Dr. Miller is the Dean and CEO of The Johns Hopkins University Medical School.

Both the House and Senate health-care reform bills call for a large increase in Medicaid—about 18 million more people will begin enrolling in Medicaid under the House bill starting in 2013, Centers for Medicare and Medicaid Services (CMS) Actuary Richard Foster estimates.

We at Johns Hopkins Medicine (JHM) endorse efforts to improve the quality and reduce the cost of health care. But we also understand all too well the impact a dramatic expansion of Medicaid will have on us and our state—and likely the country as a whole.

A flood of new patients will be seeking health services, many of whom have never seen a doctor on more than a sporadic basis. Some will also have multiple and costly chronic conditions. And almost all of them will come from poor or disadvantaged backgrounds.We know this because we’ve been caring for Medicaid patients in a managed-care setting for 14 years, as well as providing world-class care to people from all over the country and the world. Our experience provides a glimpse of the acute cost bubble that the health-care system will suffer with the reforms now being proposed.

Like Intermountain Healthcare in Utah, Geisinger Medical Center in Pennsylvania, and the Mayo Clinic, where, as President Barack Obama notes, “people fly from all over the world to Rochester, Minnesota in order to get outstanding care,” people also fly from all over the world to obtain care from JHM. But unlike those other institutions, we also serve a large number of people who can’t afford cab fare to the nearest hospital: poor, disadvantaged individuals, 150,000 of whom are in our Medicaid managed-care program, Priority Partners.

Priority Partners operates under a capitated system—that is, it receives a set payment per individual per month from the state. Over time, we’ve developed the ability to manage the care of these individuals in a way that is both cost effective and that provides them with quality care. We’ve done it by tapping into our extensive delivery system, which includes four hospitals, a nursing home, the largest community-based primary care group in Maryland, and much more.

We’ve hit above-national benchmarks on all clinical quality measures for our dialysis patients, reduced monthly costs for patients with substance abuse and highly complex medical needs, and 70% of our patients tell us they’re satisfied with our care. But the learning curve has been costly and steep, and provides a cautionary tale for what will happen under the health-care reforms currently in Congress.

The key fact is that for years the state did not cover all the costs our Medicaid program incurred. As a result of new patients whose costs were not completely covered by the state, Priority Partners lost $57.2 million from 1997 to 2005.

We stanched the losses by ensuring that the payment from the state was appropriately risk adjusted to match the health conditions of our members, and by investing heavily in primary-care and care-management and disease-management programs.

Yet this past year the losses began again, because the state expanded the program’s eligibility to 116% of the federal poverty level up from 40%.

So we are struggling with a large group of new patients—about 30,000 people. Today, like in the late 1990s, a health-care surge is overwhelming our managed-care system. The capitated rate for the new beneficiaries is not yet risk-adjusted. Priority Partners has lost a devastating $15 million in just nine months.

In time, we will be able to provide cost-effective, quality care to these new patients. But it will take years and careful management to, in the administration’s phrase, “bend the cost curve down.”

Congress can help, or at least learn from our experience to use the reform legislation to bend the cost curve if it encourages other states to institute and appropriately fund capitated systems that allow capable providers to adjust payments based on risk. There is nothing in the House or Senate legislation that does that now, even as both bills will expand Medicaid. We believe our example in Maryland can be replicated around the country. One such concept—the Healthcare Innovation Zone, currently in the Senate bill—envisions a regional alliance of an academic medicate center, local hospitals, and physicians that coordinate and deliver the entire spectrum of patient-centric care in ways that reward quality. The key is that federal support to states for Medicaid must appropriately adjust rates to match the risk of providing health care to the group of people who are covered by Medicaid.

The Senate bill would increase eligibility for Medicaid to those who make 133% or less of the federal poverty level. The Kaiser Family Foundation reports there are 308,000 people who meet that threshold in Maryland.

Even if only half of those individuals seek Medicaid coverage, such a large expansion would likely have an excruciating impact on the state’s budget. And Maryland is not alone. According to a Kaiser Foundation survey conducted earlier this year, three-quarters of the states have expressed concern that expanding Medicaid could add to their fiscal woes. Already, as Kaiser notes, 33 states cut or froze payment rates to those who deliver health care to Medicaid patients in fiscal year 2009; even more states (39) are slated to cut or freeze rates for fiscal year 2010.

We’ll meet the demands placed on us because serving poor and disadvantaged populations is part of our century-old mission. But without an understanding by policy makers of what a large Medicaid expansion actually means, and without delivery-system reform and adequate risk-adjusted reimbursement the current health-care legislation will have catastrophic effects on those of us who provide society’s health-care safety-net. In time, those effects will be felt by all of us.

