of our advertisers or authors.

14 Hey Doc! This ACO’s for YOU!by Pamela Mullahy

Transforming Transcription“Confessions of a CEO”by Kevin Shrake

28 A Wellness Partnership Well Worth Toastingby Christopher Silva

32 Engagement & Participation are Key for a Successful Corporate Wellness Programby Deborah MacArthur

PHYSICIAN SHORTAGE:FACT OR FICTION?by Richard A. Longo

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Potential Medical Insurance Solutions for Uninsured Individuals in New Yorkby Michael L. Frank

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17EDITORIAL

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Jonathan Edelheit

Letter from the Editor Rhetoric of Politics in Our Industryby Jonathan Edelheit

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THE CARDS ARE DEALT:HOW TO PLAY THE HAND FOR YOU AND YOUR EMPLOYEESby Richard A. Longo

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FACING REALITY IN 2011…IT’S YOUR JOBA NEW HEALTH BENEFIT MANAGEMENT PROGRAMby Park Miller

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normally try to stay out of politics. In fact isn’t that what everyone always tells you. Don’t mix politics or religion with business. This month I simply cannot sit on the sidelines anymore. Unfortunately, politics has become like reality TV. It is more about the ratings and drama than “reality.” Scenes are staged, some shows are

scripted, and the producers edit films, switch up video and actually change the time sequence of events, solely for the purpose of making things look more dramatic and emotional. For those of you who don’t realize it, most things in Reality TV, are not really “reality.”

Politics has truly become reality TV. It’s no longer about what is good for the people or what is right or wrong, or what the moral high ground is. It is now about positioning, drama, emotion with an end focus on only one thing, getting reelected. In Wisconsin and other states some Democrats went into hiding, some left the state to hold up voting indefinitely on Unions, one part of the legislation was requiring the Union members to pay for their own health insurance. Have we really fallen so low that politicians now go into hiding to hold up voting? Are we five years old again and playing hide and seek? Why is it that we are allowing our politicians to behave like children and take action that would never be tolerated as an adult or in the business world? Everyone is getting caught up in the drama and not calling for an end to it. I find other editorials in benefits magazines, blogs from people in the health insurance industry, focus on blasting one political party, or blasting Obama or democrats on Healthcare Reform. What is happening is they are all keeping your eye off the real game. They are just part of the show, keeping you distracted and emotional.

Now that the Republicans have taken over the House of Representatives, do any of you really expect anything different? Do you see Republicans and Democrats working together and making change? Are you demanding change? Or are you trapped in the “reality” of it all.

IEDITOR’S LETTER: Rhetoric of Politics in Our Industry

Jonathan Edelheit



Headaches, Heartburn and Healthcare Reform: An overview of healthcare reform mandates for businesses

This month, March 23, Healthcare Reform celebrates its first birthday. Although it is nearly a year old, many people, including many agents, still do not

understand much of the bill, what it means or how it relates to them. There is much confusion over the “how to” of the Bill.

The Bill spells out what will happen, but does not say how it will happen. There are five main government agencies working on “how to” make it all work: 1) Health and Human Services (HHS), 2) Department of Labor (DOL), 3) Internal Revenue Service (IRS), 4) Centers for Medicare and Medicaid (CMS), and 5) Department of the

Treasury. Five major divisions of the government, along with their lawyers, are trying to figure out how to make it all work. Getting 5 attorneys to agree can be a challenge, let alone five major departments of the federal government.

There are 14 main mandates they are working diligently to define. While there are many others, we are going to focus on the mandates that impact businesses and brokers.

1. No pre-existing condition exclusions (PCE) – One of the major goals of Healthcare Reform was to expand coverage. The main mechanism for this is the elimination of pre-existing conditions. It started for children under age 19 on September 23,

by Cammie Scott

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2010 and beginning in 2014, there will be no pre-existing conditions for anyone regardless of age. This is a major change in the way companies underwrite their policies.

The impact will be the greatest in the individual market. Group health plans are already subject to the Health Insurance Portability and Accountability Act of 1996 which states that when an insured moves from group to group coverage, as long as there is not more than a 63 day break in coverage, they will not be subject to any pre-existing conditions. However, individual plans are currently free to underwrite based upon health status and decline individuals as well as place restrictions on coverage based on health conditions. Beginning in 2014, insurance companies will no longer be allowed to do this. This provision will in effect do away with the HIPAA certificates of creditable and breaks in coverage and allow anyone to change coverage without fear of facing pre-existing condition exclusions.

2. Elimination of Lifetime Limits – As of September 23, 2010, plans can no longer have lifetime limits on their coverage options. As a cost control measure, many plans place a lifetime limit of $1 to $5 million. Under Healthcare Reform, there can be no limits. This places plans that are often referred to as “mini meds” or “limited benefit plans” which supply benefits for doctor visits and hospital stays on a limited basis in jeopardy.

Many of the larger corporations offer plans such as these to hourly employees. In order to not cause a loss of coverage for these employees, HHS is allowing companies to apply for waivers for these types of plans. In order to qualify, the plan must have been in effect as

of March 23, 2010, and as a result of the new provision either cause a significant increase in the premiums for the plan or a significant loss of coverage. More information can be found at www.hhs.gov.

3. Elimination of Annual Limits – By 2014, plans can no longer have annual benefits on essential benefits. Plans can still have limits on non essential benefits (these are still being defined). There is a phase in period for this listed in the chart below.

Restricted Limit Plan Years$750,000 Beginning on or after September 23, 2010, but before September 23, 2011$1.25 million Beginning on or after September 23, 2011, but before September 23, 2012$2 million Beginning on or after September 23, 2012, but before January 1, 2014No Limit Plan years after January 1, 2014

Once again, companies can request a waiver on these restrictions through HHS. Applications must be received at least 30 days prior to the beginning of the plan year and are valid for one year. If the waiver is granted, notification must be given to the affected employees.

4. Prohibition on Rescissions – A rescission is when a plan terminates coverage back to the effective date of the policy. It has a retroactive effect. It is not a rescission if it only has a prospective effect or if it is as the result of lack of payment of premiums. Rescissions are still allowed for intentional acts of fraud; however, it is difficult to prove intent. It is effective for plan years beginning after September 23, 2010.

5. Dependent Coverage of Children to Age 26 – Starting with plan years renewing after



September 23, 2010, dependents must be covered through their 26th birthday regardless of their tax dependence, residency, student status, marital status, or employment status. The exception to this is if they are covered by their employer plan. However, beginning in 2014, this will not apply. This provision applies to biological or adopted children, stepchildren, or eligible foster children. It does not apply to children of a domestic partner, grandchildren or the spouse of a child. A special notice should be distributed to all employees informing them of this provision and their right to re-enroll dependents who may have aged off the plan previously.

6. Patient Protections – Beginning with plan years after September 23, 2010, patients will now be allowed, if the plan requires it, to elect any in network provider as their Primary Care Physician (PCP) including pediatricians. Women will also be allowed to visit OB/GYNs without prior authorization from their PCP. They can also see other licensed specialists, such as midwives,

without prior authorization. The impact of this provision varies greatly from state to state. Generally the more metropolitan the state is, the bigger impact it will have. Many plans in rural states do not require PCPs.

If a plan covers emergency services, they must now be covered whether in or out of network with the same cost sharing provisions and no pre-authorization. The services must be provided in connection with an “emergency medical condition”. According to the HHS definition, an emergency medical condition is evidenced by acute symptoms of sufficient severity so that a prudent layperson, with average knowledge of health and medicine, could reasonably expect that absence of immediate medical attention would place the individual’s health in serious jeopardy, or seriously impair bodily functions, bodily organs, or parts.

This provision does not apply to Grandfathered Plans.

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7. Coverage of Preventive Health Services – For new plans and plans that are not Grandfathered, beginning after September 23, 2010, preventive services must be covered at 100% with no cost sharing. HHS has developed a list of these services. There can be a doctor’s co-pay if 1) the primary reason for the visit was not preventative in nature, or 2) there is separate billing and the primary reason for the visit was preventive, but other issues were discussed. Wellness exams do not have to be covered out of network and there can be cost sharing.

8. Non Discrimination Testing – Originally in effect for September 23, 2010, the requirement stated that fully insured plans, except Grandfathered Plans must now begin to comply with Section 105(h)(2) of the Code. The IRS has pushed this date off until they can further clarify the guidelines and the testing requirements. Self insured plans are already subject to these rules.

9. Quality of Care Reporting - In 2012, HHS will release guidance on annual quality of care reporting requirements for plans that address plan structure, benefit structure and reimbursement arrangements. The purpose of this is to determine whether coverage is satisfying the following criteria:

• Whether the coverage improves health outcomes through activities such as quality reporting, case management, care coordination, etc.

