!"#$"%&"'!()!*+,,!-!*+,,!&.!/0."'1!2!/'3456"'1!/7&85195:;)!

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Two California healthcare philanthropies have
awarded $4.1 million in grants to nine
organizations statewide to boost the
development of community clinic-based
medical homes.
Seven of the
recipients
including the Medi-
Cal managed care
plans in the Inland
Empire and San
Joaquin Counties
received $500,000
apiece. Three other
organizations
received $200,000
each.
The money was
allotted by the
Health Home
Innovation Fund,
managed by the
Community Clinics
Initiative (CCI). Its
a joint venture of the Los Angeles-based
California Endowment, and The Tides, a San
Francisco-based philanthropy. A total of 42
organizations throughout California submitted
applications for funding.
According to CCI Managing Director Jane
Stafford, applicants focused on creating
unlikely coalitions with hospitals, health
plans and more disparate entities such as food
banks. The intent is to create medical homes
for those who frequent community clinics by
July 2013. Those patients are usually low-
income individuals
who cannot afford
insurance or those
who do not receive
coverage from their
employer, and
therefore experience
uneven preventive
care at best.
In addition to
promoting several
entities working in
tandem, Stafford said
her organization was
also looking for
changes in the
payment streams for
medical home
workers.
For the medical
home concept to be successful, there needs to
be some payment reforms in place, Stafford
said. In particular, the promotion of funding
for patient navigators who would ensure that
those enrolled in a medical home have
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September 21-23
October 17-19
Calendar
15 September 2011
September 19-21
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E-Mail
info@payersandproviders.com with
the details of your event, or call
(877) 248-2360, ext. 3. It will be
published in the Calendar section,
space permitting.
www.lakesidecommunityhealthcare.com
California Edition
Millions Awarded For Medical Homes
Nine Grantees Encouraged to Foster Coalitions
Continued On Next Page
Grantees For Medical Home Creation
$500,000 Grants
1. Coalition of Orange County Community Clinics
2. Community Clinics Health Network
3. Health Improvement Partnership of Santa Cruz
4. Health Plan of San Joaquin
5. North Coast Clinics Network
6. San Francisco Community Clinic Consortium
7. Inland Empire Health Plan
$200,000 Case Study Grants
1. Redwood Partnership Health Plan/Redwood
Community Health Coalition
2. Los Angeles County Education Foundation
3. Health Alliance of Northern California
Source: Community Clinics Initiative
!"#$"%&"'!()!*+,,!-!*+,,!&.!/0."'1!2!/'3456"'1!/7&85195:;)!<<=
Payers & Providers Page 2
Top Placement...
Bottomless Potential
Advertise Here
(877) 248-2360, ext. 2
In Brief
UCLA-Santa Monica
Replacement Campus
Nears Opening
UCLA Santa Monica Medical Center
is nearing closer to opening a $572
million replacement campus several
miles southwest of its main campus in
Westwood.
The 266-bed facility was
dedicated earlier this week, and will
be open to patient care early next
year. It will feature an inpatient
pediatrics unit and an orthopedics
branch afliated with the
Orthopaedic Hospital Institute.
UCLA-Santa Monica previously
opened a new emergency department
and a 16-bed neonatal intensive care
unit.
"This wonderful new facility not
only accommodates scientic and
technical excellence, but also creates
an environment that is healing," said
David Feinberg, M.D., president of
the UCLA Health System.
Once the new hospital is on
line, the 1950s-era patient tower
which was replaced in order to
remain seismically compliant will
be demolished. Landscaped gardens
will be put in its place, ofcials said.
Roth Named New
SCAN COO
Former Cigna executive Bill Roth has
been named chief operating ofcer of
Long Beach-based SCAN Health Plan.
Roth begins in the newly created
position immediately. He previously
served as Cignas president of the
small business and individual
markets.
The Medicare marketplace is
incredibly complex and will become
even more so given healthcare reform
and the aging of our population, said
SCAN Chief Executive Ofcer Chris
Wing. Adding someone with Bills
accomplishments and values helps
Continued on Page 3
NEWS
appropriate transportation to appointments
was emphasized.
The client has to have a seamless
experience no matter what door they enter,
Stafford said.
Specic information about what the
specic grantees would do remained sketchy
this week, as an ofcial announcement of the
grants has yet to be made. Stafford declined to
share specic grant proposals, noting they
would be ne-tuned until an ofcial launch of
the initiative in November.
Stockton-based Health Plan of San
Joaquin will team with two local hospital
operators and San Joaquin County Behavioral
Health Services to place medical homes in
four community clinics. The initial focus will
be treating diabetic patients who also have
depression conditions that tend to
exacerbate one another.
The project will involve signicant
modications to the way care is provided,
said Health Plan of San Joaquin spokesman
David Hurst. It will include initiatives such as
the use of disease registries and the integration
of psychiatrists into the community clinic
setting, he added.
Inland Empire Health Plan, the Medi-Cal
managed care payer for San Bernardino and
Riverside Counties, said it would use its
