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Published Monday, California Healthfax is copyrighted by HealthLeaders Media, a division of BLR, 35 Village Road, Suite 200, Middleton, MA 01949 and is transmitted solely to the sub-scriber. Any unauthorized copying, duplication or transmission is strictly prohibited. Subscriptions are $179 for 48 issues. For group and bulk sub-scriptions, call 800-650-6787.
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August 8, 2016 | VOLUME 23 | NUMBER 31
T O P S T O R I E S
John Muir and UCSF Expand Network to Form Canopy Health Health plan to launch this fall with Health NetThe Bay Area Accountable Care Network established by John Muir Health and UCSF Health has added seven new hospitals to its network and changed its name to Canopy Health as it prepares to launch this fall.
Canopy Health also added three new medical groups to its network to bolster a provider base that now includes more than 4,000 physicians. “We’ve made significant strides in a short amount of time as we work to provide Bay Area residents with an option to choose Canopy Health during open enrollment in the fall of 2016,” said Canopy Health CEO Joel Criste.
As part of its expansion, Canopy Health added Marin General Hospital, Sonoma Valley Hospital, San Ramon Regional Medical Center, Washington Hospital Healthcare System, Alameda Hospital, Highland Hospital, and San Leandro Hospital. Medical groups joining the network are Hill Physicians Medical Group, which has more than 2,250 physicians in the Bay Area, the John Muir Physician Network, and Meritage Medical Network.
The addition of three new medical groups expands the provider base to more than 4,000 physicians and the addition of seven hospitals increases the number of hospitals in the Canopy Health provider network to 12 hospitals. The network also includes two John Muir hospitals in Concord and Walnut Creek and three UC San Francisco hospitals.
“We have a lot of independent, like-minded providers who have come together under this strategy, and we all want to provide the appropriate care in the right setting at the right time,” said Michael Moody, senior vice president of partnership, integration, and development for John Muir Health.
Canopy Health received its limited Knox-Keene license from the state Department of Managed Health Care on August 3. The license allows it to pro-vide services in San Francisco, Alameda, Marin, and Contra Costa counties and in portions of Sonoma, Solano, and San Mateo counties.
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John Muir and UCSF Expand cont. ° The United States Courts for the
Ninth Circuit has ruled that Dignity Health's pension plan is subject to the requirements of the Employee Retirement Income Security Act (ERISA) and does not qualify as an ERISA "church plan.” According to a July 29 report from Courthouse News Service, the Ninth Circuit court ruling upholds a U.S. District Court, Northern California ruling that Dignity Health's retirement plan does not qualify for the ERISA exemption because it was not established by a church. In a 26-page opinion, U.S. Circuit Court Judge William Fletcher wrote that "the parties' dispute would have been easily resolved under ERISA's original-ly enacted text, which unambiguously provided that a church plan must have been established by a church." Dignity Health formed its retirement plan as a church plan in 1989 under its former name of Catholic Healthcare West. In 2013, a former Dignity employee sued the health system and challenged its right to operate a church plan, which provides benefits not extended to reg-ular retirement plans and are not sub-ject to disclosure, funding, and vesting requirements that regulate private sector plans.
° The University of California Boardof Regents agreed to pay nearly $8.5 million to settle two lawsuits that allege a UCLA spine surgeon failed to dis-close conflicts of interest with medical device manufacturer Medtronic while using the company's products to per-form surgeries. According to a July 29
Criste said Canopy Health is different from health plans launched by other health systems. “Our model is unique, as we are partnering with health plans to offer a competitively priced insurance product rather than selling our own plan,” said Criste. He added that Canopy Health currently contracts only with Health Net but is in discussions to form partnerships with other insurers to join its network.
Canopy Health will launch this fall with approximately 13,000 University of California employees. Canopy signed a contract with Health Net to provide coverage for employees and families covered under its Health Net Blue & Gold Plan with San Francisco Hill Physicians Medical Group. It will also offer its HMO plan to more UC employees this fall during open enrollment for coverage starting in January 2017.