• Whether coverage implements activities to prevent hospital re-admissions

• Whether coverage improves patient safety and reduces medical errors through best clinical practices, evidence-based medicine, and HIT

• Whether coverage implements wellness and health promotion activities

10. 4 Page Benefits Summary - Beginning in 2012, plans must distribute a new 4 page benefits summary to insureds at open enrollment and each time a change is made to their coverage. This is different than the summary plan description. It must be no more than 4 pages in length, in 12 point font, on an 81/2” X 11” page and written in a culturally and linguistically appropriate manner. It must include the following information: Uniform Definitions, Description of Coverage, Cost-Sharing Requirements, Essential Health Benefits Covered, Renewability, “Coverage Facts Label”, Clear Statement about “Minimum Essential Coverage”, Summary of the Plan, and a phone number to call for additional questions. This is different from the Summary Plan Description. More guidance will be given on this.



11. Automatic Enrollment - Employers who are subject to the Fair Labor Standards Act (FLSA), basically those with 200 or more full time employees, and that offer more than one benefits plan, must begin to auto enroll employees in one of the health plans and continue coverage of existing enrolled employees. This was originally thought to be in effect with the enactment of the law, however the Department of Labor (DOL) has stated it is still working on the definition of “full time employee” and will have the regulations finalized by 2014.

12. Limits on Cost Sharing – In 2014 there are limits on the amount of cost sharing allowed. Cost sharing under this definition includes deductibles, co-insurance, co-payments and other charges related to essential health benefits. It does not include premiums, balance billing for out of network providers or charges for services not covered. Under the guidelines the cost sharing can be no greater than the provisions set forth by the IRS for High Deductible Health Plans. The current limits for out of pocket expenses, which do allow Cost of Living Adjustments (COL) are $5,950 for an individual and $11,900 for a family.

13. Restrictions on Waiting Periods – Beginning January 1, 2014, waiting periods for new employees cannot be longer than 90 days. Traditionally, this has been used as a cost control measure for industries with high turn over among employees. It eases the administrative burden and reduces the cost for employees that leave quickly. This will increase the cost for businesses with longer waiting periods as they will need to add employees more quickly and increase the administrative burden of adding and deleting employees and reconciling invoices.

14. Clinical Trial Coverage – Beginning in 2014, a group health plan may not: 1) deny any qualified individual the right to participate in an

approved clinical trial, 2) deny, limit, or impose additional conditions on coverage in connection with participation in the clinical trial, and3) may not discriminate against any qualified individual who participates in a clinical trial. More guidance on this is sure to come, but the mandate basically states that the part of the treatment attributable to items and services that would normally be covered such as IV supplies and materials should be covered on the same basis as for any other type of routine covered procedure. The treatment must be for a life threatening condition.

A complete list of all mandates, the text of the law and the updated mandates can be found at hhs.gov.

This is a changing time for every American as we are all impacted in some way by health care. Now is the time to stay active and to learn what these mandates mean to you, your business, and your clients.

About the Author

Cammie Scott graduated with honors with a Master of Science in Industrial Engineering (MSIE) in 1997 from the University of Arkansas in Fayetteville. While at the University, she participated in many extra curricular activities including serving as President of the Industrial Engineering Honor Society and as President of the Student Chapter of the Institute of Industrial Engineers.

Currently, she is the President of CK Harp & Associates, a company located in Springdale, AR that specializes in working with businesses to create, implement, and administer employee benefit plans.

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Health IT: The ACO Backbone Accountable Care Organization (ACO) is the new buzz word in the healthcare world. ACO, a term coined by Dr. Elliott Fischer in 2006, describes the development of partnership between hospitals and physicians to coordinate

and deliver efficient care. There has always been a need for an alternative healthcare delivery model due to inability of the current Medicare FFS payment system to reduce healthcare spending. The goal of ACO is to improve the health of a defined population through care coordination and increased quality services at reduced cost.

ACO & Health Reforms

ACO has been included in the Patient Protection Affordable Care Act (PPACA) under SEC 1899 Medicare Shared Savings Program. Providers who meet the specified criteria will work together to manage and coordinate care for Medicare FFS beneficiaries under Part A and Part B through an ACO. A participating ACO will receive payment of shared savings if it achieves the established quality performance benchmarks. After the enactment of PPACA, a number of providers and payers developing ACOs have increased substantially.

by deepak Padmanabhan



PPACA has established the following guidelines for participating ACOs.

• Accountability for the quality, cost and overall care of Medicare FFS beneficiaries• Establish a formal legal, leadership and management structure that will allow the organization to receive and distribute shared savings payments including clinical and administrative systems• Include sufficient number of primary care professionals• Promote evidence-based medicine and patient engagement• Report on quality and cost measures• Coordinate care through the use of telehealth, remote patient monitoring and other enabling technologies

ACO vs HMO

Though HMO and ACO model share commonalities there are couple of differences in ACO

• Providers or provider groups, rather than insurance companies, are evaluated on the quality and outcome of care. • Direct contracting with provider organizations without health plan intermediaries. • Accept new payment models liked “shared savings” approach to share in any savings as a result of reduced costs and bundled payments. • Payment approach is related to the level of financial risk the providers will assume. • PCPs are not just gate-keepers, but also care coordinators

ACO has the potential to redefine the US healthcare landscape. However, its critics claim that it is old wine in new bottle. Providers and Payers

have already started to claim that they satisfy ACO requirements and they look forward to take ACO model concept to commercial markets and employers.

Role of Health IT

ACO will require Telehealth, EHR, Health Insurance Exchanges and Analytics to meet its goals. Hence the role of Health IT towards the success of the ACO model is paramount. Hence it is not surprising to find its mention in PPACA.

PPACA mentions that under the Medicare Shared Savings Program, group of providers may work together to manage and coordinate care. At a minimum, ACO must have atleast 5000 beneficiaries assigned to it. Health IT will play a crucial role in coordinating care between these beneficiaries and

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health care providers which include physicians, hospitals and other providers. Physicians could use Telehealth and remote monitoring to improve quality and provide care at reduced costs. Remote monitoring will help in preventing complications by early symptom diagnosis.

The PPACA and HITECH provisions together will stimulate the growth of ACOs. For example, HITECH provides a stimulus funding of $548 million to setup Health Information Exchanges to enable organizations to share data and improve patient care. Physicians are also mandated to adopt EHRs and achieve meaningful use. HIE will provide connectivity of disparate clinical systems and interoperability of clinical information captured by them. Hence providers in an ACO can share clinical data with each other. EHRs will automate and streamline a physician’s workflow and will also support evidence-based decision support, quality management and outcomes reporting which are essential for efficient functioning of an ACO.

ACOs will be required to provide reports

regarding care transitions across healthcare settings, including discharge planning and post-discharge follow-up by ACO professionals. ACOs will be required to provide data related to clinical outcomes, quality and efficiency measures, pay for performance reporting gain and participating professionals. Health IT will help ACOs in achieving these requirements.

Business Intelligence capabilities like predictive modeling and correlation analysis will be required by ACOs to identify inefficient operational areas, analyze historical healthcare outcomes data, predict cost of care and also to comparing the performance of participating providers.

Finally as Tom Enders says, “HIT investments to achieve ACO status will go beyond those required to address other HIT trends, such as meeting EHR meaningful use criteria, converting to ICD-10 coding standards and evolving pay-for-performance and value-based purchasing initiatives. As a result, organizations aspiring to ACO implementation need to carefully consider how they allocate spending for HIT along with

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Hey Doc! This ACO’s for YOU!

Creating Integrated Delivery Systems

As the new regulatory and economic healthcare landscape continues to evolve, professionals

at the ground level are assuming different positions. Some are taking a “wait and see” attitude.

Others, generally led by physicians who are reading the demographic Writing on the Wall – aging boomers with similarly retiring doctors (and nurses) – are taking steps to do more with less.

Providers alone are not regarded as innovators. But when they team up to form Integrated Delivery Systems (IDS’s), they assume a

leadership role and are looked to as authorities and trendsetters – think Geisinger and the Mayo Clinic.

In the September 7, 2010 issue, we outlined the first steps towards forming Integrated Accountable Care Organizations (ACO)- http://healthcarereformmagazine.com/article/building-fully-integrated-aco-s-nuts-bolts.html. Initial steps included Workgroup formation led by a third party neutral agency, Initial Healthcare Information Technology (HIT)/Data Evaluation and Design, Reimbursement and Incentive Alignment, as well as Funding Options.

Now we continue to outline steps to building an Integrated Delivery System, still under the ACO umbrella.

by Pamela Mullahy



Hey Doc! This ACO’s for YOU! Partial physician ownership of these ACO operations, if structured properly using HIT and non-MD/DO services, can be a way doctors can supplement diminishing Medicare reimbursements in other areas. Integrated Delivery Systems – Benefits for ProvidersProviders historically have created IDS’s out of a desire to create a system of better care. It has been a complicated, politically charged task and the rewards were vague. ACO’s present a new opportunity to get rewarded for developing better care by the 800 pound gorilla in the room – Medicare.

