Buffalo-based HealthNow New York fined $1 million for denying claims for infertility treatment and other violations

http://www.buffalonews.com/145/story/396995.html

State insurance regulators on Monday imposed a hefty $1 million fine on HealthNow New York for multiple violations of state law, but the Buffalo-based company said it has already corrected past claims practices.
The state penalized Buffalo’s largest health insurer for improperly denying claims for infertility treatment and for not giving consumers enough notice of rate hikes.

Health insurer executives earn healthy pay

http://www.buffalonews.com/businesstoday/localbusiness/story/370612.html

The CEOs of HealthNow New York, Independent Health Association and Rochester’s Excellus Health Plan, which owns Univera Healthcare, took home more than $6.5 million combined last year in salary and other pay.
That’s a 72 percent increase from $3.77 million in 2006

Highmark settles suit

http://www.bizjournals.com/pittsburgh/stories/2008/01/07/story1.html?b=1199682000%5E1571338

Highmark Inc. will pay $9.9 million and change the way it does business with doctors, including how appeals are handled, to settle a class action lawsuit that was filed in 2003 against Blue Cross Blue Shield plans nationwide, according to terms of a preliminary agreement.

"The news is the reforms Highmark has agreed to adopt," said attorney William Maruca, who practices with the Downtown offices of Fox Rothschild LLC and represents the Allegheny County Medical Society. "The major impact will be in improving the way Highmark deals with physicians."
Among the terms of the proposed settlement is disclosure of fee schedules to participating physicians; expanded arbitration provisions for claim disputes; an end to recovering overpayments after 18 months except in cases of fraud; and establishment of a 12-person physician advisory committee to consult with the insurer on a variety of matters, such as clinical quality improvements. The tentative agreement also requires a committee of physician peers to evaluate medical necessity issues and an external review panel to mediate appeals of insurance claims that have been denied.
"Payments vary sometimes, and it's hard to tell why," Maruca said.

Do Primary Care Physicians Treating Minority Patients Report Problems Delivering High-Quality Care?

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.3.w222

Primary care physicians treating a disproportionate share of black and Latino patients typically earn less, see more patients, provide more charity care, treat more Medicaid patients, and receive lower private insurance payments than their counterparts treating fewer such patients, according to a national study published today as a Health Affairs Web Exclusive. These same physicians also reported more problems providing high-quality care, ranging from inadequate time with their patients to difficulty obtaining specialty care. In addition, the Commonwealth Fund-sponsored study examined how higher Medicaid payments might help physicians treating mostly minority patients provide high-quality care and reduce racial and ethnic disparities.

Two Tier Health Care

State budget includes drug discount cards for seniors, millions more for hospitals

http://http://www.buffalonews.com/home/story/313292.html

ALBANY — The 2008 state budget will prod Medicaid patients into less expensive outpatient and home settings, provide prescription drug discount cards for 400,000 senior citizens and disabled people and restore hundreds of millions of dollars that hospitals and nursing homes were facing in cutbacks.

How Unemployment Affects Families

Job loss doesn't just affect individuals. It impacts families and even whole communities. Stress, uncertainty, and lost income affect children in various ways.

Living in Disadvantaged Neighborhoods is Bad for Your Health

Why is your street address such a good predictor of your health? Increasingly, Southeast Asian immigrants like Gwai Boonkeut are moving into neglected urban neighborhoods where African Americans have long suffered, and now their health is being eroded too. What can be done to create a neighborhood that promotes rather than destroys health?

The Importance of Culturally Appropriate Care for Native Americans

Modern medicine teaches a rigid, scientific approach to disease prevention. Yet practitioners like Dr. Donald Warne argue that to be effective, health care programs must be locally controlled and responsive to the needs and beliefs of diverse individuals and groups. For Native Americans in particular, role models and interventions must come from within the community.