This piece was first published in the Wall Street Journal.

DR. EDWARD MILLER was named chief executive officer of Johns Hopkins Medicine, the 13th dean of The Johns Hopkins University School of Medicine and vice president for medicine of The Johns Hopkins University in January 1997. His appointment followed a year-long national search for the first-ever CEO of Johns Hopkins Medicine, a then-new organization that formally integrated operations and planning of the school of medicine with the Johns Hopkins Health System and hospital to ensure their continued preeminence in education, discovery and patient care. As CEO, Dr. Miller is responsible for both the school and the health system and reports directly to the university president and the chairman of the board of Johns Hopkins Medicine.

Under his aegis, both The Johns Hopkins Hospital and school of medicine continue to be ranked among the very best in the nation

An anesthesiologist who has authored or co-authored more than 150 scientific papers, abstracts and book chapters, Dr. Miller joined Johns Hopkins in 1994 as professor and director of the Department of Anesthesiology and Critical Care Medicine and was named interim dean of the school of medicine in 1996. He came to Hopkins after eight years at Columbia University, where he served as professor and chairman of the Department of Anesthesiology. Prior to that, he spent 11 years at the University of Virginia.

Dr. Miller is a member of the Institute of Medicine of the National Academy of Sciences and is a fellow of the Royal College of Physicians and the Royal College of Anaesthetists.  He is also a member of the State of Maryland’s Health Care Access and Cost Commission and serves on the boards of the Greater Baltimore Committee and the PNC Bank.

Born in February 1943 in Rochester, N.Y., Dr. Miller received his A.B. from Ohio Wesleyan University and his M.D. from the University of Rochester School of Medicine and Dentistry. He was a surgical intern at University Hospital in Boston, chief resident in anesthesiology at Peter Bent Brigham Hospital in Boston, and a research fellow in physiology at Harvard Medical School. He also spent a sabbatical year as a senior scientist in the Department of Pharmacology and Physiology of Hospital Necker in Paris.  He and his wife, Lynne, are the parents of four adult children.

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40 Responses for “Health Reform Could Harm Medicaid Patients”

  1. Jeff Goldsmith says:

    I emphatically agree with Ed Miller. The Medicaid expansion is a reckless move, both fiscally and for the reasons Miller cites. States will never be able to afford even a portion of the cost of this expansion, and the only way to make it fly economically will be to further savage safety net provider payments, which are already being cut as states attempt to balance their recession savaged budgets.
    The only reason it’s part of health reform is because it’s CHEAPER than expanding private coverage, and the reason for that is unsustainable payment levels to providers. I think it’s ironic that hospitals killed a modest (3 million) Medicare expansion for uninsured boomers, but “agreed to” a 15 million person Medicaid expansion. This is terrible health policy. It’s like TennCare times ten.

  2. Peter says:

    Priority Partners operates under a capitated system—that is, it receives a set payment per individual per month from the state. Over time, we’ve developed the ability to manage the care of these individuals in a way that is both cost effective and that provides them with quality care. We’ve done it by tapping into our extensive delivery system, which includes four hospitals, a nursing home, the largest community-based primary care group in Maryland, and much more.
    We’ve hit above-national benchmarks on all clinical quality measures for our dialysis patients, reduced monthly costs for patients with substance abuse and highly complex medical needs, and 70% of our patients tell us they’re satisfied with our care. But the learning curve has been costly and steep, and provides a cautionary tale for what will happen under the health-care reforms currently in Congress.
    JHM is to be commended, but Dr. Miller, does this mean that JH does not insitute the same cost saving measures to it’s non-Medicaid, well insured patients?

  3. Ben says:

    Of the countless teams who have tackled impossible goals, there are those that say “no, I can’t do this” and those that say “it’s impossible, but we’ll find a way.” The latter, if they have a great leader and a great team, do indeed figure it out however complex and vexing.
    Yes, we can argue whether expanding Medicaid or whatever is the right approach. But there’s a bigger issue here, isn’t there?
    What I don’t hear from Dr. Miller is the huge demand for leadership talent who can create the next Geisinger, the next Intermountain, and all the Accountable Care Organizations to drive a more coherent delivery system. It seems like he’s in a unique position to help create the leaders who bring “yes I can.”
    It can’t be done in a vacuum, so here are the legislative and judicial steps which should accompany it:
    (1) expanding primary care. Shift from specialists
    (2) driving reimbursements to at-risk and episodic payments
    (3) big investment in transparent and comparative quality measures
    (4) break up anti-trust protections to foster competition (on quality)
    (5) incentives for creating clinical practice teams that can compete (on quality)
    (6) shift medical education to create a new generation of leaders
    My two cents