Physician leaders can also use the integrated structure to build Medical Teams, staff-model HMO’s, or develop other arrangements that can lead to increased flexibility, a bigger market share, as well as new contracting arrangements with other providers, payers, and patient groups.

Whether reimbursement is via ACO Shared Savings or dividing up Global Capitation, physicians can structure ACO’s to profit while gaining efficiencies along with increased safety, quality, and efficiency for the customer. And by using HIT, ACO’s can more easily meet CMS benchmarks to gain reimbursement and increase profit margins.

For example, the DRGs with the most frequent readmissions are Chronic Heart Failure, Psychosis, Vascular and Cardiac Surgery, and COPD. CMS found that more than 50% of patients readmitted within 30 days appeared not to have had an outpatient or home health visit between hospital discharge and readmissions. In an uncoordinated (non) system, the hospital was finished with its job.

In an IDS with a well designed HIT system, however, immediate Home Health Care follow-up visits could be built into the connected ACO systems’

care paths for these diagnoses to ensure appropriate medication, outpatient care, and necessary home care adjustments. Care paths for the IDS can be structured and standardized on the HIT system, complete with alerts and next steps.

BOTTOM LINE: Such coordination can prevent readmission penalties for hospitals as well as increase margins for physician-owners in a globally Capitated system. This will be increasingly important as Medicare moves towards reimbursement for entire Episodes of Care.

Providers of Integrated Delivery, including physician-owned Medicare Advantage plans will be able to increase Market Share by grouping together and showing that they use IT to provide tighter integration with each other and the patient.

Integrated Delivery Systems – Benefits for Patients

Currently, patients do not understand the benefits of Full Integration – the increased odds of success when a coordinated team is behind them, resulting in safer care, better outcomes with fewer treatment complications.Integrated Delivery Systems can achieve greater market share by marketing these benefits of more complete and safer care. Advertising and outreach can educate the patient on that level.

But it would probably be more effective to reach consumers by trumpeting the convenience of One Stop Shopping for medical information about their well being. People love to obsess about themselves and the ACO presents an opportunity to display diagnosis, treatment, drug, and lab information as well as lifestyle recommendations and coaching/communication in one place.

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Very few patients have the ability to access their medical information, the exceptions being Kaiser Permanente members, who can take advantage of the fully integrated HealthConnect IT system. A physician-owned ACO or Medicare Advantage Plan can use HIT to create such full integration in a way that third party payers cannot.

Meeting Regulatory Changes

A Hospital CEO recently noted that the Feds and State Governments call the song and everyone dances.

There will be Federal Trade Commission changes to Stark laws. Further developments are expected from CMS and will be interpreted at the local level. What is known now is that there will be increased flexibility to develop joint venture arrangements based on delivering higher value care. Individual state governments will regulate specifications within the broader regulations. Several State governments have already indicated that they will require Knox-Keene licensure from ACO’s.

Implementing ACO’s and/or IDS HIT with Current Business

As we outlined last fall, forming and ACO will be easiest with a third party Agency to organize, design governance, as well as guide onsite implementation and change management.

This third party may be a Managed Care Organization affiliated with physicians, part of a hospital foundation, or its own entity, depending on the regional distribution of power and resources.

But regardless, the neutral third party will be legally necessary in order to manage and distribute the shared savings or global capitation among

the providers after coordinating the design and implementation of the ACO. Health providers have widely varying integration and HIT levels. A complete plan for creating a successful Integrated Delivery System will start with an environmental assessment, including current community involvement and standards, public Information Technology, existing legal coordination via contracts, as well as a thorough needs assessment as to the technological, legal, labor, and administrative resources that would be needed along with timing.

The Agency can then form a schedule where the governance of physician, hospital, subacute, and community leaders can meet to determine needs, resources, and actions on a regular basis, moving the project forward. The Agency can run the necessary change management with minimal disruption of daily business.

The result will be better care, more market power, and increased revenue development flexibility.

Coming soon: Increasing provider strength by creating using HIT to create ACO/IDS Networks.

Health Economist Jennifer Zaft ([email protected]) understands the dysfunction of the current industry and the promise behind the Affordable Care Act. Currently she is Principal and Founder of The JAZ Group, LLC, a design, management, and HIT consulting company that builds and assists teams of physicians and other providers so they can best meet current and upcoming challenges. Her consulting group includes experts who have successfully started or added to healthcare businesses using Care Pathway Data, Hospital and Physician Liaisons, Finance, HIT, Change Management, as well as Program/Product Development.



Transforming Transcription“Confessions of a CEO”

Introduction

We are in the midst of arguably the most significant healthcare reform in our nation’s history.

Although our legislative leaders are still shaping and debating the final changes, it is certain that healthcare executives are going to receive less money to care for a growing number of patients. This will require us to “transform” operations across every aspect of care delivery to accomplish the cost savings necessary for future success.

“Confessions of a CEO”

When you are the CEO you are suppose to know everything right? Here is an honest confession from someone who has been in the C-Suite for many years. We don’t know everything! This is

illustrated clearly if you take the responsibility for approving invoices for your facility. I noticed during a recent sign off session that my organization had 4 different outsourced transcription companies with 4 different rates per line. While being asked to approve these invoices I could only verify 3 things. Did I recognize the name of the company? Did the per line charge match our contract? Was the amount similar to previous months? Beyond that, it was impossible for me to verify the number of lines, how those lines were produced, (typed or speech recognition) and if I was being billed only for visible black characters (VBCs) or for template work. Whether you outsource or continue to employ your own transcriptionists, the following are my recommendations for transforming transcription.

Transforming Transcription

This document is not designed to make a case for in-sourcing or outsourcing transcription services.

by Kevin Shrake

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There is no universal answer to that business question because of all of the variables such as size of community, volume of work, availability of transcriptionists, physician acceptance and local politics to name a few. My transformation advice is whatever you do; design a system that is efficient, timely, production based with a data base and reports management process that YOU control. The essence of such a system is having control of a transcription platform that provides for speech recognition, accurate monitoring of volumes based on VBCs, sophisticated report generation and the ability to establish a production based workforce.

Employed Transcriptionist Model

If you choose to continue to employ transcriptionists there are a few suggestions to maximize the advantages of such a system. Convert the transcriptionists from hourly employees to production based employees and allow them to work at home. This will maximize employee productivity and create valuable space in the hospital that can be used for other purposes. In the event that your facility is part of a system, you

can create your own transcriptionist pool that can share work across all facilities. Deploy a system that allows you to track your own volume data by hospital or across a system.

Outsourced Transcription Model

If you choose to outsource the transcription process, consolidate to one vendor, look to companies with a track record of excellent quality and turnaround times and require them to utilize the hospital based platform that you control. If you possess the backbone infrastructure that provides accountability, you are in charge of a process that is vendor neutral and lowers your costs.

How are Costs Reduced and by What Percentage

By controlling your own platform, you can lower your costs in several ways. If you have a system that identifies VBCs you can reduce your costs by not paying for template work. This creates cost saving regardless of whether you employ your own transcriptionist or outsource. Additional cost



savings are realized by allowing the hospital to gain the financial advantages of using a speech recognition system. This places the transcriptionists in an edit mode rather than total document creation on the dictation that qualifies, thus reducing costs. Typical costs savings of 20% or more from current spending levels can be achieved by transforming your transcription system and taking control of the accountability process. Costs saving calculators are available to estimate your specific cost savings based on your current fees and volumes.

Summary

Healthcare executives have not only extracted the “low hanging fruit” cost reduction opportunities in their organizations but have already climbed high into the tree to accomplish more difficult savings. This process sometimes leaves us scratching our head in regards to how the necessary cost savings to support health care reform will be accomplished. In order to be successful in the future we must think differently than we have before and truly lead transformation initiatives across every aspect of care and service deliver.

Transcription is an area where such transformation can be accomplished. By demonstrating success in this area through the implementation of an accountability platform that hospitals control, healthcare executives can apply that same line of reasoning to other aspects of their care delivery system.

About the Author

Kevin Shrake is a 35 year veteran of healthcare whose career has spanned from Registered Respiratory Therapist to CEO in some of the largest healthcare organizations in the country. He has been a trusted advisor to many health care executive colleagues across the country and assists facilities of all sizes and configuration in margin development initiatives. Mr. Shrake holds a Masters Degree in Health Administration from the University of Illinois and is board certified as a Fellow in the American College of Healthcare Executives. He currently serves as the Executive Vice President and Chief Operating Officer of M*D Resources, Inc. based in Fresno, California.

