http://knowsource.com/2012/05/corporate-wellness/ http://knowsource.com/2012/05/corporate-wellness/#comments Wed, 16 May 2012 20:44:22 +0000 John Santilli http://knowsource.com/?p=1031

Corporate wellness programs are a proven way for companies to not only save money, but improve the productivity of their workers and increase overall employee satisfaction.

Small and mid-sized employers can now offer comprehensive and customizable company wellness programs for their employees at little or no cost due to the passage of the Patient Protection and Affordable Care Act (PPACA).

One of the key features of the Healthcare Reform allows for certain preventive health screenings to be 100% covered under company wellness programs with no employee copayment. Additionally, employers with less than 100 employees may be eligible for wellness grant funding pending appropriations.

The Corporate Wellness market remains extremely fragmented with numerous companies offering some type of wellness service. However, there are very few large companies in this growing market.

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Aetna has differentiated itself in the area of provided collaboration by commercializing the concept of accountable care organizations and formed a new business unit called Accountable Care Solutions.

Aetna has signed 9 ACS contracts and has 16 letters of intent with over 180 leads in the pipeline. These partnerships are strengthening Aetna’s position in local markets and catalyzing growth in its core business.

Aetna’s ACS contracts include:

Banner Health Network in Arizona and the introduction of Aetna Whole HealthSM, a new commercial health care product that provides members access to highly coordinated care from physicians and facilities in the Banner Health Network.

Sharp Community Medical Group (SCMG) to deliver more coordinated and personalized medical care to Aetna members in the San Diego market.

Carilion Clinic to launch a suite of new health benefit plans – called Aetna Whole Health(TM) – now available to Virginia employers with two to 100 eligible employees. Aetna Whole Health plans create a unique opportunity for Roanoke-area businesses to help their employees optimize their health and get healthier faster.

Genesis HealthCare which may be setting the model for ACOs in long-term care. The program is part of a strategy to reduce re-admissions to hospitals, a costly proposition for insurers, long-term care and hospital providers.

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Health Insurers are increasingly positioning themselves as a health solutions or health services company that engages customers to a greater extent in their health and well-being.

Health Insurers increasingly will need to establish a brand identity to recruit customers and retain them — as a greater number of consumers gain more choice in selecting a health plan through a public or private health exchange by 2014.

The insurers that are in the forefront of this change include:

Aetna unveiled a refreshed brand promise as the company continues its evolution from an insurance carrier to a health solutions company.

The most visible element of Aetna’s refreshed brand is a vibrant new look and logo – reflecting Aetna’s new vision to the marketplace. Far beyond a look or logo, the revitalization of the brand is focused on driving increased consumer engagement in their health care and empowering people to live healthier lives.

Aetna is reframing its offerings into four benefit-focused categories that connect people to:

•Quality health plans and benefits: plans, products, networks, services, programs and tools that promote individual, family and employee health.

•Healthier living: wellness information, resources and support to help individuals, families and communities thrive.

•Financial well-being: plans, products, services, programs and tools that help people manage their health care spending and deliver financial peace of mind.

•Intelligent solutions: insights and expertise that enhance productivity or business results.

Blue Cross and Blue Shield of Florida, Inc. (BCBSF) is now Florida Blue. The new name, new logo and tagline – ‘In the pursuit of health’ – are all part of the company’s transition to a health solutions company with an overarching mission to help the people of Florida and their communities achieve better health.

The brand transition reflects a host of initiatives inspired by Florida Blue’s expanded mission, including: a focus on affordable products; the introduction of new health plans and services; the personalization of health care services and customer support through the company’s unique Florida Blue retail centers; an expanding suite of online tools to empower healthcare consumers and even stronger state-wide outreach to support Florida communities in their quest for better health.

All of these programs and services support the company’s commitment to providing accessible and affordable health solutions to all Floridians.

Introducing the new Florida Blue name marks a new era for the company – moving from a one-dimensional business model focused primarily on health insurance to a multi-dimensional health solutions company with a more comprehensive approach to health.

Cigna recently announced a national brand campaign that reflects an innovative approach to meeting the evolving health and well-being needs of consumers.

With the theme “GO YOU,” CIGNA launches its largest advertising campaign, supporting the company’s focus on delivering easy-to-use programs and providing distinctive customer service.

