!!!"#$$!%&!'(&)*+!,!'*-./0)*+!'1%2/+3/456!

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When Blue Shield of California launched a
program 18 months ago to allow enrollees to
post reviews of their health coverage, the San
Francisco-based insurer touted itself as a
model of openness.
We're proud to be the rst health plan in
the country to be fully transparent and
encourage our members to share their
healthcare experiences online in a richer and
more visible way," Blue Shield Senior Vice
President Rob Geyer said at the time.
The feature, called Ratings and Reviews,
allows most Blue Shield enrollees to post a
review of their specic health plan. Users can
rate Blue Shield in six different categories,
including access to physicians, value,
customer service and overall satisfaction. They
may also leave written comments, which are
vetted prior to posting.
Blue Shield ofcials claimed in a
statement last month that nearly 2,000
enrollees have posted reviews, with an
average rating of four out of ve stars.
However, nding the reviews is a challenge at
best. They have been meticulously siloed by
the health plan from most of its enrollees and
members of the public.
While enrollees are able to post reviews
and comments, they are only able to view
reviews that pertain to the specic plan in
which they are enrolled, according to an
examination of its member portal and a Blue
Shield spokesperson (Blue Shield offers about
a dozen plans altogether). If fewer than 10
reviews are posted for a specic plan, none
are available for member viewing.
Meanwhile, members of the public can
only access about 200 reviews for a Blue
Shield Medicare plan and some employer
group PPOs. Few new reviews have been
added since the rst round of preliminary
reviews were released from a pilot program
that began in 2009.
Consumer advocates say they havent
heard of such handling of consumer reviews
by a business that invites their submission.
Siloing them defeats their purpose of
educating consumers, they added.
Laurie Sobel, a senior attorney with
Consumers Union in San Francisco, said it
was the equivalent of allowing people who
buy a specic model of Sony television read
only those reviews in Consumer Reports,
while barring them from the Panasonic
reviews until they buy the product. Sobels
organization publishes Consumer Reports
magazine.
People want to read reviews in order to
buy something, Sobel added. This situation
can only serve in the limited capacity of
conrming their own experiences with their
specic health plan.
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September 21-23
August 25-30
Calendar
28 July 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.
California Edition
Blue Shield Posts Reviews...Sort Of
Enrollee Criticism is Compiled, But Mostly Hidden
Continued on Next Page
HEALTHCARES BEST ADVERTISING VALUE
]
PAYERS & PROVIDERS reaches 5,000 hospital, health plan and non-
prot executives statewide. There is no better venue for marketing
your organization or conference, or recruiting new staff.
CALL (877) 248-2360, ext. 2
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Payers & Providers Page 2
Top Placement...
Bottomless Potential
Advertise Here
(877) 248-2360, ext. 2
In Brief
Adventist Reorganizes
Northern California
Hospitals
Roseville-based Adventist Health has
restructured the management of its
hospitals in Northern California,
placing them into a single regional
entity.
Terry Newmyer, a veteran
Adventist executive who has served as
president of its St. Helena region, has
been named the new CEO of the
Northern California Network.
Newmyer will oversee management
of Frank R. Howard Memorial
Hospital in Willits, Ukiah Valley
Medical Center, St. Helena Hospital
Napa Valley, St. Helena Hospital
Clear Lake, and the St. Helena
Hospital for Behavioral Health.
Terrys leadership of the St.
Helena hospitals has been exemplary
and their successes are well
documented, said Adventist Chief
Operating Ofcer Scott Reiner. His
guidance over the Northern California
Network will allow us to expand
services to communities throughout
the region.
Adventist operates 17 hospitals
in Hawaii and the Western U.S.
Prime Healthcare
Division Gets Okay To
Buy Victorville Hospital
The second time is the charm for
Prime Healthcare Services.
Primes non-prot arm won the
approval of a federal bankruptcy court
last week to purchase 100-bed Victor
Valley Community Hospital in
Victorville for $35 million. Prime had
bid on the hospital earlier this year,
but lost out to medical group
management rm KPC Global
Healthcare. However, the KPC deal
Continued on Page 3
NEWS
Blue Shield (Continued from Page One)
Judy Dugan, research director for
Consumer Watchdog, an advocacy group in
Santa Monica, believes the reviews may be
more for Blue Shields internal use than for
enrollees and other consumers.