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Potential Medical Insurance Solutions for Uninsured Individuals in New York

For those of you that have medical insurance and those that do not have coverage, one thing we all know is that premiums are

very expensive. Whether you are an individual or part of an employer group plan, insurance coverage is not cheap. Group plan insurance averages more than $600.00 per month for single employees and more than $1,800.00 per month for family coverage. Medical plans for individuals (not part of an employer group plan) are higher in cost and will have less medical benefits than traditional employer (company) sponsored plans. As a result, we are seeing a growing population of uninsured people especially in our community. Job layoffs due to the economy have not helped the situation.

Many individuals do not have the luxury to wait and see if healthcare form at the state and federal level will result in affordable healthcare. For those individuals today without insurance due

to financial, unemployed or uninsurable reasons, there might be some immediate solutions. Many of you may not be aware that the New York State Department of Health (NYSDOH) offers insurance for those without the financial ability to obtain it. The purpose of this article is to educate those that might not have the resources or assistance to find health care. If you are aware of people that might benefit from reading this article, please forward along. Since insurance carriers participate at the county level, there will be variations of insurance companies and HMOs by county. For illustrative purposes, we showed county level information for Westchester County, however these government programs are offered statewide. Many of the websites and sources listed further in this document are applicable to all counties in New York and not solely Westchester County.

School district and local municipality officials will find this article beneficial since will identify solutions for lower cost health care for uninsured members of their community as well

by Michael L. Frank

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as students in their school district that might be without healthcare.

Medicaid

The New York State government offers medical insurance through Medicaid. The income level (needs basis) to obtain this coverage is very low and might be difficult to meet. In addition to income levels, you may be eligible to be covered by Medicaid if you have high medical bills, receive Supplemental Security Income (SSI) or you meet certain resource, age, or disability requirements. To learn more about Medicaid eligibility, the toll free number is 1-877-472-8411. For information about your local Department of Social Services Offices (Children’s Medicaid), contact the following:

Westchester County DSSCounty Office Building #2112 East Post RoadWhite Plains, NY 10601(914) 995-5000

Child Health Plus

Other New York state benefits offered include health insurance plan for kids, called Child Health Plus. Depending on your family’s income, your child may be eligible to join a medical program. Coverage is available through dozens of providers (health plans) throughout the state. For this coverage, there is no monthly premium for families whose income is less than 1.6 times the poverty level. That’s about $563 a week for a three-person family, about $678 a week for a family of four. Families with somewhat higher incomes pay a monthly premium of $9, $15, $30, $45, $60 or more per child per month, depending on their

income and family size as posted on the New York Department of Health website in February 2011.

For larger families, the monthly fee is capped at three children. If the family’s income is more than 4 times the poverty level, they pay the full monthly premium charged by the health plan. There are no co-payments for services under Child Health Plus, so you don’t have to pay anything when your child receives care through these plans. This is important since traditional health insurance plans will have deductibles, coinsurance and/or copays (cost per visit) requiring a covered person to spend additional out of pocket costs beyond medical insurance premium.

To be eligible for coverage, children must be under the age of 19 and be residents of New York State. Qualifications will depend on gross family income. To obtain more information, please call the 1-800-698-4KIDS (1-800-698-4543).



Resources are available for non-English speaking people as well. For additional information about Child Health Plus, please see website http://www.health.state.ny.us/nysdoh/chplus/.

Family Health Plus

Besides Medicaid & Child Health Plan, another program exists called Family Health Plus, which is a state insurance program for adults between the ages of 19 and 64 who do not have health insurance (either on their own or through their employers), but have income or resources too high to qualify for Medicaid. Family Health Plus is available to single adults, couples without children, and parents with limited income who are residents of New York State and are United States citizens or fall under one of many immigration categories.

Most of the carriers that participate in Child Health Plus also offer the Family Health Plus plan. To learn more about these coverages, please see website http://www.health.state.ny.us/nysdoh/fhplus/.

Access is available in all counties in New York State. In this document, we are illustrating Westchester County, but the New York State Department of Health website above will provide information by county.

The Family Health Plus will provide comprehensive health care coverage to adults, with and without children, who have incomes or assets greater than the current Medicaid eligibility standards. Individuals meeting the following criteria will be eligible to enroll in Family Health Plus:

• Permanent residents of New York State. • Age 19 through 64. • Citizens or Medicaid eligible qualified aliens.

• Not eligible for Medicaid based on income and/ or resources. • Not in receipt of “equivalent” health care coverage or insurance.

Parent(s) living with a child under the age of 21 will be eligible if the gross family income is up to:

• 120% of the Federal Poverty Level (FPL) as of January 1, 2001; • 133% FPL as of October 1, 2001; and, • 150% FPL as of October 1, 2002.

Individuals without dependent children in their households will qualify with gross incomes up to 100% FPL.

Access in Westchester

For health plans that participate in Westchester County, the phone numbers are as follows:

• Affinity Health Plan: 1-866-247-5678 • Empire BlueCross BlueShield: 1-800-431-1914 • Fidelis Care New York: 1-888-343-3547 • Health Insurance Plan of Greater NY: 1-800-542-2412 • Hudson Health Plan: 1-800-339-4557

The above numbers are posted on the NYSDOH website and are provided in this article for those that do not have internet access. Phone numbers and available health plans vary by county, so if you reside outside of Westchester, but still reside in New York, then there are other health plan solutions available to you. In addition, there are community organizations that can help you enroll state wide. For example, residents of Westchester can contact Westchester County Department of Health at 914-813-5048.

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Individuals with internet access can go online to if they qualify for state programs such as Medicaid, Child Health Plus, and Family Health Plus. As an example, one company, Hudson Center for Health Equity & Quality (Hcheq), which is a non-for-profit organization in Tarrytown, has a website www.enrollny.org. Individuals can go online to this site and see if they qualify for benefits and start the enrollment process. It is available for use throughout New York State.

Healthy New York

Lastly, if you are not eligible for any of the plans above, New York State offers another program called Healthy New York. This coverage is available to individuals and small employers. To find out more information about Healthy New York, the toll free number is 866-HEALTHY-NY (866-432-5849) or visit website at the New York State Insurance Department at link http://ins.state.ny.us/website2/hny/english/hny.htm. New York State lists 15 HMOs offering coverage though there participation varies by county. Carriers in Westchester include Aetna, ConnectiCare, Empire, GHI, HIP, and Oxford. Note that ConnectiCare, GHI and HIP are all part of the same company EmblemHealth. In general, each company offers four health plan options. The standard plan and a high deductible health plan with each option offered with and without prescription drug coverage. Depending on the health care plan and coverage selected, the monthly cost of coverage for a single person in Westchester could be slightly above $200.00 (low end) to $400.00 (high end).

In order to participate, you must meet the following eligibility criteria: (1) reside in New York State; (2) must either be currently employed or must have been employed within the past 12 months’ (3) Your employer does not currently provide you

with health insurance; (4) You have not had health insurance in effect for the twelve-month period preceding application or have lost that coverage due to a qualifying event. Qualifying events are described on the NYSDOH website. Healthy New York is not only available to individuals, but also small employers. Eligibility requirements are described on the NYSDOH website.

Individuals without insurance today might find this program beneficial. In addition, children graduating high school and college without employment might find this beneficial. Hopefully this information will benefit those that need it. Please note that this is not an advertisement nor is the writer of the article compensated for this, nor support a political agenda. This information is solely being provided as a service to the community that may not be aware of options for the uninsured. Again, the above information for all of these plans come from the NYSDOH website and is public information. Information will periodically change, so see website for updates. Healthcare Reform at the state and federal level could change some of the coverages and requirements in the future. If you have any questions pertaining to whether or not you may qualify for coverage, please call any of the phone numbers listed through this document and you should be able to obtain guidance. Although this article is geared towards to Westchester county residents, coverage for the above programs (Medicaid, Child Health Plus, Family Health Plus, and Healthy NY) is accessible to all New York State residents though premium rates and health plan participants may vary.

Individual (Direct Pay) Plans

The last alternative that we would mention available to individuals is the direct pay plans. These plans are significantly higher in cost to consumers than the other plans referenced above. These



benefits are not income-means tested so available to all consumers that are uninsured. Carriers in Westchester County include Aetna, ConnectiCare, Empire, GHI, HIP, and Oxford.

These rates are posted on the New York State Insurance Department website by county, carrier and plan design. For current rates, visit http://www.ins.state.ny.us/hmorates/html/hmowestc.htm. For single (individual) coverage, the lowest cost plan is slightly below $900 per month with the highest cost plans at or exceeding $2,000 per month. Family coverage will be significantly more expensive (approximately three times the single rates). These plans are typically very expensive due to the guaranteed issue and guaranteed renewable nature of these policies. These plans typical waive pre-existing conditions and have no underwriting requirements making them very expensive to the consumer.