The Impact of Poverty and Stress on Diabetes among Native Americans

As Dr. Donald Warne explains, there is a direct biochemical connection between living in poverty and blood sugar levels. The stress of being poor and of having family members die young creates a complicated web of cultural values and beliefs that make controlling diabetes more difficult. Add to that the lack of availability of healthy food and it's no wonder diabetes rates are high.

The Latino Paradox

Recent Latino immigrants are healthier than the average American, despite being generally poorer. Researchers believe that some aspects of immigrant communities may protect health. But for Latinos, the longer they are here, the worse their health becomes. Why?

How Racism Impacts Pregnancy Outcomes

UCLA obstetrician and gynecologist Dr. Michael Lu believes that for many women of color, racism over a life time, not just during the nine months of pregnancy, increases the risk of preterm delivery. To improve birth outcomes, Lu argues, we must address the conditions that impact women's health not just when they become pregnant but from childhood, adolescence and into adulthood.

Unraveling the Mystery of Black-White Differences in Infant Mortality

Neonatologists James Collins and Richard David specialize in the care of infants born too soon or too small. Their research on differences in birth outcomes between African American and white American women points to a provocative idea: the cumulative stress of racism is taking a toll on African American families even before they are born.

Kim Anderson's Story

When Atlanta lawyer Kim Anderson was pregnant with her first child, she did everything right: she ate a healthy diet, exercised, and got the best prenatal care. But her baby was born almost three months premature. This excerpt from When the Bough Breaks explores racism's impact on pregnancy outcomes.

Unnatural causes is inequality making us sick?

VIDEO EXCERPT: Health in America
The U.S. is one of the richest countries in the world, yet we rank 29th for life expectancy. We spent more than twice what other countries spend per capita on health care. Why aren't we healthier?

African American and Latino Pastor’s unite to combat health care disparities among the minority populations

Pastor Matthew L. Brown, who in November of 2007 challenged Pastors to take a pledge toward healthy living in order to fight diseases such as Diabetes, which is prevalent among African Americans and Latinos, now has another larger issue to champion and has rallied the faith community in support of the poor and their legitimate right for health care services regardless of their economy. Pastor Brown and the local clergy are supporting Dr. Raul Vazquez and other partner physicians, who recently revealed alarming treatment of two patient case studies dealing with the same illness and having different types of health care coverage, yet treated vastly different. In some instances, patients with Medicaid were denied services from the growing number of physicians who do not accept Medicaid.

Pastor Brown says, “the distinction between patients and the disparity of their treatment should not be discriminative. Now that Dr. Vazquez has provided us with the facts, we will not standby and ignore the issues that hinder the communities that we serve and reside in.”

PATIENT COMPLAINT AGAINST MANAGED CARE

Explained how Community Blue targets inner city community

Private plans, public money: Insurers target federal funds

http://www.ama-assn.org/amednews/2008/01/28/bisa0128.htm

The nation's biggest health plans see government business -- not employer-based or other private-pay customers -- as the biggest engine for growth.

Cuomo's reasonable investigation into health plan pricing

http://www.ama-assn.org/amednews/2008/03/10/edsa0310.htm

New York takes on United over an allegedly rigged system for pricing services by out-of-network physicians.

The American Medical Association, which is involved in a separate suit against United over the UCR system, commended the attorney general's efforts. At Cuomo's news conference announcing his investigation, AMA President-elect Nancy H. Nielsen, MD, PhD, said the problems he detailed are pervasive.

Insurers feel backlash over policy cancellations

http://www.ama-assn.org/amednews/2008/03/17/prl20317.htm

A lawsuit and a punitive damage award against a California plan are two of the latest developments.

Members of the BNMA

Press Conference March 5 2008

City doctors mobilizing to address inequities in health care system

http://www.buffalonews.com/cityregion/story/292701.html

Dr. Raul Vazquez stood onstage Wednesday evening in Pucho Olivencia Center on Swan Street and ran through the symptoms of what he said was becoming a “two-tiered health care system.”
At the heart of it, he said, was the gap between the treatment given to patients covered by commercial managed-care organizations, the HMOs, and patients who receive care through Medicaid.
In many instances, he said, hospitals and other doctors turn away Medicaid patients or do not provide them with timely care.

