Solano County Medical Society

One of the most significant changes to come from the Affordable Care Act and the Center for Medicare and Medicaid Services (CMS) is the development of the CMS Star Quality Rating program for Medicare Advantage plans. This new pay-for-performance system is a comprehensive program that objectively rates over 30 quality measures in five main categories, including staying healthy, managing chronic conditions, member satisfaction, access to primary care and specialists, and customer service. Nine health plans in the United States earned the highest overall rating of 5 stars for 2011. Four of these nine plans were Kaiser Permanente regions, including the Northern California region.

Although several of the measures are health plan functions, most are directly related to how well we care of our patients. Several measures use HEDIS data sources to rate our care, including screening for breast and colorectal cancer; cholesterol and glaucoma testing; primary care visits; treatment of osteoporosis; management of diabetes; and control of hypertension. We are also rated on how well we monitor chronic medications and how well we give preventive vaccines. In addition, we are measured for how well we advise our patients about fall risk and bladder control. There are many more.

It is clear that no one physician can do all of this. It truly takes a village. Kaiser has achieved the 5-star rating by embracing a robust electronic medical record and building an infrastructure of nurse case managers, clinical pharmacists and support staff to provide our physicians with the information we need to achieve these goals. The first time we measured hypertension control in 1994, I was only treating 32% of my patients effectively. I would never have guessed it was that low. Now my team and I are able to routinely exceed 90% blood pressure control for my panel of patients.

As of now, the Medicare Star Quality program applies to Medicare Advantage plans, but it is clear that pay for performance is the way of the future. We will be measured and publicly rated for the care we provide our patients. The challenge for all of us will be to find efficient and effective systems to identify and help us manage our patients’ problems and then to demonstrate the high quality care we are providing.

PartnershipAdvantage boosts pay for annual physicals to $250

By Robert Moore, MD, MPH

Chief Medical Officer, Partnership HealthPlan

Partnership HealthPlan’s board of commissioners has approved a substantial change to the incentive payment made to primary care providers for completing an annual physical examination on PartnershipAdvantage members. The payment will rise from $100 to $250, in addition to the usual visit fee, in exchange for a set of services: completion of an annual health assessment form, having a discussion of advance-care plans with each patient, addressing all chronic conditions that the patient has, and updating the status of five preventive measures.

PartnershipAdvantage is a MediCal-MediCare-Part D combined product serving Yolo, Napa and Solano counties. It is a voluntary program, so eligible patients must sign up. The program currently serves about 8,000 members, with about half of all eligible patients signed up.

Partnership HealthPlan will help compensate providers for spending the increased time with patients that PartnershipAdvantage requires. The program will increase the risk scoring of patients and thus increase money paid from Medicare to Partnership which is based on the illness burden of our population. The incentive is structured to pass on the bulk of this increased revenue to primary care providers. Patients benefit from a more comprehensive update of their medical problems with generation of a personalized prevention plan, an assessment of risk factors that can be modified to improve health. Additionally, the increased time that primary care providers spend with patients will help with solidifying the trusting relationship that is the core of each person’s health care. We expect patients will be more satisfied and hope that regular discussions of advance-care planning will increase use of the POLST form and Advance Directives, and otherwise put patients in a position of autonomy in decision-making in stressful times.

To prepare primary care physicians, non-physician clinicians and office staff for the new program, I will be conducting a series of webinars in February. Please contact our provider relations department to register for a webinar.

Judge blocks state’s attempt to slash Medi-Cal reimbursement rates

By CMA President James Hay, MD

On Feb. 1, because of the efforts of a coalition led by the California Medical Association, a final ruling was issued by Judge Christina Snyder of the California Central Federal District Court, which blocks a 10% Medi-Cal reimbursement rate reduction. Her decision is a huge win for physicians in California and for the patients they treat.

California faces a budget deficit every year, and to close that widening gap, programs are cut and services are slashed. Medi-Cal is a program that is constantly targeted, and proposals always seem to include reducing reimbursement rates for physicians as a short-term solution. CMA has repeatedly informed the state, the federal government and the courts about the unacceptable impact of those cuts.

Year after year, we’re obliged to tell the same story: if Medi-Cal rates are cut, physicians will be forced to stop accepting the patients that need care the most. Thanks to the hard work of CMA’s legal and legislative staff, our voices have been heard, yet again. As we argued, Judge Snyder’s ruling stated that “fiscal crisis does not outweigh the serious irreparable injury plaintiffs would suffer absent the issuance of an injunction.”