Despite the very high cost for these plans, this line of business is not profitable to the HMO community due to the adverse selection of the participants that join the plan. As high as the premium rates are, the claim cost to insurance companies may be materially higher.For individuals interested in learning more about the coverages available, visit websites for the New York State Department of Health and New York State Insurance Department. Both provide a variety of information and might be able to assist you in identifying solutions. Page 5

We hope that the above information is beneficial to the reader. If you have any comments on the article, please call (914) 933-0063 or alternatively e-mail at [email protected]. The writer of

this article is an actuary in healthcare and insurance as well as an insurance/reinsurance broker. He is also a resident of Westchester County, New York. About the Author. Michael L. Frank, is President & Actuary of Aquarius Capital, an organization that provides customized solutions in insurance, reinsurance and employee benefits in the life, accident and health insurance fields. He has twenty four years of experience in providing consulting to employers, including school districts, townships and other municipalities, as well as insurance companies/HMOs, Medicaid providers and government organizations. He has also completed more than 500 Other Postemployment Benefits (OPEB) valuations including GASB 45, FAS 106, SOP92-6 and other retiree valuations for employers and insurance companies. For information on his company, please see website www.aquariuscapital.com.

About the Author: Michael Frank is credentialed as an actuary and licensed as a broker, reinsurance intermediary and managing general underwriter, and is very active in various Healthcare Reform task forces. He was recently elected President of the Actuarial Society of Greater New York (ASNY) and will serve as President in 2011.

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Market Based

Patient Care

Health plans are expensive because medical care is expensive. Will shopping across state lines for insurance fix that? It’s a nice sound bite,

and will allow the insured to drop some of their own state mandates, but the biggest input to the cost of a health plan, is the underlying cost of the medical care financed by this plan. If you buy a plan in Shreveport, and use it in San Francisco, it will trend up in costs.

During the year-long healthcare debate, I did not hear ONE person ask why medical care is so expensive. They barely even asked why health insurance was expensive, but if 85% of the premium for health insurance must be paid out in medical costs with the new medical loss requirement, and we have not addressed the cost of medical care, then insurance premiums

will CONTINUE to rise at an unsustainable rate. Enacting health insurance reform without addressing the cost of medical care, is like putting a new roof on a building which was in an earthquake.

Here’s how the Feds put the fix on health care pricing.

It all starts with a Federal agency called the Center for Medicare Services (CMS). They set the reimbursement rates for some 14,193 medical procedures. How they come up with these figures is based on a “secret formula” calculated like most government methods of accounting. Then CMS pays the AMA (American Medical Association) to produce and manage “secret codes” called Current Procedural Terminology codes (CPT codes). The AMA then sells these codes to all doctors and hospitals, and insurance billing clerks. Altogether, they receive annual income reported to be $69.9 million, to

by Ralph Weber



manage these codes. Insurance companies then use the reimbursement rates as a starting point in determining how much should be covered as an insurable benefit under the term, you no doubt recognize: “co-insurance”.

In any business model where prices are fixed and paid by a third party, the patient (consumer) and doctor (provider) both have an incentive to consume more services than may be needed in order to gain maximum benefit. This is why these programs have become entitlements, rather than indemnity programs. If patients travel to Kansas for a bunionectomy or to New Jersey for a knee replacement, or Oklahoma for a Coronary Artery Bypass Graft, and you allow doctors and hospitals to compete across state lines, with their own rates, THEN you will achieve fair market rates, and sustainable costs.

Each doctor and hospital has different costs for different procedures, and each medical provider includes different services with any given procedure. When a third party arbitrarily decides to pay Dr. X in Los Angeles the same as they pay Dr. Y in Miami, some doctors will be overpaid for certain procedures, and underpaid for others. Patients will receive “cost effective” procedures, which may not be what they really need. How many times have you turned on the TV and heard a vendor offer, “If you have Medicare, we’ll get it paid for, or you get your scooter free.”? Would you get one if you had to pay $25,000 of your own money? Take your car to a body shop and get an estimate to fix a dent. Then say: “oh, I forgot to mention, I have insurance”. The price will suddenly go up. This is because both the consumer and the provider are spending other people’s money.So how can we address the costs of medical care? By allowing doctors and hospitals to compete across state lines, not just insurance companies, and by having the patient see the true cost of the care, and direct their own care. A key element

completely missed in healthcare reform.

In recent years, an industry known as “Medical Tourism” has emerged, and is projected to grow at an estimated 35% per year. Medical tourism brokers send people overseas with “promised” savings which compare “billed rates” in the US to “paid rates” overseas. There often exists an added incentive for these brokers to send you overseas in the 20% to 80% or more that they get in commissions/referral fees from the facility they send you to. These kinds of commissions/referral fees are illegal in the US, so these brokers usually won’t refer you to a US facility. Deloitte estimates that by the year 2017 as much as $599.5 billion per year of medical care revenues could be lost from the US, in favor of overseas facilities. There is a very important place for overseas medical facilities in caring for US patients, but they are often not competitive on price. When US doctors and hospitals are permitted to set their own rates, they can usually compete very favorably with overseas facilities.

The status quo, and the reformed healthcare model lack transparency, as well as financial incentives for both provider, and consumer to reduce costs. In order to reduce costs while encouraging technological improvements, we need to introduce competition among doctors and hospitals.

About the Author

Ralph F. Weber, President of MediBid, started an international health insurance brokerage in Canada, then moved to the U.S. and expanded his brokerage. Ralph has contributed healthcare reform policy to Rudy Giuliani and Mike Villines. Driven by a passion for greater access and transparency, Ralph and private investors started MediBid, a truly free-market solution to healthcare.

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I have a job that makes me the envy of many people around the world: I am the CEO of a winery. For most people that conjures up images of grape-stomping festivals, bountiful

picnics amidst Sonoma County vineyards and long evenings by the fire with a great glass of “Old Vines” Zinfandel. There is all of that. But a thriving winery like St. Francis Winery is still a business and, as with any business, it comes with its fair share of challenges, including employee health.

As with most businesses, healthcare costs are a heavy burden to the bottom line. So it makes sense to encourage employees to be healthy. At St. Francis Winery, a majority of our 138 employees are skilled laborers charged with very physical duties that require them to be constantly on the move. They work an array of jobs that support the planting, growing, harvesting, winemaking, bottling and distribution of our products. Thus, they need to be particularly healthy.

In recent years, wineries like ours have seen rising healthcare costs and increasing employee absenteeism—both of which impact productivity. Though we didn’t have a clear picture of why costs were rising at businesses like ours, we knew we needed to get to the root of the problem. I became familiar with a new worksite wellness concept – the Workforce Health Initiative -- being offered by St. Joseph Health System in our county. After meeting with St. Joseph’s Workforce Health Initiative representative and hearing about the success of the program at other local worksites, we were convinced that St. Joseph’s program offered a number of advantages that other wellness plans could not offer. For example:

• The program sponsor, St. Joseph Health System-Sonoma County, has long been the health and wellness pillar of our community and a trusted source of healthcare information. We knew any program we introduced with St. Joseph would have instant credibility in the eyes of our employees.

A Wellness Partnership Well Worth ToastingWriten By Christopher Silva



• The program’s mission and approach were consistent with the values of St. Francis Winery: quality products, quality people and quality relationships.

• The Workforce Health Initiative was available at a very low cost for local employers – an important distinction in today’s difficult economic climate.

• The program was developed in collaboration between St. Joseph and Aegis Health Group, in Nashville, Tennessee, a highly regarded workforce health partner.

Rolling Out the Workforce Health Initiative

After initial planning, a small team of individuals put together a three-step launch plan for our Workforce Health Initiative that consisted of:

1. An onsite kick-off program of screenings and health risk assessments.

2. Identification of primary issues and high-risk areas specific to St. Francis’ workforce.

3. Development and implementation of health education workshops to focus on prevention and lifestyle management to help give employees the information and motivation to live fuller and healthier lives.

Our kick-off program was held in our outdoor park and included both English- and Spanish-speaking nurses and nurse practitioners to take blood draws, check blood pressure, discuss health and diet, and explain the importance of preventive health screenings and healthy lifestyle choices. The kick-off was very exciting—with plenty of healthy snacks and natural juice offerings—and we had virtually 100 percent participation from employees. The mere act of having everyone there discussing health and wellness was very powerful – and empowering. For many of the employees, this was the first time anyone had acknowledged the importance of their personal health and happiness or offered

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them a health profile to assess their health.

All information was collected confidentially. The hospital later presented our management team with aggregate population health data, allowing us to better understand which health issues affect our population. What we discovered was eye opening. Despite enjoying one of the best health insurance packages in our local industry:

• More than half of our employees had no primary care physician (the national average is 23.5 percent).

• 42.7 percent had never had a physical exam, compared to a national average of around 10 percent.

• Nearly half had high blood pressure (hypertension).