State Medicaid Fact Sheet

http://www.statehealthfacts.org/mfs.jsp?rgn=34&rgn=1

Total Medicaid Spending, FY2006

http://www.statehealthfacts.org/comparetable.jsp?cat=4&ind=177

Consumer Driven Health Care

http://cdhc.ncpa.org/

NY still tops in Medicaid spending

http://buffalo.bizjournals.com/buffalo/stories/2007/11/05/daily4.html?jst=s_cn_hl

New York also ranked No. 1 in total and per-capita hospital spending. New Yorkers spent more than $9.8 billion dollars on inpatient and outpatient hospital care in 2006, or $509 per capita--140 percent above the national per-capita average. New York's total hospital spending made up 15 percent of all Medicaid hospital spending nationwide, although the state has just 6 percent of the nation's population.

Doctoring Medicaid

http://www.nysun.com/article/47383?page_no=1

As Governor Spitzer plans to take on the problem of rocketing Medicaid spending on the elderly, he needs to get his focus right

Adult Asthma

http://www.myhealthfinder.com/newyork07/reg.php?table=15

State Avg: 147.0

Erie (635 : 67.8% , 81.7%)(74.7%)

New York (2957 : 202.4% , 213.1%)(207.7%)

Congestive Heart Failure

http://www.myhealthfinder.com/newyork07/reg.php?table=08

State Avg: 372.7

Erie (3722 : 366.8% , 392.1%)(379.5%)

New York (4548 : 326.0% , 347.6%)(336.8%)

Hypertension (high blood pressure)

http://www.myhealthfinder.com/newyork07/reg.php?table=07

State Avg: 49.0

Erie (216 : 19.7% , 28.0%)(23.9%)

New York (716 : 48.6% , 55.4%)(52.0%)

Perforated Appendix

http://www.myhealthfinder.com/newyork07/reg.php?table=02

State Avg: 26.2

Erie (183 : 28.9% , 36.3%)(32.6%)

New York (300 : 21.5% , 26.5%)(24.0%)

Diabetes Short-Term Complications

http://www.myhealthfinder.com/newyork07/reg.php?table=01

State Avg: 45.4

Erie (469 : 54.8% , 64.3%)(59.6%)

New York (684 : 44.6% , 51.6%)(48.1%)

Hysterectomies

http://www.myhealthfinder.com/newyork07/regu.php?table=28

State average: 314.6 per 100,000

Erie 2047 cases (549.8)

New York 2685 cases (398.2)

Coronary artery bypass graft (CABG)

http://www.myhealthfinder.com/newyork07/regu.php?table=26

State average: 200.8 per 100,000

Erie 1545 cases (318.5)

NIAGARA HEALTH QUALITY COALITION

http://www.myhealthfinder.com/hospital_care/Quality_Reports/Patient_Survey/2007/PS05-medical.pdf

Niagara Health Quality Coalition gets passing grade

http://www.bizjournals.com/buffalo/stories/2005/01/10/daily7.html

The hospital quality report card assembled by the Niagara Health Quality Coalition has received top ratings from a Web site that compares health care data sources across the country.

The seven original members of the P2 corporation are:

Independent Health
Univera Healthcare
Roswell Park Cancer Institute Corporation
State University of New York at Buffalo, Department of Family Medicine
Buffalo Medical Group, PC
Promedicus Health Group, LLP
Highgate Medical Group, PC