The only useful thing about siloing these
comments is that no consumer can see if
theres an overall pattern of problems with
Blue Shield and some of their plans, she said.
Dugan was also skeptical of another Blue
Shield consumer-oriented initiative called
Member Stories. Enrollees are encouraged to
publish their own personal healthcare stories,
photos and videos on the Blue Shield website.
Story submissions are subdivided into 14
categories such as positive parenting, aging
gracefully, and cancer.
The topics are very self-help oriented,
with nothing you can choose to voice a
complaint or suggest that Blue Shield could be
doing better she said.
In the meantime, Blue Shield ofcials
indicate it may make changes to its review
process soon.
We are currently developing the ability
for non-members to be able to read all
reviews of any Blue Shield health plan to
better enable them to make decisions about
their healthcare coverage, said company
spokesman Johnny Wong.
Contexo Media is an independent provider of revenue-enhancing solutions for medical practices
to maximize their coding, reimbursement and compliance efforts. Thousands of health care
professionals rely on Contexo Medias coding books, software, eLearning and educational
workshops to stay on top of critical updates across the fast-changing medical landscape.
To learn more about our products and services,
visit our website at www.contexomedia.com
19144
Kaiser Tactic Boosts Heart Health
Mail Order Statins More Effective at Lowering LDLs
Filling the prescriptions of patients who take
cholesterol control drugs via mail order led to
signicantly better outcomes than those who
obtained the drugs in a traditional pharmacy,
according to a new study by the research arm
of Oakland-based Kaiser Permanente.
The examination of more than 100,000
Kaiser enrollees in Northern California newly
prescribed statins between 2005 and 2007
indicated a roughly 15% improvement in
meeting their cholesterol targets versus those
who received their drugs through one of
Kaisers bricks-and-mortar pharmacies. Among
those receiving the mail-order statins, 85% met
their cholesterol targets. By comparison,
slightly more than 74% met cholesterol targets
who received the drugs through a pharmacy.
Researchers suggest that receiving the
medicine via mail-order which Kaiser
enrollees can do through the Internet and do
not incur shipping charges makes it more
likely they will comply because they dont
have to travel to receive their medications.
The study was extensively controlled for a
variety of biases, including the possibility that
those enrollees who use mail-order services
were more committed to improving their
health.
"While the ndings of this study should be
conrmed in a randomized controlled trial,
they provide new evidence that mail-order
pharmacy use may be associated with
improved care and outcomes for patients for
risk factors with cardiovascular disease," said
Julie Schmittdiel, an investigator with Kaisers
research division. "Though mail order may not
be right for all patients, this study shows that it
is one possible tool in the broader healthcare
system-level toolbox that can help patients
meet their medication needs."
A previous study Kaiser undertook in
conjunction with UCLA researchers
concluded that mail-order medications also
improved regimen adherence among patients
with high blood pressure, high cholesterol or
diabetes.
The results of Kaisers more recent
cholesterol study were published in the August
issue of the Journal of General Internal
Medicine.
!!!"#$$!%&!'(&)*+!,!'*-./0)*+!'1%2/+3/456!778
Page 3
Payers & Providers
Longer ALOS!*
Advertise Here
(877) 248-2360, ext. 2
*For our ads, not your hospital
NEWS
In Brief
fell through, opening up the bidding
once again. Victor Valleys
management accepted Primes new
bid.
The transaction still requires the
approval of the California Attorney
Generals ofce. It has rejected some
Prime offers in the past, but this would
be the rst such deal involving the
Prime Healthcare Services
Foundation. The non-prot subsidiary
of Prime was recently formed to make
such transactions easier, although
industry observers say it plays into
Primes long-term plan of creating an
accountable care organization.
Consumer Advocates
Blast DMHC Autism
Settlement
A settlement recently reached
between the Department of Managed
Health Care and Anthem Blue Cross
of California and Blue Shield of
California for treating autistic children
has been blasted by a Santa Monica-
based advocacy group as lacking
teeth.