It is more important than ever that we fight these fights and that we set a precedent for other states to follow. As the nation faces a changing health care landscape over the coming years, it is also critical that we physicians stand together. We thank our members for helping us accomplish this important outcome, preventing deterioration of access to care. My hope is that this achievement will serve as a reminder to those who are not yet members, and encourage them to join CMA today. To have continued success winning these battles for all California physicians and patients, it is crucial that we gain the support of those who benefit most.

Workshop on claims denials and ICD-10 in Napa on Feb. 24

A free lunchtime workshop on managing claims denials and ICD-10 coding will be held at Napa’s Queen of the Valley Medical Center on Friday, Feb. 24. The workshop, located in Conference Rooms 2-3, will run from noon to 2 p.m. Lunch will be provided.

To RSVP for this free event, contact Maryann Eckhout at 707-255-3622 or meckhout@ncms.com.

Enroll now for important Medicare seminar in Santa Rosa

Physicians and office staff are encouraged to attend “Medicare 2012 & Beyond: Know Your Rights,” a 6-hour seminar scheduled for April 18 at the Fountaingrove Inn in Santa Rosa. The seminar, which runs from 8 a.m. to 2 p.m., is cosponsored by the Sonoma County Medical Association and CMA. Topics include the Medicare physician fee schedule, 2012 updates and reminders, medical review audits, and preparing for ICD-10. The presenter is Michele Kelly, associate director of the CMA Center for Economic Services. Continental breakfast and lunch will be provided.

Cost is $55 for NCMS/SCMS members and $105 for nonmembers. To register, fax the flyer below to SCMA at 707-525-4328 or contact Rachel Pandolfi at 707-525-4375 or rachel@scma.org.

April 18 Medicare Seminar flyer

Unspent military funds could be used to repeal the Medicare SGR formula

Now that Congress is back in session, one of the first orders of business is to address the looming 27% cuts in Medicare payments to physicians. The cuts have been delayed until March 1 in the hopes that some kind of compromise can be found. One such possibility is a plan recently floated by House Democrats to use unspent military funding from early troop withdrawals in Iraq and Afghanistan to repeal the Medicare SGR payment formula.

That idea and others will be considered by a House-Senate conference committee that includes two strong physician advocates from California: Rep. Henry Waxman (D-Los Angeles) and Rep. Xavier Becerra (D-Los Angeles). CMA, AMA and many other medical associations have united to push for the House Democrats’ plan, which could cover the $300 billion cost of eliminating the SGR formula. The AARP has joined in as well, launching a campaign with the message, “Medicare patients could lose access to the doctors they know and trust in just a few weeks.”

CMA continues to urge physicians to call Senators Dianne Feinstein and Barbara Boxer and ask them to protect access to care in California by using unspent military funds to repeal the Medicare SGR. Let them know that the SGR cuts must be stopped before the March 1 deadline. Call the AMA Grassroots Hotline at 800-833-6354, plug in your zip code, and you will automatically be connected to your senator.

Blue Cross ordered to pay money owed to doctors, dating back to 2007

The California Department of Managed Health Care has ordered Anthem Blue Cross to pay physicians money owed to them, with interest, for services provided dating back to 2007. The action is a result of Anthem’s refusal to remediate physicians and other providers following a financial claims audit that identified errors in payment of medical claims.

CMA President Dr. James Hay applauded the DMHC order. “We provide necessary care to our patients based on the assumption that the health plans will promptly and accurately reimburse us for services rendered,” he said. “Anthem Blue Cross’s refusal to pay for a mistake on their end puts an undue burden on those of us who provide care.”

In 2008, DMHC launched claims audits of the seven largest health plans in California due to a growing pattern of complaints regarding late and inaccurate payments and inappropriate claim denials. These audits found claims payment violations above the threshold allowed under California law at all seven health plans.

In response to the audits, DMHC required the plans to pay providers the money they were owed and to demonstrate improvements to claims processes to prevent future errors. In addition, each plan entered into settlement agreements to pay administrative fines. To date, six of the seven plans have undertaken remediation efforts, but Anthem has refused to pay for claims violations uncovered in the audit. The company has to send DMHC a corrective action plan this month to identify the claims that were not correctly paid and pay the providers as prescribed by law.