P2 Collaborative of Western New York

Board of Directors
Michael W. Cropp, MD - (Chairman)President and CEOIndependent Health
Matthew BannisterSenior Vice PresidentHealth StrategiesAmerican Heart Association / American Stroke Association
Donald K. BoswellPresident and CEOWNED-TV Channel 17
Mary Lee Campbell-Wisley - (Secretary)Regional PresidentUnivera Healthcare
Daniel J. Scully - (Treasurer)CEO, Buffalo Medical Group, P.C.
Kevin DonovanAssistant DirectorRegion 9 UAW(NY, PA, NJ)
Stephen B. Edge, MD, FACSChair, Breast & Soft Tissue SurgeryRoswell Park Cancer Institute
George I. GellmanChairmanThe Benchmark Group
Richard D. Hague Jr.Pastor, Mount Erie Baptist Church
Yvonne S. Minor-Ragan, PhD - (Vice President)PrincipalWestminster Community Charter School #68
Jay Pomerantz, MDSenior Vice President & Chief Medical OfficerHealthNow
Thomas Rosenthal, MD - (President)Professor and ChairmanDepartment of Family Medicine, UB

One Friday, Four Futures Initative Launched

http://www.p2wny.org/news/?id=8
“Scenario planning is a dramatically new concept for our region as far as addressing a public policy issue because it offers the community an opportunity to look ahead and shape the system of the future through community wide conversation and dialogue,” Ann F. Monroe, president of the Community Health Foundation of Western and Central New York said. “The conversations that will take place over the next several months are intended to gather community input so we can put forth recommendations for a health system that can meet the needs of diverse constituencies, including the elderly, rural communities and families in poverty to name just a few.”

All of us are users of health care,” Monroe continued. “This initiative is structured to hear from as many users as possible about what they need and want from their health care system. Then, these many perspectives can be rolled up to create an accurate picture of the community’s priorities.”

Oishei grant aids P2 Collaborative

http://buffalo.bizjournals.com/buffalo/stories/2007/07/02/daily31.html

The P2 Collaborative of WNY Inc. has received a major grant from the John R. Oishei Foundation.
The three-year $335,000 grant will be used to increase consumer engagement in improving healthcare.
The nonprofit P2 Collaborative works to strengthen communication between healthcare providers and patients in an effort to improve compliance through education and more active participation.
The organization is focusing on several indicators related to growing community health concerns, including cardiovascular disease, diabetes, asthma, cancer and depression. Other goals include creating open exchanges of best practices among healthcare providers.

Penn. says Medicaid won't pay for hosp. errors

http://www.msnbc.msn.com/id/22804799/

Pennsylvania announced Tuesday it would no longer make Medicaid payments to hospitals for serious, preventable medical errors, apparently the first state in the nation to follow a similar policy by the federal government.

Health care spending to top $4 trillion by 2017

http://www.msnbc.msn.com/id/23342260/

By 2017, consumers and taxpayers will spend more than $4 trillion on health care, accounting for one of every $5 spent, the federal government projects

Consumer Bill of Rights and Responsibilities

http://www.hcqualitycommission.gov/cborr/chap5.html

Chapter Five Respect and Nondiscrimination

Source of payment. The health care system currently is undergoing an historic transformation in which low-income Medicaid beneficiaries are being enrolled into private health plans. While this is a positive development in terms of access for traditionally vulnerable populations to high-quality care, it is almost certain to create additional tensions that could be manifest in discrimination. Providers who agree to accept Medicaid beneficiaries must provide equal access, care, and waiting times to those patients. It will be vitally important for State and Federal agencies to closely monitor the provision of care to Medicaid beneficiaries as they move into new health plans


Health plans will need to examine the standards and incentives that exist within their systems that may inadvertently discourage providers from attending to the interpersonal aspects of health care quality that can be manifest as disrespect. Consumers enrolled in health plans with defined networks of providers should have access to their plans' participating providers, without regard to the source of their coverage (e.g., Medicare, Medicaid, employer-sponsored plan