According to Consumer
Watchdog, the agreement for the two
plans to cover what is called applied
behavioral analysis is impermissibly
awed. Among the reasons cited by
Consumer Watchdog include charges
that the settlement still requires ABA-
specic licensure for therapists, which
does not exist in California; does not
require the plans to have ABA-
oriented therapists in its provider
network; and still allows Blue Shield
specically to challenge covering ABA
on the grounds of medical necessity.
"Remarkably, the agreement
appears to have been entered into
without discussion or consultation
with the Department of Insurance
(CDI) or the autism providers or
advocacy community, and was
misleadingly portrayed in a positive
light by DMHC ofcials at a legislative
hearing last week held to review
DMHC practices, read a letter
Consumer Watchdog and several
autism-related advocacy organizations
sent to Gov. Jerry Brown.
Molina Reports Strong Quarter
Earnings Soar; Guidance Revised Upward
advantage of the enormous potential growth
of the Medicaid market due to the Patient
Protection and Affordable Care Act.
Although we face challenges,
particularly when serving new populations,
our long-term commitment to the health care
needs of low-income families has
consistently enabled us over time to thrive in
nearly every new market we have entered,
Molina said. Our past successes, and our
strong rst-half results, reinforce my belief
that we are well-positioned to take
advantage of the enormous market
opportunities that will open up in the next
few years.
Partly as a result, Molina Healthcare
raised its earnings guidance for calendar
2011 to $1.55 a share. The company did not
specify what the previous guidance was, but
in prior quarters it said it was as high as
$2.20 per share.
Long Beach-based Medi-Cal managed care plan
Molina Healthcare reported a strong earnings
boost for the second quarter, and revised its
earnings guidance upward for the remainder of
2011.
Molina reported net income of $17.4
million for the quarter, compared to $10.6
million for the second quarter of 2010, an
increase of 65%.
The company attributed the rise to a variety
of factors, including a signicant reduction in its
medical cost ratio, to 84.1% in the second
quarter, compared to 86% in the second quarter
of 2010, driven by an 8% reduction in hospital
costs. Premium revenue was also up 16%,
although revenue for the Medicare dual-eligible
market was up more than 40%, to $95.5 million
from $67.6 million. Company ofcials
attributed that in part to its recent entry into the
Michigan market.
Molina Chief Executive Ofcer J. Mario
Molina, M.D., believes the company will take
Prime Will Sue Investigative Website
Claims Report on Malnutrition Was Defamatory
Ontario-based hospital operator Prime
Healthcare Services said it will le a
defamation lawsuit against the not-for-prot
investigative journalism website California
Watch over its reporting on how the chain
billed Medicare for malnourished patients.
California Watch published the report in
February, claiming the for-prot Prime had
billed Medicare to treat patients for a
malnutrition condition called kwashiorkor at
frequencies far higher than the statewide
average.
Prime has countered in a variety of press
releases that the reporting was inaccurate. It
also blamed the Service Employees
International Union which represents
employees at several Prime hospitals for
stirring the tide of public opinion. The SEIU
performed research into Primes billing for
kwashiorkor, although California Watch
performed its own data analysis for its report.
Prime would not comment on the status
of the litigation. A motion was led July 22 by
Prime in Alameda County Superior Court to
preserve evidence prior to any civil actions.
Prime, which operates 14 hospitals in
California and is currently in negotiations to
purchase a 15th in Victorville through a
recently established not-for-prot afliate, is
under state investigation for allegedly
overbilling Medicare for treating patients with
septicemia.
California Watch ofcials declined to
comment specically on the pending suit as of
late last week, saying it had not had yet been
served with the litigation. However, editorial
director Mark Katches said in an e-mail that
Primes assertions have no foundation.
In the past several months of interacting
with the chain, Prime has yet to present to us
any factual inaccuracies that merit correction
or clarication, stated Katches, and we have
continued to stand by our reporting -- which is
ongoing.
California Watch published an extensive
report earlier this week documenting how
Prime admitted patients into its hospitals via
its emergency rooms at far higher rates than
statewide averages, in some instances
boosting ER-based admissions by 60% or
more after acquiring a hospital. In a statement,
Prime denied all of the facts in the story, said
California Watch was a union mouthpiece,
and would contine with its litigation.