John Muir and UCSF join a growing list of health systems forming their own health plans. In 2015, Sutter Health launched an HMO called Sutter Health Plus in the Sacramento area and now operates in more than a dozen counties in Northern California. The HMO includes a network of 25 hospitals and more than 5,600 physicians and now has more than 37,000 members.
A 2016 report from McKinsey & Company found that “offering a health plan can give health systems an opportunity for growth but is not without finan-cial risk,” noting that “40 of the 89 provider-led health plans we analyzed have had negative margins in some or all of the past three years.” The report also noted that, “health systems, if they are to benefit from offering a health plan, will need to be able to understand how they can use consumerism to their advantage and where the best opportunities for growth exist.”—DOUG DESJARDINS
Huntington Hospital to Take Part in End of Life Option ActCalifornia hospitals not expected to play large role in new lawHuntington Hospital in Pasadena announced that it will participate in the End of Life Option Act but that it doesn’t expect to be part of many end-of-life plans.
The hospital made its announcement in a Letter to the Community pub-lished in the July 31 edition of the Los Angeles Times.
"Earlier this year, our hospital began ongoing, thoughtful deliberations about whether and how to participate in this new law," the Letter to the Community stated. "In June, as the law came into effect, we announced that we would partici-pate in the act while we completed our deliberations. Now, after careful evaluation
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report from the Los Angeles Times, the $4.25 million and $4.2 million settle-ments resolved cases involving Jeffrey Wang, MD, UCLA, and Medtronic, and two former patients who claimed their surgeries led to recurring pain and the need for additional surgeries. The lawsuits claimed that from 2004 to 2013, Medtronic paid Wang more than $275,000 for consulting work, lectures, and product royalties while Wang was using Medtronic products in surgeries. UCLA said it agreed to the settlement "so that UCLA Health and the David Geffen School of Medicine at UCLA could move for-ward with their ongoing commitment to excellence in patient care, research, education, and community service." Medtronic also denied any wrongdoing and said that Wang "was not paid for using the Medtronic products used in the surgery."
° Nine hospitals in California receivedfive-star ratings from the Centers for Medicare & Medicaid Services (CMS) in its annual Overall Hospital Quality Star Ratings. The five-star hospitals include Scripps Memorial Hospital - La Jolla, Scripps Green Hospital in La Jolla, Goleta Valley Cottage Hospital in Santa Barbara, Santa Barbara Cottage Hospital, Community Hospital of the Monterey Peninsula, Hoag Orthopedic Institute in Irvine, Sutter Maternity & Surgery Center of Santa Cruz, Fresno Surgical Hospital, and Methodist Hospital of Southern California in Arcadia. The Overall Hospital Quality Star Ratings
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of the law … our board of directors determined that Huntington Hospital will con-tinue to participate in the End of Life Option Act. As has always been the case, physicians will individually decide whether to participate or not."
Huntington Hospital officials began debating the merits of opting out of the new law in April and considered the opinions of hundreds of physicians, nurses, clinicians, and administrators. "In conversations with our physicians, palliative care experts, nurses, bioethicists, patients, and the community, the most critical factor in end-of-life discussions is individual choice," the letter stated.
The Letter to the Community added that, "we fully respect those who dis-agree with the law and expect it will be quite rare that patients choose to end their own lives in our hospital." Huntington Hospital cited data from Oregon— the first state to approve a death with dignity law—that shows physician aid- in-dying at hospitals is rare.
"In Oregon, for example, which has had a similar statute in place since 1998, patients have overwhelmingly decided to exercise this option outside of a hospital setting. According to the most recent Oregon data, 990 of the 991 patients who terminated their lives chose to do so in their homes or in non-hospital settings."
Jan Emerson-Shea, vice president of external affairs for the California Hospital Association (CHA), said the CHA encourages all hospitals to adopt a policy regarding the End of Life Option Act but does not expect hospitals to play a large role in implementing the law.
"We encourage all hospitals to adopt a policy," said Emerson-Shea. "But we don't expect people who choose to use the End of Life Option Act to choose a hospital as the setting."
The Oregon Death with Dignity Act: 2015 Data Summary report from the Oregon Public Health Division found that 90.1% of patients who opted for physician aid-in-dying in 2015 died at home and that 92.2% of patients were enrolled in hospice care at the time of their deaths.