  4. Gary Lampman says:

    So the Medicaid argument is not to expand medicaid? The reasons are: It involves a larger group of uninsured patients. Patients that never see a Doctor because they do not qualify because of preexisting conditions.Patients who have chronic problems because they have been rejected for coverage and /or excessively charged to maintain Coverage.Patients that of (largely)no fault of their own;have been denied this privilege to be included as a member of the human race.
    Who’s Fault is That?
    Insurance bets overwhelmingly on the Healthy and will denied opportunities just based on a suspicion or a feeling.Some patients are born with these preexisting conditions and this profession has accepted the premise of insurance selection. Our prerequisite to the Human Condition and our predisposition as members of the Human Race has predetermined who lives and who dies.
    I applaud the efforts of Doctors to meet the demands of the poor and disadvantaged. However, The extension of medicaid would cover disadvantaged populations with a reimbursement to the Profession.
    Is it only about the Money or do we need disadvantaged populations so we can feel good about ourselves?

  5. I could not disagree more with my good friend Dr. Miller. Maryland will benefit under the health reform proposed in Washington today. First Johns Hopkins like all Maryland hospitals will be paid for all patients under the current all payer system at adequate rates even for Medicaid patients. Maryland physicians will also see reimbursement for a variety of patients that they now get no reimbursement for. The good news for Maryland’s uninsured citizens is they will not have to go to the Hopkins ER and will now have a medical home with a doctor to see them.

  6. Nate says:

    “First Johns Hopkins like all Maryland hospitals will be paid for all patients under the current all payer system at adequate rates even for Medicaid patients.”
    Medicare use to say this exact same thing, until the bill came due and Congress decided to eliminate it and start cutting reimbursements. If HCR passes history will repeat, even with the 4 year head start on taxes we won’t be able to afford it and Congress will start rewriting the promises.

  7. maggiemahar says:

    Dr. Miller writes:
    “We’ll meet the demands placed on us because serving poor and disadvantaged populations is part of our century-old mission.”
    I would expand that sentence to read “and because if we don’t we could lose our tax-exempt status.”
    Miller’s complaint that, under reform,poor people who may never have seen a doctor will have access to care auggets something less than a “century-old” dedication to helping the poor.
    Moreover, as Dr. Benjamin points out, in Maryland Medicaid pays the same rates that private insurers pay. (In most states Medicaid pays roughly 30% less than private insurers.))
    Medicare also pays the same rates private insurers pays. (These rates are set by the state.) And those rates have left Maryland hospitals with a 2% surplus after year.
    That’s enough of a margin for a non-profit, especially because it’s been pretty consistent. This explains why “Maryland has consistently had the highest proportion of hospitals rated ‘investment grade’ of any state.” (Here i’m quoting from my part 3 if my Maryland post on healthbeatblog; you’ll find sources there: http://www.healthbeatblog.com/2010/02/how-maryland-broke-the-curve-a-solution-for-massachusetts-part-3.html
    You’ll find part 2 of the post here.
    Ronald Peterson, president of Johns Hopkins Health System recently told the Wall Street Journal that Hopkins’ surplus has been running between 2% and 4%.
    (Ass part 3 of my post here http://www.healthbeatblog.com/2010/02/
    massachusetts-problem-and-marylands-solution-we-dont-have-to-wait-for-washington-part-2-.html
    So why is Dr. Miller poor-mouthing?
    I would assume that, in the past, Johns Hopkins treated some uninsured patients who didn’t qualify for Medicaid and had to eat the cost– though when applying rates to individual hospitals, the state does adjust for how many uninsured patients they care for.
    Perhaps Dr. Miller thinks that Johns Hopkins was doing better with the adjustment than it will do when it is paid the rates that Medicaid will pay for these formerly uninsured patients?
    If so, this suggests that the adjustment was too high?
    Finally, shouldn’t the headline read: “Health Reform Could Harm the Hopper?” (what some med students and residents call JH)

  8. In all fairness, I think Dr. Miller is referring to loses incurred by the non hospital services they also provide for their capitated Medicaid patients.
    I can see how adding folks to Medicaid will cost the state more money and I can see how the lack of risk adjustment would be a problem for JH.
    However, I can also see, as Dr. Benjamin notes, that these newly covered people will not need to impose on JH charity care any longer.
    So if hospitals like JH find themselves providing less and less charity care, until hopefully all care is reimbursed, would it still be proper for them to retain full non-profit status?