!!!"#$$!%&!'(&)*+!,!'*-./0)*+!'1%2/+3/456!778
Payers & Providers Page 4
For many years the care and cost conversation
has been a bifurcated discussion, with
providers managing medical care and billing
departments handling allowables with carriers
and employers. Now that a new paradigm has
emerged that shifts more of the nancial
responsibility for medical care to patients and
families, consumers are starting to wake up.
Consumer-directed health plans and other high-
deductible health plans are forcing patients to
weigh their costs, especially since U.S. census
data reports median gross household income at
$50,000 placing absolute limits on what
average families can afford.
Although many doctors have
taken note of the high number of
patients that question the cost of a
procedure, test, or prescription, it
still is an ad hoc conversation. Just
yesterday I heard a story from a
neighbor. She took her son to the
dermatologist for acne. The doctor
wrote a script for Doryx; no one
discussed price. She went to the
pharmacy and left the
prescription with the pharmacist;
again, no price discussion.
When she went to pick up
the 30-day supply, however, the bill was $400.
She was incredulous that no one bothered to
tell her beforehand. And it never occurred to
her that acne medicine would be this
expensive, so she didnt ask. When she called
the dermatologists ofce to complain and ask
for a different prescription, she was told a
generic equivalent doxycycline was available,
but that it would need to be taken twice a day
instead of once. The cost was $20, certainly
enough of a price differential to accept the two-
times-a-day dosing schedule. So who is
responsible for initiating the cost discussion
the patient or the provider? With bad debt
rising for providers, it would seem to be in their
best interest to take this on as routine, but it
also presupposes that costs are available to
providers as theyre sorting out treatment
options. In addition, it requires providers to
look at medical services through the lens of
nancial burden and affordability, which is not
how our physicians are trained. Asking
patients to take full responsibility for the cost
discussion assumes that all patients have the
personal authority to ask a question that can
feel like a challenge to an experts credibility.
Patients who are less educated and feel less
empowered are at an increasing disadvantage
when it comes to high engagement with medical
providers. Often, they become passive, non-
compliant patients. However, since consumers
are ultimately responsible for their portion of the
bill, its no longer an option to avoid the cost
conversation and act on the physicians
recommendation without knowing the price tag
attached. One
solution to better managing care and costs is to
increase consumer education regarding patient
choices, and how to make decisions. This will
require more than one solution to
account for age, ethnicity, language,
and educational differences. It will
need to show patients how to work
with their providers to identify the
right treatment choice for them
one that meets personal criteria for
quality and affordability.
Another solution is to bring
pricing out from behind everyones
wall. Insurance carriers regard
allowables as intellectual
property, so they dont want to
share pricing information. And
most hospitals dont publish charges. Also, when
you call the hospital billing department, they
dont want to give you the information. Only
Medicare publishes rates by DRG and has created
a consumer-friendly Medicare.gov website to
compare prices. If pricing transparency is
essential to lowering costs, then those owning the
data need to be willing to share it more openly.
The care and cost conversation needs to be
owned by both patients and providers with
support from institutions that have pricing data.
Consumer engagement and purchasing savvy will
help to make patients better partners with
providers; considering affordability in all
treatment decisions will help providers become
better partners with patients.
OPINION
Starting The Conversation On Cost
Providers Should Know What The Patient Has to Pay
By Sarah Wilcox
Sarah Wilcox is president and CEO of
www.MyHealthandMoney.com, a web site for
consumers trying to navigate the healthcare
system.
9-21:)!;6!<++1)!"=
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Op-ed submissions of up to 600 words are
welcomed. Please e-mail proposals to
dmoore@payersandproviders.com,
!!!"#$$!%&!'(&)*+!,!'*-./0)*+!'1%2/+3/456!778
MARKETPLACE/EMPLOYMENT
Payers & Providers Page 5
MANAGER, FINANCE AND TRANSACTION ADVISORY SERVICES
Responsibilities include managing consulting engagements and teams; interfacing with clients at
senior management and board levels; and some business development.! The companys client
base consists of healthcare systems and hospitals, physician groups, insurance/managed care
organizations and other healthcare service/product/technology companies.! The successful
candidate will have excellent analytical and communication skills with proven ability to interact
with C-level executives and boards.! Consulting experience with a national rm is also preferred.!