The customer-centric business model and associated “GO YOU” campaign encourages customers to embrace and nurture what it is that makes each of us one-of-a-kind; it’s time to celebrate your true self.

The company also has updated its logo to more directly reflect its focus on individual customers.

Cigna already has put into place 24/7/365 worldwide customer service, mobile applications that locate the nearest pharmacies and emergency rooms and decision-support tools that compare quality and medical costs.

Customers have broad access to health coaches for chronic conditions like diabetes as well as programs to support healthy lifestyles.

The company will engage customers through a new www.cigna.com website as well as social media channels. As part of the range of options for consumers, CIGNA is accelerating the expansion of its proven accountable care organizations and other partnership models with physicians and hospitals, all seeking to achieve quality, choice and affordability.

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Retail Clinics have resumed their growth over the last few years as the market has continued to evolve. In our annual Retail Clinics Market Overview 2012 we see the growth in clinic numbers, but a decrease in the number of clinic operators.

A number of observations quickly emerged from this year’s report:

1. More independent market participants are exiting the market then entering, as they have struggled to make money in the business.
2. The major industry participants (MinuteClinic, Take Care Health, The Little Clinic and Target continue to grow backed by the resources of parent companies.
3. Clinic operators interested in succeeding in the market would be wise to affiliate with Bellin Health or Walmart, as their business models seem to be working.
4. As with almost everything, prices for treatment have increased across the board for the most part since last year.

Additional information available

Federal regulators have reversed a controversial proposal that would have required facilities to hire consultant pharmacists to review residents’ medications.

Officials from the Centers for Medicare & Medicaid Services announced this week that the independent pharmacists regulation proposed last October would be “highly disruptive to the industry.”

Federal and state regulations mandate that long-term care facilities, in addition to providing a source of pharmaceuticals, retain consultant pharmacist services to monitor and report on prescription drug therapy in order to maintain and improve the quality of resident care.

On September 30, 2008, the United States Department of Health and Human Services Office of Inspector General published OIG Supplemental Compliance Program Guidance for Nursing Homes.

The guidance stressed that facilities must provide pharmaceutical services to meet the needs of each resident and should be mindful of potential quality of care problems when implementing policies and procedures on proper medication management.

It further stated that facilities can reduce risk by educating staff on medication management and improper pharmacy kickbacks for consultant pharmacists and that facilities should review the total compensation paid to consultant pharmacists to ensure it is not structured in a way that reflects the volume or value of particular drugs prescribed or administered to residents.

In October 2011, Centers for Medicare and Medicaid Services issued a proposed rule that outlined its concerns, and requested comments, regarding certain contractual arrangements between Long Term Care facilities, LTC pharmacies, consultant pharmacies, and pharmaceutical manufacturers.

Specifically, CMS explained its perception that the provision of consulting services by pharmacy providers that supply medication to the facility leads to lack of independence of consultant pharmacists.

CMS proposed requiring the independence of consultant pharmacists from LTC pharmacies. Institutional pharmacies believed that the proposed rule, which could require the independence of consultant pharmacists, might increase overall costs for payers and customers and reduce the quality of care and service to long-term care patients and residents.

Under current federal laws, nursing homes are required to review resident drug regimens once per month. This task frequently is outsourced to the companies that already supply the same facilities with medications.

Services typically offered by consultant pharmacists include:

Monthly reviews of each resident’s drug regimen to assess the appropriateness and efficacy of drug therapies, including the review of medical records, monitoring drug interactions with other drugs or food, monitoring laboratory test results, and recommending alternative therapies

Participation on quality assurance and other committees of customers, as required or requested by such customers

Monitoring and reporting on facility-wide drug utilization

Development and maintenance of pharmaceutical policy and procedure manuals

Assistance with federal and state regulatory compliance pertaining to resident care

Additional information available

There has never been a more important time for entities to be diligent in ensuring they have effective compliance programs that can prevent, detect and respond to potential noncompliance issues such as overpayments.

On February 16, 2012, the Centers for Medicare & Medicaid Services (CMS) proposed regulations for Medicare providers and suppliers concerning their obligations under the 2010 Patient Protection and Affordable Care Act (ACA) to report and return identified overpayments.

Under the ACA, overpayments must be reported and returned by the later of 60 days after the date the overpayment was identified or the date any corresponding cost report is due, if applicable.