  9. Nate says:

    what does amount of charity care have to do with non profit status? I think we should do away with all non profits as it is more abused then properly utilized. We can start with healthcare providers then add the churches and “social” organizations and end with a double tax on political activity.

  10. smith says:

    Iam not for any healthcare with our president

  11. smith says:

    This health care package is makeing me sick. I mean sick. I think he should give up all of this because none of us want it the way it is written.

  12. “what does amount of charity care have to do with non profit status?”
    They have to provide a certain amount of charity care in order to maintain non profit status, but they don’t.
    I wonder how much money we can collect if we revoked this nonsense from all providers and insurers?
    Maggie has this frustrating story on her blog about a non profit hospital in New Jersey that has “A salon for couples’ massages with private shower.”
    http://www.healthbeatblog.com/2010/03/hospital-breaks-new-ground-in-luxury.html
    I bet you call it something else in Vegas….

  13. notmd says:

    some insight..
    1)the uninsured who will become medicaid eligible are not new patients..they have been entering the hospitals emergency room as uninsured and when not admitted have left as uninsured..hospitals have effectively been the insurer of last resort..
    2)medicaid should be expanded to cover community services like primary care and hospitals should be allowed to enroll patients under presumptive eligibilty..up to now we have left it up to the states who do not have an incentive to enroll..
    3)when medicaid patients were enrolled in a managed care plan that plan had to add close to 20% of additional administrative costs for systems..all managed care plans should leave the administrative part to the state and the plan should improve the patients health status..

  14. Nate says:

    They have to provide a certain amount of charity care in order to maintain non profit status, but they don’t.
    Where is this codified? I’ve never seen any requirement for charity care to be classified as a non profit. I would bet there are many ways to be a non profit provider besides delivering charity care.

  15. Thanks for the interesting and informative post. I look forward to more in the future.

  16. Thanks for the interesting and informative post. I look forward to more in the future.

  17. Thanks for the interesting and informative post. I look forward to more in the future.

  18. Thanks for the interesting and informative post. I look forward to more in the future.

  19. Thanks for the interesting and informative post. I look forward to more in the future.

  20. Thanks for the interesting and informative post. I look forward to more in the future.

  21. Thanks for the interesting and informative post. I look forward to more in the future.

  22. Thanks for the interesting and informative post. I look forward to more in the future.

  23. Thanks for the interesting and informative post. I look forward to more in the future.

  24. Thanks for the interesting and informative post. I look forward to more in the future.

  25. You are correct, Nate. There is the “community benefit” standard that is usually construed to include charity care, but it is only one factor in the assessment of the non profit status for hospitals.
    Here is the IRS guy talking about it last year
    http://www.irs.gov/pub/irs-tege/miller_speech_011209.pdf

  26. propensity says:

    Dr. Miller,
    You and JHH can do it. Be creative. Hire a few more NPs and PAs and arm them with some of these new fangled HIT EMR NPOE and PAPOE systems with decision support.
    Save on labor costs. The care will not be any different when run by NPs and PAs clicking on HIT.
    After all, is that not what the government wants?

  27. Student Doctor says:

    Boo to you Dr. Miller!
    Just when this country is on the brink of actually attempting to solve one the the biggest dangers to millions of American’s health and financial well-being you take the time to use your bully pulpit to talk about what is wrong with the bill.
    Sir we all know it is not perfect but can we wait another 10 years to see if another congress can get it right?

  28. The article is very well written, I am also looking at such problems, opportunity to exchange

  29. Health Care reform is an interesting topic and much needs to be reformed. My first question is what will actually be reformed. Patient care or accessibility to care for patients. Services are often dropped or overlooked and that would be tragic. Intermountain and the Mayo clinic are both forces to be seen. It will be interesting to see what will happen to medicare. I fear that entire systems will be abandoned and new untested programs will be installed. If Medicare remains it really needs to be update and more closely monitored.
    Logan
    http://www.iahealth.net

  30. yolanda benjamin says:

    Overwhelmingly, I agree with Dr. Benjamin on his point (not because we have the same last name-lol, I do not know him. But seriously lets think, What hospital does not want to take 30% less on medicaid capped payments as oppose to no payment at all doing (CHARITY CASES). Is not and insured patient less hassel.
    What I hear is that Dr. Miller is not in terested in helping the poor, but instead is happy with the boasting that he can do on the hospital’s name for treating charity cases because they are poor or disadvantaged, unisured. I also hear a lot of belly aching from him as well. So what there will be a lot more patients, do what all yall businesses do appeal to the government to give you a loan and build a few new offices. Oh but wait that won’t be good because then THE HOSPITAL WILL BE KNOWN FOR CREATING JOBS. Hello Dr. Miller more jobs more workers to spend money the better we are with our deficits. Here is my end question for anyone that feels like Dr. Miller. Are you all U.S. Citizens, because I thought that we were supposed to help eachother and especially the less fortunate.
    Thanks,
    Yolanda

  31. Medtipster says:

    This is a very thought provoking article. You answer the questions that most people are afraid to ask. I look forward to reading more of your writings.