Requirements: Masters Degree, 4 years of healthcare industry experience, hospital/medical group
nance, managed care operations, and/or experience with a national healthcare consulting or
national advisory rm.! Experience with managed care contracting, predictive modeling, and
clinical integration is highly desirable.
The rm provides a broad range of advisory services involving nancial acumen including:
strategic planning, nancial planning and modeling, managed care, ACO development, bundled
payments and clinical integration strategies, feasibility studies, M & A transactions, valuations,
fairness opinions, nancial advisory services, debt capacity analysis, private equity and venture
capital transaction services.
Also must have the ability to work well with individuals at all levels of an organization, and
excellent analytical written, and oral communications skills.! Comprehensive compensation
packages offered. Los Angeles-based position.
Contact Information:
Mary Lasnier, The Camden Group
HR@TheCamdenGroup.com
www.TheCamdenGroup.com !
!!!"#$$!%&!'(&)*+!,!'*-./0)*+!'1%2/+3/456!778
Payers & Providers
MARKETPLACE/EMPLOYMENT
Page 6
HEALTH PLAN MEDICAL DIRECTOR (Southern California)
Physician licensed by the State of California, with board certication in primary care or medical subspecialty. Have
ve (5) years of Medical Director experience in a managed care setting, such as a HMO or IPA/Medical Group.
Medical oversight and physician liaison in the areas of: Utilization Review, Credentialing, Quality Improvement, Peer
Review, Case Management, and Disease Management.
Works under the direction of the Chief Medical Ofcer to ensure the delivery of high quality and efcient care for all
members. Provide administrative management of patient care with specic responsibility to provide direction and
assistance in achieving optimal medical performance in an efcient manner. To participate and lead in the review of
all inpatient admissions. Direct and review all inpatient utilization activity at hospitals by interfacing with the
clinicians and utilization review nurses. Oversee the review process of prior authorization (medical and pharmacy)
requests in a timely manner. All denials must be individually reviewed and signed by the Medical Director or
physician reviewer.
HEALTH PLAN NATIONAL DIRECTOR OF QUALITY & ACCREDITATION (Southern California)
Under the supervision of the Associate Chief of Managed Care, the National Director of Quality and Accreditation is
responsible for the agency wide quality improvement program and its outcomes.
Essential Duties and Responsibilities:
Ensures the QI programs in California and Florida meet contractual, regulatory and accreditation standards.
Trains, develops and mentors the Quality staff in California and Florida to ensure QI program objectives are met.
Sets an example for the Leadership team in terms of quality initiatives and quality process to achieve organizational
goals.
Supports compliance with AAAHC accreditation standards and NCQA standards, where applicable.
Assists with preparation of HEDIS data collection, validation audits and data submission.
Ensures HEDIS results are used to establish clinical and quality improvement projects to improve member
outcomes.
Works collaboratively with Leadership team to prepare for audits and surveys
Support the effort to complete the annual Member Satisfaction and Provider Satisfaction surveys and ensure results
are incorporated into the QI Program.
Collaborates with MIS and QI Data Analyst to ensure data is presented and used efciently to meet the needs of the
QI Program.
Ensures the annual Quality Program and Work Plan are documented, approved and contents implemented.
Ensures all contract requirements are represented by quality monitors that are documented, reviewed and support
compliance to contractual quality standards.
Assist staff, as needed, in the investigation, documentation and resolution of grievances and appeals to contribute
to member satisfaction, quality outcomes and required regulatory reporting.
Ensure Medicaid and Medicare regulations and standards are included and well managed in the QI Program.