Managed Care Consumer Bill of Rights

http://www.legalaction.org/gmed28.htm

The right to be treated no differently than commercial enrollees

Managed Care Consumer Bill of Rights

http://www.oag.state.ny.us/health/compliance.html

There are three general areas in the new statute which the Attorney General is particularly concerned about because of their impact on consumers. First, the Bill gives consumers certain rights to information about their health plans. Second, the Bill provides consumers with certain rights to access specialty, out-of-network, and emergency care. Third, consumers are given various rights to contest certain health plan decisions through mandatory grievance and utilization review procedures

New York Medicaid Fraud May Reach Into Billions

http://www.nytimes.com/2005/07/18/nyregion/18medicaid.html?pagewanted=7

Among the biggest beneficiaries of the Medicaid program have been executives of the state's nursing homes and clinics, many of whom earn substantial salaries and profits from the program.
According to records obtained from the Health Department under the Freedom of Information Law, 70 executives of nursing homes and clinics personally made more than $500,000 in 2002, the last year for which figures are available. Twenty-five executives made more than $1 million.

The table below displays HMO complaints for the years 2004, 2005 and 2006

http://www.nyshmoguide.org/CompareHmoTrends.asp

A Guide to Monitoring Medicaid Managed Care

http://www.familiesusa.org/resources/tools-for-advocates/guides/monitoring-medicaid-mc-2.html

Multiple state agencies may have responsibility for monitoring the performance of Medicaid managed care plans

State Medicaid agencies are responsible for making sure that plans comply with federal Medicaid law and regulations and with Medicaid managed care contracts

Policing Medicaid and Medicare Managed Care: The Role of Courts and Administrative Agencies

http://muse.jhu.edu/login?uri=/journals/journal_of_health_politics_policy_and_law/v027/27.3mello.html

The Role of Courts and Administrative Agencies Michelle M. Mello Harvard School of Public Health Abstract: The much-publicized 2000 case of Frew v. Gilbert, in which a federal judge castigated the State of Texas for deficiencies in its Medicaid program, brought renewed attention to the issue of regulating the quality of care in Medicaid and Medicare HMOs. Frew and other recent cases highlight both the promise and the pitfalls of relying on courts to correct deficiencies in public managed care programs

Specialists less Likely to Provide Care to Medicaid Managed Care Patients

http://hbns.org/newsrelease/medicaid12-04-01.cfm

Specialists are just as likely to treat Medicaid patients as are primary care physicians, according to the results of a recent study conducted in California. They are, however, less likely to accept Medicaid patients who are enrolled in managed care plans

The survey, published in the December issue of the Journal of General Internal Medicine, also found that specialists have fewer numbers of Medicaid patients in their practices than do primary care doctors and that most doctors hold negative views of Medicaid patients

Jack P. Smith III, Managed Care

http://www.aslme.org/news/jlme/27.1f.html

Jury Awards $121 Mil. in Denial of Benefits Case against Aetna

Health Tip

Dr Raul Vazquez comments

CIGNA settles massive managed care lawsuit

http://www.ama-assn.org/amednews/2002/12/16/prl11216.htm

That lawsuit -- which accuses CIGNA of bundling, downcoding and arbitrarily denying claims -- was the first physician-filed lawsuit against an HMO to get class-action certification. It now stands to be the first lawsuit in which physicians will recover tens of millions of dollars and will see some changes in the way that a managed care company interacts with physicians on matters of billing.
"It's a great win for doctors," said Alton, Ill., otolaryngologist Timothy N. Kaiser, MD, who originally filed the lawsuit against CIGNA along with Irving, Texas, pediatrician Suzanne LeBel Corrigan, MD, because they were tired of getting the runaround when they billed for their services. "It demonstrates that individual physicians can make a big difference."

Love v Blue Cross and Blue Shield Association

http://www.crowell.com/PracticeAreas/Page.aspx?id=39&cid=318#0706

Fighting the idiocy of health insurance

http://disgruntleddoctors.org/index.html

Health Insurance needs to be considered as a method to protect personal finances, not to assure access to health care. Catastrophic health insurance with high deductibles with or without voluntary Health Savings Accounts are a reasonable financial protection. First dollar or low deductible/low copay health insurance plans are a recipe for excessive demand on resources, artificial cost controls, regulatory intrusion, Stalinist 5-year plans, and failure of the medical economy.