  32. merilyn harrison says:

    would like copy if that’s ok?

  33. review says:

    2009 and 2010 $120,000 from your tax dollars.
    Philadelphia PA Mayor Nutter received two years in a row $60,000 checks to help keep open and operate the city swimming pools.
    These checks came from AmeriChoice Health and on the surface seems like fine gifts.
    Yet, they are Bribes non the less, these checks come from a company who receives all its money from the Federal Government as a vendor for Medicare Medicaid services is not allowed to offer bribes kickbacks and money gifts of any kind in order to promote its share of the market place.
    This is not allowed as a use of your taxpayers dollars yet it happens.What does it really cost the City of Philadelphia to receive this money?
    Americhoice Health has a long history of corruption over the years yet seems to be protected by those who are responsible to over see their actions why is that?

  34. reform needed says:

    Limo Divers Protest Medicare Mediciad Reform Cuts, It’s rumored this issue could become part of the Tea Party movement. AmeriChoice Health is also rumored to take a position on this reform. Recirculate those tax dollars? Help keep limo drivers working, benefits flowing and overpaid tax dollars remain in abuse.
    Medicare.gov as well as other Federal agency’s encourage you to report any fraudulent activities, yet, the same government agencys were notified the way this company does business yet did nothing. Three years ago they were reported to these Federal agency’s and as of todays date not only were they allowed to continue doing business but were never charged once. Protected vendor status sure, politics sure,limited government budgets sure, Federal and State officals looking the other way sure, and rather then stop these activities a strong desire not to rock the boat existed. Even with the vast changes in the laws and budgets,a hands off policy remains, you tell me what’s wrong with this picture? The Government created this monster and now they don’t know what to do about it, like shooting yourself in your own foot etc. Tons of money to advance their national growth, its market positions, tons of money for political donations, tons of money to send 75 millon back to its home office from New York state alone, tons of money to suppot National TV shows, tons of money to pay hugh State fines, tons of money to hire the very best law firms, tons of money to pay for bribes and kickbacks, tons of money for hugh salarys and bonuses, all done on the back of the American taxpayor, you see this company receives all its money from the Federal government. Should your tax dollars be held to a higher standard? Should the government agencys responsible for there review be held to that same standard?Should the IRS audit their corruption? Why has this company not been charged? How long can the buck be passed here in more ways then one? Hey, it’s your tax dollars don’t complain now.. then don’t complain later on…
    ps… I know times are tough for a lot us, but it would be great to have a free limo to go to the Doctors, Pharmacy, Movies, Grocery shopping, and given free tickets for the movies. Offered soda, pop corn and hotdogs, as well as have them receive free coupons for Grocery items……Kind of makes you wish you also had Medicare and Mediciad right?