• 29.3 percent of employees had high triglycerides and 8.1 percent were severely obese.

• 7.1 percent had diabetes and 4.9 percent had high glucose levels, a precursor for diabetes.

• Almost one in three employees smoked.

• Upwards of 27 percent of workers complained of depression.

Clearly it was time to change our culture about wellness.

Since the majority of our employee health issues revolved around lifestyle choices, we set a strategic goal to positively impact the health of our employees through prevention, intervention and management. The tactical tools we have

since implemented to support our goals include: • Quarterly company-wide lifestyle seminars to focus on nutrition, exercise, stress management, smoking cessation and the importance of preventive screenings.

• Linking employees to health specialists who can address their specific health issues, as identified by the individual’s initial health risk assessment.

• Mailings and emails of health awareness and improvement messages and hospital-sponsored interventions.

• Sponsorship of healthy activities and events to encourage healthy living, such as lunch-time walks, healthy snacking and hydration awareness.

• Encouraging family participation. By encouraging employees to discuss health issues at home with their families, we felt we could achieve greater family buy-in and increase



chances for successful lifestyle changes at home.

• Role modeling by senior management, ensuring that they “walk the talk” and set a good example for others.

We found that the more information we shared with employees and their families, the more contagious the program became. Information is power and it’s hard to close an informed and open mind. When you enlighten people about the power of their choices, it’s like a light bulb goes off. Armed with the right information, people can and do make better choices.

Results

Since implementing the program, we have been able to identify and address significant health risks that could have led to serious

employee illnesses. That change doesn’t happen overnight. Change is incremental, and we’re on the right path. We have started referring our employees to St. Joseph’s Mobile Health Clinic for medical care and have offered flu shots on-site.

By catching potentially serious health and wellness issues early, we are reducing employee absenteeism and enhancing productivity and foresee reducing future claims costs. The projected year one savings will be in the $40,000 range.

In addition, our program also serves to remind employees that they have a stake in their own health and wellness, and that their ability to be healthy and well is largely in their own hands. Like any employer, St. Francis must continue to play a leadership role in bettering people’s lives—both inside and outside of our company. We chose to lead by example. Employee health and wellness knowledge elevates health awareness and engagement not just throughout our company, but across our community at large. I encourage all business leaders to respect and empower their employees by giving them information and the tools to help them live healthier and better lives. Our Workforce Health Initiative program does precisely that.

About the Author

A fifth-generation native of Sonoma County, Calif., Christopher Silva 33, became chief operating officer of the winery, traveling the world as its spokesperson. Five years later, he became president and CEO. He currently serves as Chairman of the Board of Trustees of Santa Rosa Memorial Hospital, a voluntary position.

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Engagement & Participation are Key for a Successful Corporate Wellness Program

Many companies have or are beginning to establish corporate wellness programs for employees as it uniquely benefits both the employee and the company. The benefits for the company include a higher level of productivity, retention, achievement, better peer relationships, and reduced absenteeism among others. Sounds great, but this can only happen when there is engagement in the program and consistent participation. This is an age old question in the world of corporate wellness. How do we get our employees to engage, but more importantly, how do we keep consistent participation. This article will explore some options for not only engaging employees, but also keeping them consistently participating in your corporate wellness programming.

Company Leadership Support

One of the foundational requirements of a successful corporate wellness program is that executive management be on board and supportive. The leadership and culture of the company will steer the initial engagement and in turn continued participation in the program. The tone is established by the leadership of the company and must encourage and support each employee’s efforts to utilize the corporate wellness programming. It is extremely important for management to create an environment that is conducive to engagement and participation. In other words, management needs to create a program that actually makes it easy to participate in. Human nature will find excuses not to participate, so it is important

Writen By Deborah MacArthur



that the company stands behind the wellness investment and facilitates participation.

Employee Engagement

Once you have strong management support for the corporate wellness program, you will have to plan how to engage employees in the program. As you plan your wellness program, it is important to keep in mind that you need a variety of options to offer the workforce. Below are a few suggestions to encourage employee engagement. You may also come up with an original idea that will speak specifically to your workforce:

• Education: By educating your employees, especially the sedentary or non-wellness population, you can draw them into the program. This is a vital part of any successful health and wellness program. The sedentary population of your workforce needs to know and understand the many benefits of living a healthy lifestyle and how to make those changes. This will be the most challenging group to reach, but once you do it will be the most rewarding.

• Incentives: Depending upon the culture of your company this can be a fundamental method to engage your employees in a wellness program, especially when the incentive is monetary. But keep in mind that this can also provide a temporary motivation when the goal is to create long term positive behavioral changes.

• On-site fitness professional: Whether you have a fitness center within your company or not, you can hire someone to perform fitness assessments, personal training or to teach classes. This shows each employee that you are serious about the wellness programming.

Having a fitness professional on-site also gives your employees a resource for health and fitness information, support and motivation.

Once an employee engages in wellness and fitness programming, he or she will feel better about life and work. The employee will exhibit a more positive outlook regarding work product and the work environment. There is a two-way benefit for the employee and the company. A win-win, if you will.

Keeping Consistent Participation

Once your employees decide to engage in your Corporate Wellness program, the next step is consistent participation. Our research has shown that this can be accomplished through the 3-P’s to participation leading to program success:

1. Presence: Having highly trained, goal-oriented fitness personnel on-site to facilitate the program. A fitness professional can provide education, support, and motivation to your workforce.

2. Programming: Cutting edge programming and execution of services provides incentives and interest to your corporate wellness programming. Offering a variety of the top programs in the fitness world will draw in different audiences of your workforce.

3. Promotion: Promoting your wellness programming with targeted internal marketing that offers an educational value will help create interest in corporate wellness. There are many avenues to market to your workforce including newsletters, informational and educational emails, social media, etc.

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Combining presence, programming and promotion will drive participation, thus resulting in increased retention and reduced attrition. Consistent participation is critical because the more the employees participate, the more likely they will experience results. The results in turn fuel the continued participation of the employee. The ultimate goal of the company is behavioral change and engaging all employees, especially the sedentary population, into a healthy and fit lifestyle. For the company, this has a multitude of benefits that they are offering to their workforce, as well as creating an ROI for the company.

Additionally, there is a cutting edge way to engage employees in a corporate wellness program: technology. This concept is fairly new to the health and fitness world and will transform corporate wellness programming. By combining social media and fitness you will open up numerous avenues for employees to engage and participate in your company wellness program as well as with coworkers. With the blend of social media and fitness, your employees can communicate with each other online which will create team building, bonding and even healthy competition. Each participating employee will have access to online nutrition, and health and fitness tools. This electronic tool includes educational health and fitness blogs, networking with colleagues, forums, and a comprehensive calendar of healthy events within the company community. This type of platform will tie together the entire corporate wellness program through open communication between coworkers, education, rewards and incentives. Your corporate wellness program will become a desired commodity within the company which will encourage the engagement and participation necessary to drive results and

eventually the ROI the company is looking for from the investment.

As an employer, you may be wondering whether or not having a corporate wellness program is vital to your workforce and worth the initial investment. The bottom line is that when employees feel cared for by their company, they are more likely to have a ‘sell out’ mentality toward the employer and their position in the company. This will lead to the additional cost benefit of employee retention. The benefits of a corporate wellness program are numerous and with wise planning and executive management support, you can engage your employees to participate, thus leading to healthier employees and a healthy ROI.

About the Author

Deborah MacArthur is the Director of Marketing and PR for FACTS Fitness, a Commercial and Corporate Fitness Management Company located near Philadelphia, PA FACTS Fitness currently owns and/or manages commercial fitness centers including Ellis Athletic Center in Newtown Square, PA and Steel Fitness in Bethlehem, PA. Corporate Wellness clients have included BPG Properties, BPG Elite Properties, Coca Cola, T-Mobile, Penn State Lehigh Valley and many more.



Physician Shortage: Fact or Fiction?A Look Into the Rumors of a Shortage

Writen by Richard A. Longo

So, you need to see a primary care doctor. You’ve had a nagging lump in your neck that is causing concern and you figure it’s time

to get it checked. After dialing your family physician, you’re told that you can schedule an appointment, but you’ll have to wait for almost 2 months before the doctor has time to see you.

This is a scary scenario, but unfortunately this is what some patients in Massachusetts are facing today. In 2006, the state legislature passed a healthcare reform that bears similarities to the Obama administration’s recent bill. This

healthcare reform, combined with an already stressed healthcare system, is making it a little bit tougher for Massachusetts residents to access healthcare.

Growing Shortage Concerns

For years, the healthcare industry has been plagued with growing concerns over a potential physician shortage. Studies by different organizations have reached forecast assumptions about what the shortage could look like in terms of patient to doctor ratios. The lowest projection from the Department of Health and Human Services shows a shortage of over 65,000 by 2020, while other projections have the shortage upwards toward the 200,000 mark.