State Health Facts

http://www.statehealthfacts.org/mfs.jsp?rgn=34&rgn=1

10 things your hospital won't tell you

http://articles.moneycentral.msn.com/Insurance/InsureYourHealth/10ThingsYourHospitalWontTellYou.aspx


Treatment errors are common, finding someone in charge can seem impossible, and patients sometimes wind up sicker than when they arrived. And here's a tip: Try to avoid hospitals late at night and in July

More going without health care

http://articles.moneycentral.msn.com/Insurance/InsureYourHealth/MoreGoingWithoutHealthCare.aspx


Nearly half (48%) say they pay more in health-insurance premiums than a year ago, and 37% say they pay more out of pocket for medical services or prescriptions.
The results of the poll of 9,765 adults suggest that medical expenses are becoming a heavier burden on household finances, even for middle-income Americans. They underscore the findings of other recent studies that the cost of health care is becoming a more widespread problem.

Wal-Mart expanding in-store health clinics

http://articles.moneycentral.msn.com/Insurance/InsureYourHealth/WalMartExpandingInStoreHealthClinics.aspx


Wal-Mart is among several supermarket and drugstore chains that in the past couple of years have begun opening store-based health clinics, which are staffed mostly by nurse practitioners or physician assistants and offer quick service for routine conditions from colds and bladder infections to sunburns.

The three top executives of Western New York's dominant nonprofit health insurers boosted their combined takehome pay

http://news.manta.com/articles/description/200707081707520_10853300_0-0304

Jul. 8, 2007 (McClatchy-Tribune Regional News) -- The three top executives of Western New York's dominant nonprofit health insurers boosted their combined takehome pay to $3.77 million last year, even though their companies' total earnings surplus fell by more than 18 percent, according to state regulatory filings. HealthNow New York, Independent Health Association and Excellus Health Plan earned a total of $287.6 million in 2006, down significantly from $351.1 million the year before. Yet only Excellus' CEO, David Klein, saw any drop in pay -- and only by $3,300, holding above $1.78 million. Meanwhile, consumers continue to see high-single-digit or even double-digit premium...

CUOMO ANNOUNCES INDUSTRY-WIDE INVESTIGATION INTO

http://www.oag.state.ny.us/press/2008/feb/feb13a_08.html

NEW YORK, NY (February 13, 2008) – Attorney General Andrew M. Cuomo today announced that he is conducting an industry-wide investigation into a scheme by health insurers to defraud consumers by manipulating reimbursement rates. At the center of the scheme is Ingenix, Inc., the nation’s largest provider of healthcare billing information, which serves as a conduit for rigged data to the largest insurers in the country.

Dr Mark Hyman Review of Sicko

Part 1

http://video.msn.com/video.aspx?vid=213535c5-7d86-448f-84ec-b3b85e75ba93

Part 2

http://video.msn.com/video.aspx?vid=637320c6-f3a4-46c9-89c5-d5171e48073b

Michael Moore Sicko

http://video.msn.com/video.aspx?mkt=en-US&brand=&vid=382f4fbc-9dbc-4bf0-b41c-eaa8fe4fe204

Life Tables for WHO Member States

http://www.who.int/whosis/database/life_tables/life_tables.cfm

World Health Organization USA death rate by years

http://www.who.int/whosis/database/mort/table1.cfm

Number of deaths (N) at ages (in years) and age-sex-specific death rates (rate) per 100 000 population (Infant death rates per 100 000 live births)
2000 all causes males numbers 1177518
females numbers 1225773

1999 all causes males 1175469
females 1215939

This rise in salaries has generated controversy because non-profits are essentially subsidized by taxpayers. They are exempt from property, sales

http://compensationresources.com/press-room/non-profit-agencies-following-corporations--lead-in-paying-executives.php