Lori Dangberg, vice president for the Alliance of Catholic Health Care, said more than 45 Catholic and Catholic-affiliated hospitals in California have chosen not to participate in the new law, including Dignity Health.
The End of Life Option Act allows physicians to prescribe lethal medication to terminally ill patients with less than six months to live. There is no current data on how many California residents have requested physician aid-in-dying so far this year and the state will not release those statistics until 2017.—DOUG DESJARDINS
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are incorporated into the CMS Hospital Compare website and rank hospitals on a one-to-five star system based on 64 different metrics that include length of emergency department waits, hospital readmission rates after heart attacks, and complication rates following hip surgery. Overall, 4,599 hospitals were rated and 20.3% (934) received four-star ratings, 38.5% (1,770) received three-star ratings, 15.7% (723) received two-star ratings, and 2.9% (133) received a one-star rating.
° A study of more than 3.8 millionKaiser Permanente members showed that heart attack rates among mem-bers in Northern California declined 23% from 2008 to 2014, according to a study published in the August issue of the Journal of the American College of Cardiology. "Our findings show heart attack rates have continued to decline since 2008, overall and in key patient subgroups, within a large community that reflects racial, ethnic, and socio-economic diversity," said Alan S. Go, MD, senior author of the study and chief of Cardiovascular and Metabolic Conditions at the Kaiser Permanente Northern Cal ifornia Division of Research. Researchers attributed the decline in heart attacks to better man-agement of patients' blood pressure, cholesterol, diabetes, and other con-ditions that can increase the risk for heart attacks.
° A statewide poll found that nearlytwo-thirds of state voters support a November ballot measure that would
Dignity Health Opens First Urgent Care Center in San FranciscoNew center opening is one of five planned for 2016Dignity Health opened its first urgent care center in San Francisco as part of an effort to extend its reach into ambulatory and emergency care.
Dignity Health opened its first Dignity Health-GoHealth Urgent Care Center August 1 on Market Street in San Francisco. Dignity plans to open 12 urgent care centers over the next 15 months in the Bay Area in a partnership with GoHealth Urgent Care, an Atlanta-based company that also operates urgent care centers in New York through a partnership with Northwell Health and in Oregon through a partnership with Legacy Health.
"At this location and future Bay Area centers, Dignity Health clinicians will have the resources and the tools they need to ensure that all urgent care patients are treated with the same level of high-quality [and] low-cost care," said Todd Strumwasser, MD, senior vice president of operations for Dignity Health in the San Francisco Bay Area.
Dignity Health said it plans to open two more urgent care clinics in Glen Park and Cole Valley by late September and that there will be “other openings in Santa Clara, San Mateo, and San Francisco counties over the course of the year.”
The new urgent care center accepts appointments and walk-in patients and provides basic care for minor ailments such as upper respiratory infections. The urgent care center also offers imaging and lab services along with physical exams and integrates patient records with Dignity Health's electronic medical record systems.
Dignity Health said the urgent care centers will fill a need for nonemergent care in the Bay Area and provide another point of entry into its health system. It cited a recent study from the San Francisco Department of Public Health that said a shortage of primary care physicians in the Bay Area "was one of the main reasons for inappropriate emergency room use" and that "increasing access to urgent care centers would decrease inappropriate use of ERs."
Other health systems are branching into nontraditional venues of care. St. Joseph Health signed a deal in February to acquire 26 Nurse Next Door franchises, which provide home-based care for patients with acute and chronic healthcare needs. In a statement, St. Joseph said the acquisition expands its continuum of care by "helping patients recover at home after they are discharged from the hospital, providing support as they age, or assisting them with other healthcare needs."—DOUG DESJARDINS
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T O P S T O R I E SBlue Shield to Appeal State Decision
to Revoke Not-for-Profit Status
Insurer says appeals process could take two years
Blue Shield of California plans to appeal a state decision to rescind its tax-
exempt status in California as a not-for-profit insurer.