Education and/or Experience:
Bachelors degree in a healthcare related led from a four-year college or university Preferred Masters in Public
Health (MPH) and/or Masters in Business Administration (MBA) and/or Masters in Health Administration (MHA)Please
Contact:
Executive Search & Placement
Sonia Varian - 818-707-7118,
or espsonia@pacbell.net
!!!"#$$!%&!'(&)*+!,!'*-./0)*+!'1%2/+3/456!778
MARKETPLACE/EMPLOYMENT
Payers & Providers Page 7
EXECUTIVE DIRECTOR, CARE DELIVERY INNOVATION
The Blue Cross Blue Shield Association (BCBSA) is seeking an Executive Director, Care Delivery Innovation.
Located in the heart of downtown Chicago, BCBSA is the national federation of the 39 independent
community based Blue Cross and Blue Shield (BCBS) companies serving 100 million people.
The Executive Director, Care Delivery Innovation is a newly created position housed within the Strategic
Services Division of BCBSA. Strategic Business Services works with Member Blue Plans to develop business
solutions through strategic business relationships that strengthen the competitive position of the Blues. For
additional information on BCBSA, please visit their website at www.bcbs.com.
Reporting directly to the Vice President, Strategic Business Services, the Executive Director, is responsible for
providing leadership, strategic direction and actionable solutions in support of the imperative to transform
care delivery in the United States to ensure a long term sustainable/viable health care system. The Executive
Director manages ongoing market assessments, integration and synthesis of care delivery activities to
supplement Plan thinking and evolution of their alternative approaches. The Executive Director has three
direct reports and a total staff of seven.
The successful candidate must have a Masters degree. A minimum of 15 years of broad-based care delivery
experience at the executive level in a large, sophisticated integrated delivery system, health plan, or health
system with a strong provider orientation is required. He/she must possess high standards of excellence and a
proven track record of driving innovation in a mature market. Excellent compensation, benets and
relocation assistance are offered. Interested candidates or condential recommendations should be sent to
the Witt/Kieffer consultants, Stephen J. Kratz and Shirley Cox Harty at CareDelivery_BCBSA@wittkieffer.com.
!!!"#$$!%&!'(&)*+!,!'*-./0)*+!'1%2/+3/456!778
Page 8 Payers & Providers
MARKETPLACE/EMPLOYMENT


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promnuros und mmodutoy knov vhut's on thor mnd.
Lvory koundtubo lntoructvo v louturo u C&A sosson conductod by luyors & lrovdors lubshor kon Shnkmun. Hs
docudos ol oxporonco n ournusm und tho houthcuro ndustry v promso concso und rovoung ntorvovs.
1opcs lor upcomng koundtubo lntoructvos ncudo:
!! lntogrutod Systoms vs. lrvuto lructco: 1o vhut dogroo v physcuns not uroudy n urgor modcu groups or ntogrutod
houth systoms romun n prvuto pructco durng ths docudo, und vhy. \hut uro tho udvuntugos, dsudvuntugos und
mpcutons n toduy's onvronmont:
!! Modcud luns und Dovory Systoms: Hov much s thor cout grovng us Modcud onromont s prooctod to sour us
purt ol rolorm: \ Modcud ncrousngy bo usod us u vohco lor sottng houthcuro pocy: 1o vhut dogroo v muor
houth puns und systoms try to ncrouso shuro und concontruton n ths murkot:
!! Accountubo Curo Crgunzutons: Aro thoy ovorhypod: \hut typo ol houth curo systoms shoud bo pursung ACCs, und
vhut systoms shoud bo sttng on tho sdonos lor nov: Hov tod s tho ACC movomont to tho succoss or luuro ol
Modcuro ACC pots: Doos tho dolnton ol ACCs nood moro spoclcty, or s t prolorubo to huvo u bg tont ol
ncuson:
Do you vunt to proposo or purtcputo n u luturo koundtubo lntoructvo: lurtcputon s ontroy onno, vth u commtmont ol
no moro thun ono hour. Cu kon Shnkmun ut 877-248-2360, oxt. |, or o-mu hm ut odtorpuyorsundprovdors.com.
It costs up to $27,000 to fill a healthcare job*
will do it for a lot less.
Employment listings begin at just $1.65 a word
Call (877) 248-2360, ext. 2
Or e-mail: advertise@payersandproviders.com
Or visit: www.payersandproviders.com
*New England Journal of Medicine, 2004.
6
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