$500,000 grant to improve care coordination
through the use of a referral tracking system
and the use of electronic health records in
conjunction with 10 community clinics. IEHP
has more than 500,000 enrollees in Medi-Cal,
Healthy Families and related programs. In
addition, IEHP is pledging another $178,000
in it funds toward the initiative.
"Improving care coordination and
communication in primary care sites is critical
to meet the challenge of delivering healthcare
to our members," said IEHP Chief Executive
Ofcer Bradley Gilbert, M.D. "What we learn
from this partnership could set the stage for
our developing future health homes for
members."
CDPH (Continued from Page One)
Blue Shield Begins Enrollee Rebates
$180 Million Returned as Part of Profit Cap Pledge
Blue Shield of California will rebate as much
as 30% of a months premiums beginning
next month.
The San Francisco-based health insurer is
issuing to its policyholders credits totaling
about $180 million. The rebates are part of a
pledge by the not-for-prot carrier to limit its
net income to 2% of total revenue.
"As a mission-based, not-for-prot health
plan, we made this commitment to help keep
coverage affordable for our members. While
these credits will help our customers, every
player in the healthcare industry must do
more to reduce the cost of care," said Blue
Shield Chairman and Chief Executive Ofcer
Bruce Bodaken.
Individuals and families that have
purchased non-group coverage will receive a
30% credit, averaging $80 for an individual
and $250 for a family of four. For small
employer groups, it will be $125 per
employee. For large employer groups, the
average will be between $110 to $130 per
employee.
The promise to cap prots and the
subsequent rebates have come as the result of
pressure from consumer advocates and
regulators over multiple premium increases
Blue Shield has tried to impose in recent
years, in some instances as high as 85%.
www.healthexecstore.com
Continued On Next Page
!"#$"%&"'!()!*+,,!-!*+,,!&.!/0."'1!2!/'3456"'1!/7&85195:;)!<<=
Page 3
Payers & Providers
Longer ALOS!*
Advertise Here
(877) 248-2360, ext. 2
*For our ads, not your hospital
NEWS
In Brief
assure that SCAN remains a strong
presence in the marketplace and
continues to fulll our mission of
serving seniors and others on
Medicare.
SCAN has 130,000 Medicare
Advantage enrollees in California and
Arizona.
AHF Launches
Campaign Critical of
Obama
The Los Angeles-based AIDS
Healthcare Foundation has launched
a television advertising campaign that
criticizes the Obama administrations
handling of programs subsidizing
access to anti-retroviral drugs to those
who have tested HIV-positive.
The campaign, entitled
President Obama: Whose Side Are
You On?, criticizes the president for
expanding the waiting list for the
federal AIDS Drug Assistance Program
from fewer than 100 people in 2008
to nearly 10,000 currently. The ad will
run on CNN in several markets where
the waiting list is the largest.
Though the President has
spoken eloquently about AIDS issues
at certain moments, his words have
been pretty, but empty, said AHF
President Michael Weinstein. Since
AIDS treatment can also reduce the
transmission of new HIV infections by
as much as 96%, the Presidents
inaction on this issue is also hurting
efforts to prevent the spread of the
disease.
Nurses Plan One-Day
Strike
More than 23,000 registered nurses
afliated with the California Nurses
Association/National Nurses United
will stage a one-day strike at hospitals
in Northern and Central California on
Sept. 22.
The work stoppage is aimed
primarily at facilities operated by
Oakland-based Kaiser Permanente
and Sacramento-based Sutter Health.
The union objects to proposed cuts in
retirement and healthcare benets.
Healthcare Bills Go To Gov. Brown
Physicians Receive Funds For Education, Promotion
Blue Shield (Continued from Page Two)
HEALTHCARES BEST ADVERTISING VALUE
]
PAYERS & PROVIDERS reaches 5,000 hospital, health plan and non-
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Meanwhile, the insurer sits on reserves that
exceed $3 billion.
I think every Blue Shield member will
be happy to get that money back, said
Anthony Wright, executive director of the
advocacy group Health Access and a
member of the Payers & Providers editorial
board. At the same time, its always
preferable not paying it in the rst place.
Blue Shield was opposed to Assembly
Bill 52, legislation that would have allowed
the Department of Managed Health Care
and the Department of Insurance to regulate
large premium increases for individual
policyholders. The bill was recently shelved by
its author, Assemblyman Mike Feuer, D-Los
Angeles, due to lack of support in the Senate,
even though it passed three Senate committees
by comfortable margins. Blue Shield and other
payers have contributed tens of thousands of
dollars this year to senators who had a key
role in that legislations path something that
will be probed in greater depth in next weeks
issue.
Several bills that directly touch on healthcare
policy in California were passed by the
Legislature as it ended its session and now
await signature by Gov. Jerry Brown.
The bills include:
SB 222 and AB 210 These bills would
require maternity care as a covered benet
in all health plans (many plans, particularly
individual policies, exclude them for at least
a period of time after enrollment). They are
companion pieces of legislation, each
requiring the passage of the other to be
enacted.