The ruling by the California Franchise Tax Board
Shield to pay millions of dollars in retroactive state taxes. Blue Shield vice president
of corporate communications Steve Shivinsky
decision. “We have filed a protest against the FTB ruling and this will take up to
two years to decide,” said Shivinsky. “Blue Shield as a company and a management
team firm believes it is fulfilling its not-for-profit mission and commitment to the
community. We are, and will remain, a not-for-profit company…”
Shivinsky noted that the decision only pertains to Blue Shield’s status in the
state. “Blue Shield has paid federal taxes since 1986,” said Shivinsky. “Blue Shield
of California’s e�ective tax rate on pre-tax profits exceeds 45% annually …” Blue
Shield of California and other Blue Cross and Blue Shield plans in the U.S. lost their
federal tax-exempt status under reforms to the federal tax code approved in 1986.
O¢cials for the Franchise Tax Board declined to comment on the ruling or
what prompted the state audit that led to its decision issued in August 2014. The
FTB added Blue Shield to a list of companies that had their tax-exempt status
revoked and posted the information on its website but did not comment on it at
the time. The decision will also require Blue Shield to file tax returns dating back
to 2013. While state and federal laws regarding not-for-profits have changed over
the years, the action taken against Blue Shield is unusual. “I am not aware of any
nonprofit health insurer that has been stripped of its tax-exempt status prior
to Blue Shield,” said Gerald Kominski, a professor of health policy at the
Fielding School of Public Health and director of the
Policy Research. Kominski said Blue Shield has the option of converting to a for-profit insurer
but that it’s more likely to negotiate a settlement with state o¢cials if its appeal of
the Franchise Tax Board decision fails. “I imagine that Blue Shield will try to reach
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August 17–19. 7th Annual Pain Management Symposium. Hilton Los Angeles/ Universal City. A three-day semi-nar focused on the latest advances in pain management and new trends in patient-centered care. To register, please visit http://www.keck.usc.edu/events/7th-annual-pain-management-symposium-from-evidence-to-clinical-practice/
Sept. 15–16. HFMA Fall Conference. Hilton Concord Hotel. A conference for healthcare professionals with an emphasis on new payment models and programs. Sponsored by the Northern California Chapter of the Healthcare Financial Management Association. To register, please visit http://www.hfma-nca.org
Sept. 23. 15th Annual IHA Stakeholders Meeting. Hilton Los Angeles Airport. A conference for health plan admin-istrators with a focus on value-based and pay-per-performance plans. Sponsored by the Integrated Healthcare Association. To register, please visit http://www.iha.org/conferences/15th-annual-iha-stakeholders-meeting
Oct. 10–12. CAHP 31st Annual Conference. JW Marriot Desert Springs, Palm Desert. A three-day conference focused on current and recurring health-care trends that are affecting health plans. Sponsored by the California Association of Health Plans. To register, please visit http://www.calhealthplans.org/confer-ences.html
create new regulations for the state when it negotiates prices for prescription drugs with pharmaceutical companies. The poll conducted by Tulchin Research on voter attitudes toward Proposition 61—dubbed the California Drug Price Relief Act—found that 66% of voters support the measure. The poll, which was sponsored by supporters of Proposition 61, interviewed 800 likely California voters. If approved, Proposition 61 would require the state to negotiate with pharmaceutical companies when purchasing prescription drugs and pay prices that are no higher than those paid by the U.S. Department of Veterans Affairs. Opponents of Proposition 61 say the measure will not work and will likely lead to higher prices for consumers.
° The National Labor Relations Board (NLRB) filed a lawsuit against BarstowCommunity Hospital that claims the hospital is denying unionized nurses pay raises and disciplining them for working overtime. According to a July 26 report from Courthouse News Service, the lawsuit was filed in U.S. District Court, Central District of California on July 21 and claims that in 2015, Barstow Community Hospital stopped issuing pay raises to nurses and changed its overtime policies, resulting in several nurses receiving reprimands for working overtime. The NLRB lawsuit is seeking an injunction to stop the hospital from enforcing its new policies. Barstow Community Hospital issued a statement that said "Barstow Community Hospital is aware of the lawsuit filed by the National Labor Relations Board. This is an interim, legal matter with no impact on our daily operations."