The Recovery Audit Contractor Programs (RACs) identified and collected $397.8 million in overpayments during the first quarter of fiscal 2012 (October through December 2011)–the largest amount of improper payments recovered during one quarter since the RAC program began.

Hospitals are blaming Medicare overpayments to inadequate training and inadvertent errors in three recent audits by the Office of the Inspector General. Some recent hospitals in the news included:

Boston Medical Center
Boston Medical Center received roughly $90,000 in Medicare overpayments from 2006-2010 due to incorrect coding.

Billing on behalf of its physicians, the 639-bed hospital erred in coding 7,520 claims by using non-facility place-of-service codes for services that were actually rendered in hospital outpatient facilities.

The place-of-service code can bring in different reimbursements due to overhead costs. The OIG had recommended BMC refund the overpayments to the Medicare contractor. BMC has concurred and agreed to pay the $89,724.

Brigham and Women’s Hospital
Brigham and Women’s Hospital received $1.5 million in overpayments because the hospital didn’t fully understand Medicare billing requirements.

According to the report, Brigham and Women’s complied with Medicare billing requirements for 140 of the 359 claims that were reviewed, though, the hospital did not fully comply with Medicare billing requirements for selected inpatient and outpatient claims.

Carolinas Medical Center
Carolinas Medical Center in North Carolina received nearly $6,000 in overpayments. The health system said the reason was inadvertent keying errors by new coding staff and not a lack of training. The OIG found that the Carolinas Medical Center had errors in eight of the 73 brachytherapy (Iridium-192) Medicare claims the agency reviewed.

Catholic Healthcare West
Catholic Healthcare West has agreed to pay $9.1 million to settle old federal charges that it overbilled the Medicare program.
The allegations are tied to seven CHW hospitals in California and Arizona, and the overbilling occurred between 1990 and 2000. Federal investigators had begun looking into the matter in 2001.

According to the agreement CHW reached with the federal government, it admitted that three of its hospitals received overpayments due to Medicare processing errors but did not return the money once the errors were discovered. It agreed that three other facilities submitted inflated bills for home healthcare services and received overpayments. CHW also admitted another hospital had submitted claims for providing end-stage renal care to patients who were not eligible for such treatments.

The Cleveland Clinic
The Cleveland Clinic was overpaid nearly $254,000 for inappropriate Medicare claims. Although the Clinic disagreed with some the OIG’s draft report, the OIG found that the Clinic was overpaid $253,593 for 24 claims ($184,568 outpatient and $69,025 inpatient), and beneficiaries incurred $5,615 in additional copayment costs due to poor billing controls.

The OIG reviewed the Clinic’s claims for procedures regarding medical device replacements during 2008 and 2009, such as pacemakers and cardioverter defibrillators.
The OIG found that the Clinic did not fully comply with Medicare requirements for obtaining credits from manufacturers and for reporting appropriate billing codes and charges to reflect that it received the credits.

Cleveland Clinic agreed with the OIG that it needed to strengthen procedures for identifying and obtaining credits from manufacturers and establish reporting procedures in accordance with Medicare rules. It has since implemented new procedures for processing credits from device manufacturers.

Eisenhower Medical Center
Eisenhower Medical Center in Santa Maria, CA, did not bill Medicare in accordance with federal requirements for selected drug injections. As a result, the hospital received $86,846 in Medicare overpayments. The hospital has attributed the improper payments to its billing system and human error. Eisenhower has agreed to refund the identified overpayments.

Thomas Jefferson University Hospitals
Thomas Jefferson University Hospitals in Philadelphia received $43,000 in overpayments because it incorrectly billed for inpatient same-day readmissions. In four of the 133 same-day readmissions that OIG looked at, Jefferson inappropriately billed the second admission as a separate inpatient stay instead of a continuous stay.

Jefferson’s case management personnel misinterpreted the readmissions and determined they weren’t related to the first admission, but OIG in its report said the readmissions were, in fact, related to the prior stays and should have been billed as such. OIG also determined Jefferson did not have adequate training to review same-day readmissions.

Marian Regional Medical Center
Marian Regional Medical Center in Santa Maria, CA, failed to bill Medicare for selected drug injections in accordance with federal requirements. This resulted in a Medicare overpayment of $54,461. The hospital attributed the overpayments to a billing system error. Marian has also agreed to refund the identified overpayment.