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Impact of Healthcare Reform

President Obama’s signature sealed the Patient Protection and Affordable Care Act (hereafter referred to as the healthcare reform act). With that flick of the pen, the President introduced an additional 30 million patients into the healthcare system. This increase of just 4% has the potential to stress an already ailing system to the max. The question remains if our hospitals and primary care doctors’ offices are ready for the influx of patients.

Other Contributing Factors

Aside from the healthcare reform act, there are other major factors contributing to the impending physician shortage. The “baby boomer” generation is quickly reaching retirement age, and with it, many physicians will be hanging up their stethoscopes in exchange for post-retirement vacations and other leisurely activities. According to the Association of American Medical Colleges, one-third of the active physician population is over the age of 55. The Pennsylvania Medical Society reported that in 2006, fewer than 8 percent of physicians in the state were under the age of 35.

According to the U.S. Census Bureau, the trend from 1990 to 2000 in population growth showed an increase of 13.2 percent, representing 32.7 million people. Data from the 2010 census has yet to be released; however, there does seem to be a continued rise in the nation’s population growth rate.

What You Can Do It is nearly impossible to tell if the predictions of the physician shortage will come into full



bloom, and if they do, whether it will be as harsh as expected. Now, the question becomes, if a shortage rears its ugly head in the next few years, what, if anything, can you do to make sure that your employees are getting the care they need?

The answer is that, yes, you can be instrumental in ensuring that you and your employees stay covered.

Review Your PPO Network: Take another look at your PPO network to make sure that there is strong coverage for primary care physicians and urgent care facilities, such as hospitals. Make sure that this includes facilities not only close to your office locations, but also within close proximity to your employees’ home locations. If there is significant holes in your network, contact your PPO networks to find out if they can negotiate contracts with facilities within the range that you want them.

Find a Primary Care Physician: Encourage your employees to find a primary care physician as soon as possible if they do not currently have one. New employees, in particular, may not have a family doctor if they relocated for their job or if their former doctor is no longer in-network. Many physicians will stop accepting new patients if their patient load becomes too great.

Educate Employees on Retail Health Clinics: The consumer world of healthcare has arrived, and it can be a viable option when urgent care is needed quickly. Even though retail clinics have been around for 10 years, many people are still relatively uneducated about their existence. Instead of visiting a physician office or the emergency room, your employees can pull up to a Walgreens, MinuteClinic, or other retail clinic to be seen by a medical professional, who is typically a nurse practitioner or physician assistant.

While not much can be done by the general populations in terms of the broader medical care issues, every precaution and strategy should be taken to ensure that your employees are able to receive care in an effective and efficient manner.

About the Author

Richard A. Longo, RN, FACHE, FACMPE, possesses extensive and varied experience in healthcare management and strategy development gained through over 25 years in the healthcare industry. He is currently the Senior Vice President of Network Management for Devon Health Services, Inc., one of the largest regional PPOs in the Northeast. Richard can be reached at [email protected].

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The Cards Are Dealt:How to Play the Hand for You and Your Employees

To paraphrase Woody Allen, “managing benefits is like playing bridge. If you don’t have a good partner, you’d better have a good plan.”

Health Care Reform along with other legislation implemented last year required—and continues to require—a significant effort for employers. The wide range of plan design and administrative requirements that need to be implemented and communicated comes with substantial cost—both in terms of the internal and external resources needed, and the attendant hike in premiums to accommodate such changes as the elimination of lifetime maximums, dollar amounts on preventive care, and the mandatory coverage of adult dependents. Some employers have even

gone so far as to eliminate or substantially reduce benefits in an effort to escape the requirements of such recent legislation (most recently, the Screen Actors’ Guild eliminated mental health coverage to avoid the requirements and cost of mental health parity). But the new legislation also offers a “bright” side: the chance to offer your employees meaningful benefit choices that create a true partnership.

As we move ahead into 2011, most companies have already taken advantage of the golden opportunity to begin more open communications with their employees about their benefits – and, with good cause. A recent poll suggests that changes due to health care reform encouraged over two-thirds of employees, in recent annual enrollments, to review their

Writen by Jenni Aldred



The Cards Are Dealt:How to Play the Hand for You and Your Employees

benefit options more closely. And an equal number of employees are looking for ongoing communications concerning how legislative changes will continue to impact their benefits and associated costs. While some of the messages communicated—such as premium increases—may have left a bad taste in employees’ mouths, the focus now is how to show employees how actions can determine the impact new legislation will have on their benefits down the line.

So what can employers do?

Leverage What Exists

• 100% Preventive Care Benefits and Wellness. The legislative requirement to provide preventive care benefits at 100% is a perfect launch pad for creating a partnership with your employees. Because “prevention” is closely linked to “wellness,” use this focus on prevention to encourage employees to become accountable for their health and well-being. Social media venues– such as blogs, Twitter, and Facebook – enable you to keep your employees constantly updated on trends in prevention, newly covered preventive tests and diagnostics, and focused topics related to your population’s “pain points” with disease and illness (such as diabetes, high blood pressure, and heart disease).

• “We’re Ahead of the Curve.” If you’ve never imposed a lifetime maximum on benefits or were already covering preventive care at 100%, let your employees know that the company has been ahead of the curve. This positions you as a company with its employees’ best interests in mind.

• Don’t ignore non-medical benefits. Although recent legislation has scarcely touched these benefits, communicating these “employee focused” benefits is now more important than ever. According to a recent PPACA poll conducted by MetLife , “71% of employees who say they have a good understanding of health care reform also say that their non-medical benefits are very important in driving their feelings of employer loyalty.” Make sure your employees understand the full package of benefits available to them—especially those that are provided at low or no cost.

• Your 401(k) Program. In December 2010, President Obama extended the Bush-era tax cuts, including a one-year reduction in workers’ Social Security taxes by nearly a third, from 6.2 percent in 2010 to 4.2 percent. Your employees will have more in their paycheck, giving you the opportunity to boost your 401(k) participation by encouraging them to redirect those funds to another form of retirement security—one they have control over.

Look Ahead

• Incentives, incentives, incentives. Although the Health Insurance Portability and Accountability Act (HIPAA) brought more attention to wellness programs and having incentives in place for employees who participated in these programs, the Patient Protection and Affordable Care Act (PPACA) will place greater focus on having this type of program in place by 2014. The law will permit rewards or penalties, such as premium discounts, of up to 30 percent of the cost of coverage – an increase of 10% of the total premium set by HIPAA. And, as premium rates continue to rise, being able to communicate

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to your employees that they have a chance to negate the increased cost with participation in a wellness incentive plan provides you a chance to shift priorities in health care from diagnosis and treatment to focus on prevention and wellness and move responsibility to your employees.

Solidifying Your Partnership: If you already have a wellness program in place, investigate how to bring your incentives up to the current 20 percent of cost of coverage limit between now and 2014 – this will put you in a position to leverage the 10% increase in 2014 and offer your employees more ways to save. Be sure to communicate to employees the impact of participating and not participating in the program in terms of percentages added or subtracted from their current premium rate.

• W-2 Reporting. As of January 2012, employers must report the aggregate cost of health coverage on employees’ W-2. This is an outstanding opportunity to show employees the “real” dollar value of their benefits. The true cost- sharing partnership will be evident, and employees will see the impact your contribution has to their pocketbook.

Solidifying Your Partnership: Think about incorporating a more effective disclosure of health-care cost information—such as a total rewards statement—into your current communications to employees. Incorporating total rewards statements as an integral part of their employee communications, companies are achieving higher returns on their investment in their employees by helping them understand the overall value of their employment and the link between collective efforts and personal success. • Expanded Review Process. While the

expansion of the internal and external review process adds another step to the Claims and Appeals process, it also provides an opportunity to provide an opportunity for you to communicate “one extra step” in place to protect your. . It also allows you to eliminate some of the “grey” area around adverse benefit determination.

Solidifying Your Partnership: Treat this as an opportunity to communicate to employees the non-biased approach to your Claims and Appeals Process. Many employees think their employers are the “bad guy” in these circumstances. Recent legislation allows employers to provide employees with a more detailed, specific understanding of their options – once again, adding value by placing emphasis on employee-driven outcomes.

The administrative challenges associated with recent legislation are daunting. But, the security employees expect from their benefit programs—not to mention the loyalty they hope for in an employer—seem to put perspective on the task at hand. To paraphrase Woody Allen, planning is a good idea, but having a good partner is the first at hand. Make your choices with that partnership in mind.

About the Author

Jenni Aldred is a Senior Project Manager/Writer for HighRoads, Inc. She joined HighRoads with 12 years of communication consulting experience with Buck Consultants and Watson Wyatt Worldwide. Using her extensive understanding of new Health Care Reform legislation, Jenni currently provides our clients with the information needed to navigate the changes occurring now and in upcoming years.