° A study from the UCLA Center for Health Policy Research found that mostCalifornia adults don't get a flu shot each year and that vaccination rates vary by ethnicity. The study that appeared in the Journal of Infection Control used data from the 2011–2012 California Health Interview Survey and found that Korean-Americans had the highest vaccination rates at 48.9% followed by Vietnamese-Americans at 46.7%. The study also showed the lowest vaccination rates wereamong African-Americans at 28.5%. "Knowing who isn't participating can help ustarget those groups, encourage them to get flu shots, and keep them healthy during the flu season," said Christopher Almario, lead author of the study and an assistant professor of medicine at Cedars-Sinai Medical Center.
° Kaiser Permanente reported that a list containing 176 patient names and theirmedical data was accidentally placed in a pharmacy bag and given to a patient pick-ing up a prescription. According to an August 2 report from ABC 10 News San Diego, the list included patient names, medical record numbers, and some medications being prescribed to patients. In a statement, Kaiser Permanente acknowledged the incident and said it will "reach out" to all members whose names were on the list. "Our commitment is to discover how this incident occurred so that we may prevent it from happening in the future."
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Central California Faculty Medical Group (CCFMG)CCFMG is an organization of faculty physicians and staff affiliated with the prestigious University of California, San Francisco – Fresno Medical Education Program with a core purpose – To Make Medical Education Happen.
Administrator for Surgery PracticesResponsible for providing administrative and organizational lead-ership, management, staffing and services to surgery specialty practice office(s). Designs and develops standards and systems for fiscal management and responsible for overseeing and report-ing the overall budget. Integrates strategic plan of the department and organization with operations. Bachelor’s Degree in Healthcare, Business or related field required; Master’s Degree preferred. Minimum of three years’ experience in administrative role in a sur-gery care facility/unit.
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Qualifications/Experience: Bachelor’s degree in Business, Accounting, Finance, or related field; CPA or MBA preferred. 7 years’ experience in mid-size or large accounting or finance function. 5 years’ experience in Health Care, preferably managed care and/or medical group practice management, knowledge of physician com-pensation programs, physician billing and coding, capitation, and risk adjustment. 5 years’ of supervisory experience.
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North American Medical Management, California, Inc (NAMM California) partnered with OptumHealth in 2012. We are currently hiring for the following positions in our Ontario office:
Director, Payor ContractingWill participate in negotiation; implementation, and operational issue resolution of all NAMM California health plan contracts. Act as liaison with health plans and NAMM Operations Departments. Responsible for negotiating health plan contracts/amendments. Oversight of implementation process of payor contracts/amendments and issues with internal Operations, tracking renewals, financial analysis associated with payor contracts, and creation of contract tools for internal uses. Job #662444
Requirements: Bachelor’s Degree in related field or 3-5 years equivalent, related to health care experience. 3 years management experience of payor contracting process from preparation, negotiation, implementation with ability to understand key contract structure, DOFR & their financial implications. General understanding of healthcare industry and/or local physicians market, managed care alternative delivery systems and knowledge of relevant federal and state regulations.
Manager, Revenue Recoveries Provide process development, project management, company liaison, leadership, mentoring and training on multiple areas within Revenue Recovery. Responsible for monitoring timely and accurate job task completion, process development and automation, policy & procedures, and regulatory compliance in dept, inside and outside written communications for the highly regulated TPL Dept. Provide information, back-up support to Administration. Participation in management level meetings for the purpose of representation and integration of new and terminating products, systems, groups, into and out of Revenue Recovery production plans. Job # 663233
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BENEFITS INFORMATION: Excellent benefits package offered including HPSM paid premiums for employee’s coverage in the medical HMO plan and majority of PPO medical cost. Employee pays a small portion of the dependent premiums for medical and dental benefits. Additional HPSM benefits include fully paid vision, life, AD&D, STD, and LTD insurance; 457 Plan in lieu of social security (7.5% of salary/HPSM paid); retirement plan (10% of salary for com-pensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; and more.