St. Vincent’s Medical Center
St. Vincent’s Medical Center in Bridgeport, Conn., didn’t fully understand Medicare billing requirements for 41 inpatient and outpatient claims out of the 198 reviewed claims, the OIG found. The errors resulted in more than a quarter of a million dollars ($284,773) in overpayments in 2009 and 2010.

http://knowsource.com/2012/03/the-new-lahey-health-system-will-be-a-1-3-billion-organization/ http://knowsource.com/2012/03/the-new-lahey-health-system-will-be-a-1-3-billion-organization/#comments Wed, 28 Mar 2012 16:55:31 +0000 John Santilli http://knowsource.com/?p=911

The Massachusetts state Public Health Council voted to grant new hospital licenses for Lahey Clinic and Northeast Health System, giving them a key regulatory approval in their bid to form a merged hospital network that would stretch from the northwestern Boston suburbs to Cape Ann.

The council’s approval followed formal merger votes by the boards of Lahey and Northeast to create a new nonprofit umbrellas organization called Lahey Health System. It would include 675 licensed beds, more than 1,110 doctors, and about 10,000 employees across four hospitals: Lahey, Beverly Hospital, Addison Gilbert Hospital in Gloucester, and BayRidge Hospital in Lynn.

Lahey Health System will be a $1.3 billion organization that will provide medical care in Essex and Middlesex counties and southern New Hampshire.

Dr. Howard Grant, current president and CEO of Lahey Clinic, will lead the system. The affiliation is not a merger or an acquisition because no money exchanged hands. The two organizations will govern equally under the new setup, and each will have equal representation on the board of directors.

Lahey Clinic Medical Center, Beverly Hospital and Addison Gilbert Hospital will remain independently licensed. Addison Gilbert will remain open for at least three years. Lahey will assess the area served by Addison Gilbert before the three-year period ends to determine its healthcare needs.

Lahey Clinic is a physician-led, nonprofit group practice. Nearly 450 physicians and more than 4,000 nurses, therapists and other support staff work together to provide compassionate care and superior patient outcomes.

Lahey Clinic Medical Center in Burlington encompasses an ambulatory care center serving more than 3,000 patients each day and a 317-bed hospital. Lahey Clinic Medical Center, North Shore, in Peabody, serves more than 800 outpatients each day and includes a 10-bed hospital.

Northeast Hospital Corporation (NHC) represents the acute care hospitals – Addison Gilbert Hospital in Gloucester; BayRidge Hospital (psychiatric) in Lynn; Beverly Hospital in Beverly; and the outpatient facility Beverly Hospital at Danvers, Medical and Day Surgery Center.

Addison Gilbert Hospital is a full-service, 58-bed medical/surgical acute care facility. The hospital provides inpatient and outpatient care to residents of the Cape Ann community in specialties such as cancer care, surgical day care, critical care and emergency medicine.

BayRidge Hospital provides accessible, high-quality mental health and substance abuse treatment. The 62-bed hospital offers a continuum of psychiatric and chemical dependency services on an inpatient, partial hospitalization and outpatient basis.

Beverly Hospital is a full service, 221-bed, community hospital providing quality, patient-centered care to North Shore and Cape Ann residents.

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Catalyst Health Solutions seeks to continue to retain and grow its client base, manage drug expenditures and deliver innovative products and services. Catalyst Health Solutions intends to accomplish these strategies by capitalizing on its competitive strengths and helping to address the challenges confronting payors.

The recent agreement between Regence Rx and Catalyst Health Solutions is expected to be effective May 1, 2012 and the initial term runs through December 31, 2017 with a four-year optional extension. Through this agreement, Regence Rx will carve out its operational functions, and transfer related people, technology, and internal client service assets to Catalyst for them to manage and operate. Regence Rx will continue to provide clinical and contracting support to its customers.

Under the terms of the agreement, Catalyst will retain Regence Rx staff and provide Regence Rx with a full complement of PBM services, including: claims adjudication, member services, network administration, rebate contracting, mail and specialty drug management, data reporting and analytics, as well as client service and sales support.