Facing Reality in 2011…It’s Your JobA New Health Benefit Management Program

A new breed of health care management is making enormous strides in controlling healthcare costs. Healthcare activists across the United States are reporting savings

of as much as 56% in healthcare expenses. Separate programs around county are starting to show success. Though independent from each other, each of these programs has several things in common.

Each program gets its impetus from forensic analysis of medical claims and the use of intervention with the most costly employees (patients). The core of each of these programs is an ongoing physician-employee (patient) relationship, which is centric to all health initiatives (including wellness) education,

provision of care, medical care coordination, coaching, informed decision making, and application through the entire continuum of an individual’s health.

Self-Funded Corporation, TPA’s and Brokers Are Well Positioned to Reach “Tipping Point”

Although these programs are in their infancy, their potential to drive a true consumer driven healthcare system is inevitable. However, if the concept of such programs is going to reach a “tipping point” and become the practical answer to rising healthcare costs, corporate America and the self-funded healthcare industry need to take action. It is the author’s belief that corporate America, independent TPAs and the self-funded industry are ideally positioned

Writen by Park Miller

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today to lead the charge of this new breed of healthcare management. But, corporate America and the self-funded industry need to wake up and face reality before there will be any serious movement toward gaining control of healthcare costs.

Jack Welch, former CEO of GE, spoke of “facing reality.” It was his opinion that facing reality is the hardest thing an executive staff will ever do. He also understood that leaders who avoided reality will have little chance of improving their business’ performance. His motto, “Change, before it’s too late” should be corporate America’s and the self-funded benefit industry’s wake-up call. American companies must face the reality that the current system and the enacted federal legislation will not yield the cost savings they desire.

How much higher must our healthcare costs climb before serious action is taken on a large scale? How serious does the economic impact need to be before corporate America realizes how ineffective and self-serving the promoted solutions from the healthcare industry and the federal government are before taking action.

Creating a Powerful and Comprehensive Health Benefit Management Model Although each of these new healthcare management programs represents only one or two management features, combined they create a powerful and comprehensive means for “health benefit management” (HBM) similar to the “prescription benefit management” (PBM) industry.

Cutting Healthcare Cost by 56%

One innovative program showing success was developed in Camden, New Jersey. A healthcare activist group called the Camden Coalition of Healthcare Providers. The Coalition used forensic medical claim analytics to detect the most costly patients and created intervention programs that cut hospital admission by 56%. Savings reached $700,000 per month, while emergency room visits went from an average of 62 admissions per month to



37, a 40% decrease. These savings were driven by an ongoing physician intervention program, consistently tackling chronic issues proactively, thus avoiding expensive crisis management in an emergency room.

Safeway, another healthcare activist, implemented a number of health initiatives that kept their overall healthcare expenses at zero growth for a period of four years. A Wall Street Journal article about Safeway’s stunning results stated, “Market based solution can reduce the national Health-care bill 40%.”

The Avivia Healthcare website reports that when patients are fully informed about their health care options, approximately 30% of them choose a less-invasive treatment and are subsequently more satisfied with their overall healthcare experience. Avivia relies on the power of data analytics and the use of medical management and health initiatives throughout the continuum of care cycle for an individual. It’s encouraging to see providers such as those in Camden facing their reality. They know that if they don’t embrace change someone is going to do it for them. And the same will hold true for corporate America and the self-funded industry. Remember Jack Welch motto “Change before it’s too late.” It’s better to manage change toward your own goals than to have unknown change forced upon you.

Core Concepts of an HBM Model—Focusing on Most Costly Employee

An advanced Health Benefit Management (HBM) program should begin with a comprehensive employee profile developed by primary care physicians (panel) using a company’s medical claims database,

employee risk assessment and personal history, advanced biometric screening and prescription drug database analysis. Once profiles are completed each employee is placed into one of four categories; most costly, chronic, early stage disease development, and low risk.

The comprehensive profiles and employee groupings provide the foundation for a company’s overall health initiative program, coordination of medical care activities, education, primary care panel development, intervention programs, coaching and advocacy efforts. Program implementation begins by focusing on the employees who make up 70% of a health plan’s costs. Compare this comprehensive approach to other health initiative and traditional wellness programs that implement less intense activities across the entire employer workforce resulting in slow adoption rates and poor ROI.

An initial focus on those employees that make up the large majority of healthcare plan costs does not imply that a Health Benefit Program ignores the remaining employer population. It merely underlines the importance of addressing the most costly employee first using intense health initiatives, medical care coordination efforts, education and physician coaching. Secondary objectives and the remaining employees are incorporated into the overall plan during the remaining implementation phase which can last up to six months.

The Power of Primary Care

A well structured HBM program will include a highly trained panel of primary care physicians to manage general care, create

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health initiatives, provide education, wellness, coaching and coordinate all medical care. These activities are all geared toward empowering the employee-patient team to make better informed decisions about healthcare choices. The primary care panel will be heavily supported by the results of medical claims data analysis, follow-up biometric screenings, health initiatives and care coordination associates. There may be a need for outsource vendors to provide specific assistance. However, the total process must be managed directly by the primary care panel and employee. A well organized HBM program features financial incentives to use the primary care panel to overcome participation hurdles, a challenge faced by other health initiatives. The physician can then instill in the participating employee the importance of using their services as both coach and team leader for more serious interventions. Each primary care physician should be highly trained to provide the appropriate mentoring, research, and coaching as well as becoming a trusted advocate. NMD’s are a new breed of primary care physicians that are well versed in these concepts as well as providing a more holistic approach to the health process.

As Health Benefit Management programs develop and mature, most companies will begin to make it mandatory for employees to visit primary care physicians for all health initiatives and coordination of medical care. Significant financial incentives and penalties will play a vital role in directing employees to the use of the primary care panel. Today there are companies that make it mandatory to complete biometric screening to maintain employment status.

Traditional Health Initiatives and Care Coordination Will Become a Thing of the Past

In the foreseeable future, advanced HBM programs will make all other health care initiatives, disease management programs and wellness initiatives a thing of the past. HBM programs reduce vendor program costs because their services are embedded in the medical care coordination routine, health initiatives and MD coaching activities. There still will be a need for some vendor services that are directly in support of primary care physicians.

The HBM process should significantly lower per employee per month costs associated with these healthcare programs. There will be a shift in spending from unnecessary administrative and vendor costs to fees for provider services. In addition, this process will eliminate a disparate and highly disconnected system of care. These activities reduce administrative layering and filtering of information and lead to decreased stress levels for the employee-patient team and a better overall healthcare experience. HBM Programs Should be Flexible in Pricing-Implementation and Management

Several health activist started HBM type programs using different components, yet each component yielded success on its own merit. This indicates that the HBM model has tremendous flexibility and will become an attractive feature for the healthcare industry as a whole to implement. TPA’s will be able to implement an HBM program for employers as a standalone program or as a complement



to other health initiatives provided by an ASO carrier. HBM programs do not represent a one size fits all approach, but rather a collection of highly specialized components based upon each employer’s needs. Some employers and TPAs may choose to take on enhanced roles by internally managing certain components and outsourcing others, while others may wish to outsource all of the activities associated with a Health Benefit Management program.

Because HBM programs can have standalone components, pricing structures are quite flexible and implementation follows step-by-step approach. Fees are phased in based upon the component being added. Virtually all traditional health initiatives are paid on a PEPM basis across all employees, but some HBM components can be paid for by only those employees using the service.

Facing Reality in 2011…It’s Your Job

Are you ready to rally around what a health benefit plan can become or are you content with complacency and 20 to 30 percent annual

rate increases? As I travel around the country, I am astounded by the mindset of corporate managers, health industry vendors, insurance brokers and healthcare providers. Most remind me when years ago General Motors and Ford executives told Americans with confidence that they knew what was best for consumers. That was just before the Japanese car invasion brought new product ideas to the American consumer. It took a complete collapse of the industry two decades later to affect a meaningful transformation.

Is your corporate health benefit plan, health care vendor, broker or provider organization any less married to an outdated business model than the American automobile industry was decades ago? Has your organization hit a brick wall with nowhere to turn to improve its health benefit plan, no more answers for your client’s as a healthcare vendor? Does your organization have another twenty years to wait before taking action? One only needs to watch the debates in Washington about healthcare to realize the time to face our reality has come. This debate has been going on long enough.

It’s now up to the self-funded corporations, TPAs and the industry to face reality in 2011…It’s your job…Before it’s too late.

About Park Miller

Miller is the founder and CEO of NuView Health Partners, Inc. Before founding NuView, Miller served in management roles in managed care organizations, Medicaid, PBM industry, TPA and hospital administration. He holds an MHSA degree in Healthcare Administration.

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