Blue Shield begins recontracting with physicians across state

Blue Shield is in the process of recontracting with physicians across California and has begun mailing notices to physicians in selected counties, including several in the North Bay. The company explained that they have not recontracted with physicians in over a decade, and that they will be offering various tiered networks in anticipation of California’s health insurance exchange, a key feature of the federal health reform law.

The initial mailing will go to physicians in Marin, Napa and Lake counties, with others to follow later. Physicians are under no obligation to participate in any of these products, and there are no fee schedule changes at this time, other than for Medicare lines of business. The cover letter asks that physicians review, sign and return the new agreement to Blue Shield by Feb. 17, but the company has assured CMA that failure to return the new agreement will not affect a physician’s participation status.

To assist physicians, CMA has completed an analysis of the new Blue Shield contract, available to members at www.cmanet.org/ces. Physicians are encouraged to review and understand the legal and practical implications of the contract. For additional information, see CMA’s contracting toolkit, “Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations,” also available at www.cmanet.org/ces.

Physicians with concerns about the new contract should contact Blue Shield Provider Services at 800-258-3091 or CMA’s reimbursement helpline at 888-401-5911 or economicservices@cmanet.org.

Still time to get free EHR assistance from CalHIPSO

Primary care physicians who are transitioning to electronic health records have until Feb. 29 to sign up for free assistance from CalHIPSO, a nonprofit organization that offers technical advice, access to vendors, educational webinars, reduced pricing on software, and many other benefits.

Free CalHIPSO enrollment is available to primary care physicians in small private practices, community health centers, rural health clinics or certain hospital ambulatory care clinics. Primary care physicians in other types of practice settings can enroll in CalHIPSO for just $150.

Interested physicians should visit www.CalHIPSO.org or contact Kent Waldsmith at kent@calhipso.org or 510-285-5745.

Physicians needed for statewide Clinical Laboratory Advisory Committee

CMA is soliciting nominations of physicians to serve on the Clinical Laboratory Technology Advisory Committee (CLTAC), which advises the California Department of Public Health on matters related to clinical laboratories. CMA is specifically seeking nominations for physicians who are engaged in office-based laboratory testing.

The CLTAC is a multidisciplinary committee comprised of 22 representatives from various interest groups related to clinical laboratories. Interested candidates are invited to submit a statement of interest and a current CV demonstrating their qualifications and background to Kimberly Henning by email to khenning@cmanet.org or by fax to 916-444-5689. The deadline is Feb. 17.

RESOURCES

CMA is hosting a webinar, HIPAA Risk Analysis for Meaningful Use, from 12:15 to 1:15 p.m. on Feb. 15. The event provides detailed instruction on the steps needed to complete a HIPAA risk analysis, a key element in qualifying for electronic health record funding. To register, visit www.cmanet.org/events.

The 19th annual HIV/AIDS Review will be held at the Hilton Hotel in Santa Rosa on Saturday, March 24, from 8:30 a.m. to 3:30 p.m. State and local HIV/AIDS experts will cover current issues in HIV, sexually transmitted diseases, hepatitis C, and other topics. The conference, worth 5 hours of Category 1 credit, costs just $45. To register, call 707-527-6223.

The Institute for Medical Quality is sponsoring a training program for physician leaders on Coronado Island from March 8 to 10. Participants will explore solutions and creative approaches to resolving problems encountered in leading a medical staff. To register, visit www.imq.org or contact Leslie Iacopi at 415-882-5167 or liacopi@imq.org.

The American Medical Association has made several new resources available to physicians. The Practice Management Center at www.ama-assn.org/go/pmc offers easy access to tools and guidance for enhancing the operation of a medical practice. Three online educational tutorials available at www.ama-cmeonline.com can help physicians better implement health information technology. Finally, a Team Up To Stay Healthy brochure available at www.ama-assn.org/resources can help seniors receive preventive services covered by Medicare.

ABOUT NCMS & SCMS

The Napa County Medical Society (NCMS) and the Solano County Medical Society (SCMS) are both 501(c)(6) nonprofit associations that support local physicians and their efforts to enhance the health of the community. Both NCMS and SCMS are affiliated with the California Medical Association and the American Medical Association.