APPLICATION PROCESS: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 801 Gateway Blvd. Suite 100, South San Francisco, CA 94080. or via Email: [email protected] or via Fax: (650) 616-8039
File by: Continuous until filled. EOE Please visit our web site to view full job descriptions and requirements: https://www.hpsm.org/abouthpsm/employment-opportunities.aspx
DUALS DEMONSTRATION PROGRAM DIRECTOR
Responsible for all aspects of Duals Demonstration Program (Cal MediConnect and Coordinated Care Initiative). Position is focused on strategy development/execution, and accomplishment of Triple Aim for HPSM’s demonstration, including improving patient quality and satisfaction; health of populations; reducing per capita health care cost. Develop, execute strategies to meet, exceed Centers for Medicare and Medicaid Services (CMS) and State of California goals.
CARE COORDINATION CASE MANAGERPerform comprehensive assessments, develop individualized care planning; initiate and coordinate case conferences; make deter-minations regarding appropriateness of service; determine medi-cal necessity of services requiring prior authorization. Identify Member’s and family’s physical, psychosocial, environmental, safety and developmental needs; individualize plan of care based on the needs identified. Communicate with appropriate party to initiate and develop individualized care plans.
MEDICAL CLAIMS REVIEW NURSEReview retrospective authorization requests/claims documentation in specified timeframes. Review authorization requests/claims for out-of-network inpatient facilities. Clinically validate medical appropriateness and coding accuracy of services in an inpatient setting. Document audit determinations in audit tracking system by creating rationale narrative. Support findings during appeals process. Serve as clinical resource; pro-vide clinical expertise and clinical guidance to claims team.
UTILIZATION REVIEW NURSEPerform utilization reviews to ensure members receive timely and cost-effective necessary medical care. Conduct utilization reviews of inpatient facilities, including acute care, and/or process authoriza-tion requests for services including outpatient, rehabilitation and/or home health services. Review authorization requests for out-of-network inpatient facilities.
PEDIATRIC UTILIZATION REVIEW NURSEPerform utilization reviews ensuring pediatric members receive neces-sary medical care in timely/cost-effective manner. Conduct concurrent reviews of inpatient care, and review authorization requests for inpa-tient care. Provides care coordination for members who are transition-ing to new level of care.
DIRECTOR OF PHARMACYResponsible for development, implementation and monitoring of all Pharmacy initiatives. Develop overall pharmacy business plan, budget to establish goals/targets and strategies to educate physicians/providers. Will include methods to measure, monitor the effectiveness and suc-cess of pharmacy programs/services implemented. Develop, implement pharmacy-related policies, procedures, guidelines and programs.
BUSINESS SYSTEM ANALYSTImprove organizational and staff performance by analyzing/devel-oping work flows, processes, and functional gaps and developing optimal solutions. Project lead during application selection and implementation, facilitating communication and decision-making of business and technical teams. Working closely with business units and associated technical teams, develop and maintain appropriate documentation for application implementation.
HEALTHCARE FINANCIAL ANALYSTPerform financial analysis and reporting to assist in the manage-ment of health care costs for all lines of business and to ensure adherence to reporting and reconciliation requirements with the State and CMS. Analyze required monthly IBNR reserves and pres-ent results to management. Prepare monthly, quarterly standard reports on medical cost utilization, metrics and trends.
HEALTH DATA ANALYSTPlan and evaluate activities through design/development of reports and analysis/interpretation of data. Includes development of data-base tools, data analysis to evaluate effectiveness of quality stud-ies/programs, and provision of data support for programs/ad hoc reports. Develop and maintain databases for use in data analysis and tracking. Perform data cleaning, extraction, processing, storage, manipulation, and analyses. Build and maintain SAS/SQL program-ming codes.
PROJECT SPECIALIST IIProvide operational and analytical support for medium to large size projects with significant organizational impact. Assignments will be conducted by incumbent with a large degree of independence. Take lead, assist to investigate/launch potential projects relating to agen-cy policy and operational initiatives across product lines. Provide operational and analytical support for cross-departmental activities.
Please visit our web site to view full job descriptions and requirements: https://www.hpsm.org/abouthpsm/employment-opportunities.aspx