  35. Profits says:

    Selling out of the Poor? What would Elmo say?
    Full Name: Wayne Berman Title: Vice-Chair; Finance Co-Chair; Adviser
    Over the course of three years, Berman’s lobbying firm was paid $660,000 to lobby on behalf of UnitedHealth subsidiary Americhoice, a managed care HMO providing health insurance to Medicaid, Medicare, and SCHIP recipients. Specifically, according to the lobbying report, they lobbied on Medicaid issues in the Deficit Reduction Act of 2005.[Americhoice Lobbying Reports 2004 – 2007; Americhoice.com ] Berman Also Lobbied For “Absurdly Low” Rates for Medicaid Managed Care Companies to Pay Out of Network Hospitals. Also included in the DRA, and mentioned as a lobbying issue on Berman’s Americhoice lobbying report, was a provision setting rates managed care companies must pay to out-of-network providers — mainly hospital emergency rooms — for care received by Medicaid beneficiaries. Rather than forcing managed care companies to reimburse out-of-network hospitals an amount comparable to network providers, the legislation set the default amount to the state’s “fee-for-service rate,” which often is “absurdly low.” The provision thereby shifted financial responsibility for services to Medicaid beneficiaries from the managed care companies to the hospitals themselves, permitting managed care companies to rake in huge profits, while hospitals incurred added losses.[Modern Healthcare, 1/29/07; Text of S. 1932] To Save Money, Bill Cut Services to Medicaid Beneficiaries, But Left Managed Care Providers Untouched. Under the final budget package, substantial Medicaid spending cuts were achieved by imposing new premiums and increased co-payments on Medicaid beneficiaries; some costs were also shifted to the states, who in return were awarded new powers to drop coverage or reduce benefits to certain beneficiaries. In a letter to Senate Majority Leader Bill Frist, the AARP CEO decried the final bill, saying it “protects the pharmaceutical industry, the managed-care industry and other providers at the expense of low-income Medicaid beneficiaries.”[Inside CMS, 12/29/05; Los Angeles Times, 12/22/05; World Markets Analysis, 12/21/05; The Hill, 12/20/05]
    The Players and whats up for grabs. Profits United Health Group 2010 $4.293 billion
    Here are some other 2010 budget numbers: Wonder what it cost CMS ( Can’t Manage Sxxx) to operate each year.$453 billion Medicare///$290 billion Medicaid ///$78.7 billion Department of Health and Human Services/// UnitedHealth Group Awarded TRICARE Managed Care Support Contract … Jul 13, 2009 … UnitedHealth Group Awarded TRICARE Managed Care Support Contract for more than $20.3 billion. BILLIONS awarded and still to be awarded United’s AmeriChoice unit is the largest government contractor administering state Medicaid programs for the poor and federally sponsored plans for children. AmeriChoice’s revenue rose 34% last year, to $6 billion. United Health Group and its subsidiarys must be exhausted from signing Corporate Integrity agreements each and every year and as reward for their violations well what happens? they are awarded more contracts and more money and maybe even an ambassadorship here and there and if anybody should question what the heck is going on, then send them a Elmo doll.(Americhoice sponsors Sesame Street) Up side, Billions to be made, down side pay some fines (cost of doing business) move on and nobody goes to jail or gets excluded from the game. Get up the next day put on your Elmo costume and its back to work as usual. WOW, even in the Casino world or Mob world this would be a no no, suprised Hollywood has not done a movie on this or maybe even great TV.
    The Government created this monster and now they don’t know what to do about it, like shooting yourself in your own foot etc.Tons of money to advance their national growth, its market positions, tons of money for political donations, tons of money to send 75 millon back to its home office from New York state alone, tons of money to suppot National TV shows, tons of money to pay hugh State fines, tons of money to hire the very best law firms, tons of money to pay for bribes and kickbacks, tons of money for hugh salarys and bonuses, all done on the back of the American taxpayor, you see this company receives all its money from the Federal State governments. Should your tax dollars it be held to a higher standard? Should the government agencys responsible for there review be held to that same standard? Should the IRS audit their corruption? Why has this company not been charged? How long can the buck be passed here in more ways then one?