Catalyst Rx is a full-service PBM that serves more than 18 million lives in the United States and Puerto Rico. This agreement will allow Regence Rx to leverage the scale and expertise of Catalyst Rx, one of the country’s fastest growing PBMs, and its national provider network as the two organizations partner to deliver more efficient pharmacy benefit programs and better clinical outcomes for clients and individuals throughout the Pacific Northwest and Intermountain State Regions.

Regence Rx currently provides PBM services for more than 1.2 million members of Regence Health Plans and provides related services to over 7.7 million members from other Blue Cross and Blue Shield and Medicaid plans.

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Defense officials have asked Congress to approve a new governance structure for the military health care system. The centerpiece of the plan is to elevate of the TRICARE Management Activity to a more powerful Defense Health Agency (DHA), with new authorities to use more effectively the military’s direct care system and to manage more carefully purchased care through TRICARE support contractors.

The DHA also would impose new business processes and appoint market managers in areas with multi-service medical facilities so operations are streamlined. The agency also would reduce redundancies across the separate medical commands of the Army, Navy and Air Force by combining where possible functions for purchasing, logistics and information technology.

Service medical commands would continue to be run separately. The strongest reason to keep Army, Navy and Air Force medical commands, led by separate surgeons general, is operational medicine. The Navy is trained to deliver care to units afloat and to deployed Marines, the Air Force has expertise in aerial platforms and Army docs are trained to deliver medical ground support in combat theaters.

Substantial savings – in the billions of dollars annually – are expected once the DHA is operating to eliminate waste and can impose new business processes on military hospitals and clinics, and on purchased care contracts that govern TRICARE civilian networks.

America’s Military Health System (MHS) is a unique partnership of medical educators, medical researchers, and healthcare providers and their support personnel worldwide.

This Department of Defense (DoD) enterprise consists of the Office of the Assistant Secretary of Defense for Health Affairs; the medical departments of the Army, Navy, Marine Corps, Air Force, Coast Guard, and Joint Chiefs of Staff; the Combatant Command surgeons; and TRICARE providers (including private sector healthcare providers, hospitals and pharmacies).

The Military Health System is $49 billion dollar enterprise within the Department of Defense (DoD), consisting of 63 military hospitals, over 500 military health clinics, and an extensive network of private sector health care partners, which provides medical care for over 9.6 million beneficiaries and active duty service members.

TRICARE provides civilian health benefits for military personnel, military retirees, and their dependents, including some members of the Reserve Component. The TRICARE program is managed by TRICARE Management Activity (TMA) under the authority of the Assistant Secretary of Defense (Health Affairs).

TRICARE is the civilian care component of the Military Health System, although historically it also included health care delivered in the military medical treatment facilities.

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The Department of Veterans Affairs (VA) proposed in 2010 to amend its regulations regarding access to VA facilities to control the promotion of drugs and drug-related supplies at VA facilities and the business relationships between VA staff and sales representatives promoting drugs and drug-related supplies.

On March 5, 2012, the VA issued a final regulation on promotion of drug and drug-related products (i.e., supplies related to the use of a drug, such as insulin needles and inhalers) by pharmaceutical company representatives at VA medical facilities.

This rule was issued “to reduce or eliminate any potential for disruption in the patient care environment, manage activities and promotions at VA facilities, and provide pharmaceutical company representatives with a consistent standard of permissible business practice at VA facilities.” Issued nearly two years later, the Final Rule serves as an important guide for marketing drugs and drug-related products at all VA facilities.

The PBM Office provides leadership for pharmacy activities in the Veterans Health Administration (VHA), and provides advice and support regarding pharmacy issues to a wide variety of stakeholders including Veterans, the Under Secretary for Health, VA Medical Center Directors, and clinical staff across the system.

Major PBM program areas include: Pharmacy Practice, Formulary Management, Pharmacy Education, Prescription Fulfillment Activities, Drug Safety, Emergency Pharmacy Services, Clinical Informatics and Pharmacy Re-engineering and VA/DoD Collaboration.

Pharmacy Benefits Management Services (PBM) works to enhance the clinical outcomes and improve the health of Veteran patients through the appropriate use of pharmaceuticals.

The final rule, which becomes effective on April 4, 2012, includes limitations on the promotion of drugs and drug-related supplies, educational programs and associated materials, providing gifts, food, samples or other promotional items to VA employees or facilities, and the conduct of pharmaceutical company representatives. It also details penalties and procedures in the case of non-compliance.

Additional information available