AB 922 This would expand the

responsibilities of the Ofce of the Patient
Advocate to provide counseling for
enrollees in Medi-Cal and other plans not
currently covered by the agency.

SB 51 This bill would require plans to

comply with the medical loss ratio
mandates of federal healthcare reform.

SB 866 It would require insurers to use

standaridized forms for prior authorization
of care. The forms may also be submitted
electronically for a prompt response.

SB 846 It would require insurers to cover

specic forms of therapy for autistic
patients.
Brown has until Oct. 9 to veto or sign the
legislation into law.
Correction
It was reported in the Sept. 8 issue of Payers & Providers that UCSF Medical Center
was the first hospital to receive five administrative penalties from the Department
of Public Health. Southwest Healthcare System in Riverside County has received
seven administrative penalties to date.
!"#$"%&"'!()!*+,,!-!*+,,!&.!/0."'1!2!/'3456"'1!/7&85195:;)!<<=
Payers & Providers Page 4
OPINION
CMS To Medicare Fraudsters: Beware
Proactive Detection is Keeping Crime in Check
David Sayen is Medicares regional
administrator for California, Arizona, Nevada
and Hawaii.
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Op-ed submissions of up to 600 words are
welcomed. Please e-mail proposals to
editor@payersandproviders.com
People talk a lot these days about the rising
cost of healthcare. How much of a role does
fraud play in this?
A signicant one, unfortunately. The fact
is that criminals steal billions of dollars each
year from Medicare, Medicaid, and the
Childrens Health Insurance Program (CHIP).
This is taxpayer money that should be going to
medical treatment for some of
our most vulnerable citizens,
including seniors, low income
families, and kids.
Fraud hurts everyone by
driving up healthcare costs. It
also undermines the nancial
sustainability of federal
healthcare programs upon which
millions of Americans depend.
Whats the federal
government doing to stop it?
Plenty, especially with the new
tools we have under last years
health reform law.
For one thing, were
becoming more proactive about
keeping criminals out of federal
healthcare programs in the rst place. My
agency, the Centers for Medicare & Medicaid
Services (CMS), has adopted a more rigorous
screening process for new providers and
suppliers. This is intended to weed out crooks
before they can start submitting fraudulent
bills to the government. Later this year and in
2012, the CMS will have also implemented
measures to streamline the certication
process down to 10 business days, and allow
large enterprises such as hospitals to submit
multiple applications through a single unied
Internet portal.
Under the Affordable Care Act, we can
now also use sophisticated new technologies
and innovative data sources to identify
patterns associated with fraud. We also have
the authority to temporarily stop enrolling new
providers and suppliers when we detect
patterns that may indicate a signicant
potential for fraud.
When theres a credible allegation of
fraud against a provider or supplier, we can
temporarily stop payments to them while an
investigation is undertaken.
In other words, CMS is moving away from
the old pay and chase model of doing
business paying out claims and then trying
to recover the fraudulent ones. Were also
educating the provider community with
regular regional summits about fraud and how
clinicians and even enrollees can avoid
becoming its victim through identity theft and
other means.
Of course, we know that most providers
doctors, hospitals, nursing
homes, home healthcare
operators, and others are
honest. But were becoming
more vigilant about the
dishonest few. And those who
defraud federal healthcare
programs will face tougher
penalties.
The Affordable Care Act
increases the federal
sentencing guidelines related
to healthcare fraud offenses
involving $1 million or more in
losses to federal programs. The
Act also allows the government
to impose stronger civil and
monetary penalties against those
who commit fraud. And crooks kicked out of
one states Medicaid or CHIP program will
now be kicked out of all states Medicaid or
CHIP programs.
Is Medicare making progress in the ght
against fraud? Yes, we are. For example, the
federal government recovered $4 billion last
year from people who attempted to defraud
seniors and taxpayers. Thats a record amount.
In a payer program the size of Medicare, there
will always be some levels of criminal activity.
Its simply too great a temptation among some
individuals to believe Medicare is a giant cash
machine that is generally immune to the
relatively small losses they create. However, in
the coming years as more crooked vendors are
put out of business and put into jail, it will be
clear that Medicare may no longer be
perceived as a sleeping giant.
By David Sayen
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*New England Journal of Medicine, 2004.
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Payers & Providers
MARKETPLACE/EMPLOYMENT
Page 6


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