  36. Medicaid Cash Gifts Cards says:

    Welcome to AmeriChoice of Pennsylvania
    On behalf of AmeriChoice of Pennsylvania, I would like to welcome you as a participating provider in our Medicaid and Children’s Health Insurance Program (CHIP) products. We are committed to working with you and your staff to achieve the best possible outcomes for our members. This welcome kit contains valuable information about important contacts, policies, procedures and services to help you to conduct business with us as efficiently as possible. For easy navigation through the kit components, you can click on each link in the Table of Contents, which will bring you directly to that section. You can also download the Physician, Health Care Professional, Facility and Ancillary Administrative Guide by logging on to http://www.americhoice.com . This is a comprehensive reference source for the information you and your staff need regarding claims, benefits, prior authorization, medical management and other plan components. Again, we are pleased that you are one of our participating providers delivering quality care to our members. If you have any questions about your participation with AmeriChoice, or need a printed copy of this welcome kit, please call the Provider Service Helpline at 1-800-345-3627.
    Sincerely,
    Ernest Monfiletto Pennsylvania-East, Chief Executive Officer AmeriChoice of Pennsylvania AmeriChoice Provider Welcome Kit
    This chart identifies bonus payments available to you, in addition to your regular payments, for compliance with HEDIS measures as defined by the National Committee for Quality Assurance (NCQA). For more information, call Jessica Anglin at 215-832-4590.
    AmeriChoice Provider Welcome Kit This chart identifies bonus payments available to you, in addition to your regular payments, for compliance with HEDIS measures as defined by the National Committee for Quality Assurance (NCQA). For more information, call Jessica Anglin at 215-832-4590. Provider Incentives Measure Requirements AmeriChoice Will Available Referrals Adolescent Well-Care • Provider Incentive:$100/4th qtr 2008 only;$50/visit all other months • Member Incentive: 2 movie tickets Ages 12–21 years • Well-care visit • Physical exam • History of health & development • Education & guidance • Call members • Offer auto messaging for providers • Mail reminders • Provide member list with addresses and phone numbers • Provide EPSDT grid Healthy First Steps® (HFS) 877-651-6667 Lead Screening • Provider Incentive: $15/submitted test • Member Incentive:$15 VISA gift card • Documented levels • 9-19 months and <3rd birthday • Call members • Provide Case Management for elevated levels • Offer auto messaging for providers • Provide member list with addresses and phone numbers • Provide MEDTOX in-office testing MEDTOX 877-725-7241 Healthy First Steps (HFS) 877-651-6667 Childhood Immunizations All immunizations • Call members • Mail reminders • Review registry for Philadelphia County • Offer uto messaging for providers • Provide EPSDT grid Healthy First Steps (HFS) 877-651-6667 BMI Ages 2-20 years Documentation in chart • Offer auto messaging for providers • Offer BMI wheel Healthy First Steps (HFS) 877-651-6667 Dental Screenings Ages 2-20 years • Mail reminders • Call members • Offer auto messaging for providers Healthy First Steps (HFS) 877-651-6667 Case Management 877-651-6667 Asthma Ages 5-56 years • Identify as having persistent asthma • At least one Rx • Preferred asthma therapy education• Create member medication profiles • Call members • Provide Case Management referrals • Offer LifeLink Case Management 877-651-6667
    AmeriChoice Provider Welcome Kit Pa
    Measure Requirements AmeriChoice Will Available Referrals Breast Cancer • Member Incentive: $50 VISA gift card Mammogram Females, Ages 40-69 years • Call members • Mail reminders • Offer auto messaging for providers • Assist in locating providers and scheduling appointments • Assist with ransportation QM Coordinator 215-832-4524 Case Management 877-651-6667 Cervical Cancer Screening (PAP) • Member Incentive: $25 VISA gift card Females, Ages 21-64 years • Call members • Mail reminders • Offer auto messaging for providers • Assist in locating providers and scheduling appointments • Assist with transportation QM Coordinator 215-832-4524 (to help schedule) Case Management 877-651-6667 Diabetes Care Provider Incentive: • Phase 1: Completed E and M visit ($100.00) and completed Cholesterol and HbA1C Screening • Phase 2: Diabetes managed – ($150.00); Cholesterol below 100 mg; HbA1c below 9 Ages 18-75 • HbA1C testing and documentation <9 • LDL screening and documentation <100 mg/dL) • Retinal eye exam performed • Blood pressure control • (<140/90 mm Hg) • Nephropathy screening test Urine macroalbumin □ Visit to nephrologist □ Treatment for nephropathy □ Therapy with ACE inhibitor/ARBs • Call members • Mail reminders • Provide Case Management • Offer auto messaging for providers Case Management 877-651-6667 Frequency of Ongoing Prenatal Care • Provider ncentive: $250 for completed prenatal intake form • Submission of completed prenatal intake form by provider • FAX to AmeriChoice HFS at 215-832-4986 • Provide Case Management Healthy First Steps (HFS) 877-651-6667 ER Diversion • Decrease overutilization of ER services for non-urgent diagnosis • Call members • Provide Case Management Case Management 877-651-6667

  37. can tou feel the love says:

    United Health Group Defrauded 100 Million Americans Posted on January 13th, 2009 by iwaller
    An investigation begun by New York’s Attorney General, Andrew Cuomo said the company Ingenix, a research firm owned by UnitedHealth Group deliberately shorted reimbursements on out-of-network health insurance claims for Americans to the tune of hundreds of millions of dollars! Ingenix claimed it relied on ‘independent research from across the health care industry’ to determine reimbursement rates. However, UnitedHealth Group and its company Ingenix manipulated the health care claims presented by millions of Americans having health insurance and shorted their reimbursements between 10% and 28% of what the coverage should have paid. Instead, UnitedHealth Group, pocketed the millions of dollars it shorted Americans. UnitedHealth Group provides health benefits to 26 million Americans. Nearly all health care insurance companies in the country were using the same low reimbursement rates. Some of the largest health insurance companies who utilize the same Ingenix system are United Health Care (owned by UnitedHealth Group), Aetna, Cigna, Wellpoint/Empire BlueCross BlueShield and Genix. These companies are currently under investigation in New York suspected of participating in the same reimbursement fraud. How ironic UnitedHealth Group’s mission statement says in part: “We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve…We work with health care professionals to expand access to high-quality health care so people get the care they need at an affordable price.” Rather than anyone going to jail, UnitedHealth Group settled with the New York Attorney General by agreeing to pay $50 Million as the settlement to be used to establish and create a new database to determine rates for patients who choose physicians outside of the insurance giant’s network. Little good this does for the millions of Americans who were ripped off by these insurance scumbags. “This is a huge scam that affected hundreds of millions of Americans [who were] ripped off by their health insurance companies,” says Cuomo. “This was unethical, and it robbed vulnerable patients of insurance reimbursements they deserved.” Cuomo is now investigating other insurance companies that use Ingenix’s database. There may be millions more on the line as well. Of course, as is the corporate way of the guilty, UnitedHealth Group stated “We respectfully disagree with the New York Attorney General’s findings that we manipulated data … (or that our ownership of Ingenix was a conflict of interest.) We agreed to his settlement because it was an effective way to address any perceived conflict of interest.” The American Medical Association, represented by Dr. Nancy Nielson, president-elect of the AMA stated “there is a profit motive for keeping reimbursement low.” ”It is shocking and unacceptable for an insurance company to hide behind a shroud of secrecy”. Nielson also said “It is another example of UnitedHealth playing by its own rules.” This is not the first time UnitedHealth has been involved in legal action. In 2000, the AMA filed a lawsuit in federal court in New York over the exact same reimbursement issues. In May of 2008, Oxford Health Insurance, Inc, a unit of UnitedHealth Group, had to refund $50 million to small business customers in New York to settle claims it overcharged for health insurance policies back in 2006. More trouble from the past, when former CEO, William W. McGuire, M.D. was charged with securities fraud by the SEC. Mr. McGuire ultimately found guilty, had to repay $468 million as a partial settlement of the prosecution. In summary, I am of the opinion that corporate America is as corrupt as anywhere on earth. CEO bilking millions in golden parachutes and executive compensation, while American citizens fund their luxurious lifestyles with hard earn money, simply to be overcharged, cheated and ripped off by the rich and powerful. The UnitedHealth Group scam, is no different that the crooks on Wall Street: AIG, Goldman Sachs, Morgan Stanley, Merrill Lynch, Lehman Brothers, Bear Stearns, Fannie Mae, Freddie Mac, Citigroup, and other corporate manipulators such as Shell Oil, Exxon-Mobile, and so many other financial and energy leading companies. The free market system is over in America, thanks to corporate greed which took its roots during the Reagan trickledown economic philosophy. Corporate America cannot and should not be trusted and the federal government is almost in the same boat. Disdain for hardworking Americans by the Wall Street and Corporate America is so prevalent, they no longer tried to hide. The ‘haves’ continues to increase the divide between the ‘have not’s. Americans, Republicans and Democrats, should be outraged and the raping and pillaging of their money by Corporate America. We must begin to demand a government that works with incorporating fines and bringing to justice those criminals who rob, steal and cheap on a national basis from hard working citizens. None of the men leading these companies have gone to jail. Where is the justice for middle American who pays the bills for these outlaws?

  38. S.R. Cooper says:

    Here are some ideas to consider:
    MEDICADE – Overhaul/regulate
    • Use block grants for unemployed, underinsured, disabled, and high risk individuals. No loopholes.
    • Distribute payments to individual/ “certified” medical insurance carrier. Require authorization to exceed cap.
    • Remove subsidy from nursing homes. Allow home care.
    • Impose ‘graduated scale’ payments and co-pays where applicable.
    • Increase pay to doctors.
    HEALTH CARE – Privatize
    • Repeal ObamaCare. Hold hearings and de-fund. No new entitlement program. Establish regulations.
    • Allow medical insurance companies to sell portable policies in all states. Supply/demand will reduce costs.
    • Allow individuals/businesses to pool with other individuals/businesses for best priced plans.
    • No caps (maximum medical reimbursements).
    • No discrimination/cancellations for pre-existing/other medical conditions, age, or income.
    • Require reimbursements for medical care from the uninsured that are above poverty level.
    • Pass tort reform. Loser pays attorney fees. Will reduce costs.
    • Allow voluntary euthanasia for terminal (6 mo.) patients (Oregon/Washington).

  39. Medcaid is very much a needed program. However, it is run in a seriously corrupt fashion. I know this is true from personal experience, which I explain in my blog.

  40. driversed says:

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