In reaction to the rise in non-profit salaries, a 1996 law gave the Internal Revenue Service the power to fine or revoke the tax exemption of non-profits whose executives get excessive compensation. But the law gives groups a "safe harbor" if they have a written opinion from an outside expert justifying the pay. The IRS has also advised that salaries at comparably sized profit-making companies can be used as a guideline

Top hospital execs’ pay in WNY exceeds $1 million

http://www.buffalonews.com/businesstoday/localbusiness/story/250408.html

Kaleida Health paid its new chief executive officer, James Kaskie, $1.2 million last year, up from $844,333, after Kaskie was promoted to succeed Dr. William D. McGuire as CEO, according to federal tax filings provided by the hospital. That includes $852,731 in compensation, $331,085 in benefits and a $20,720 expense account.
At Catholic Health System, the No. 2 hospital network in Western New York, CEO Joseph D. McDonald received $1.03 million, a 26 percent raise from 2005. His pay includes $682,981 in compensation and $347,951 in other payments.

But even with Kaskie’s and McDonald’s salaries considered, total 2006 compensation for 16 top hospital executives in Western New York fell 7 percent to $5.9 million from $6.2 million, largely because of the departure of McGuire, who in 2005 earned $1.74 million — more than double that of any other local hospital CEO.

Construction on HealthNow New York's corporate headquarters is moving on schedule and the first wave of the company's employees

http://buffalo.bizjournals.com/buffalo/stories/2006/08/28/daily21.html?jst=s_cn_hl
"The project is on schedule," said Dennis Gorski, HealthNow's vice president of government programs and former Erie County Executive

Deaths and Death Rates* by Selected Causes - Exclusive of New York City

http://www.health.state.ny.us/nysdoh/vital_statistics/2005/table33b.htm

The Burden of Cardiovascular Disease in New York

http://www.health.state.ny.us/nysdoh/chronic_disease/cardiovascular/burdenofcvdinnys.pdf

2007 Monthly Medicaid Managed Care Enrollment

2007 Monthly Medicaid Managed Care Enrollment

http://www.health.state.ny.us/health_care/managed_care/reports/enrollment/monthly/2007/docs/en12_07.pdf

Five-Year Time Trends by County, New York State

New York State Cancer Registry

http://www.health.state.ny.us/statistics/cancer/registry/vol3.htm

2007 New York State Managed Care Plan Performance Report

http://www.health.state.ny.us/health_care/managed_care/qarrfull/qarr_2007/docs/qarr2007.pdf

60 Minutes

U.S. Heading For Financial Trouble?

http://www.cbsnews.com/stories/2007/03/01/60minutes/main2528226.shtml


David Walker, comptroller general of the U.S., totaled up our government's income, liabilities and future obligations. He concluded the numbers don’t add up
MUST SEE VIDEO

http://www.youtube.com/watch?v=KGpY2hw7ao8

Senator Kuehl's Universal Health Insurance bill in california

http://www.youtube.com/watch?v=jB0Vn_BppwM

Senator Kuehl's Universal Health Insurance bill in california
MUST SEE

http://www.onecarenow.org/index.html

The statewide OneCareNow grass roots campaign is devoted to educating Californians and building massive support for Senate Bill 840, titled "The California Universal Healthcare Act", authored by Senator Sheila Kuehl.

THE STATE OF HEALTH CARE QUALITY 2007

http://web.ncqa.org/Portals/0/Publications/Resource%20Library/SOHC/SOHC_07.pdf


THE STATE OF HEALTH CARE QUALITY 2007
NATIONAL COMMITTEE FOR QUALITY ASSURANCE
WASHINGTON, D.C.


2008 NCQA Board of Directors
Robert J. Margolis, M.D. (Chair) -- HealthCare Partners Medical Group
David F. Durenberger -- National Institute of Health Policy
Robert S. Galvin, M.D. -- General Electric Company
Elizabeth Gilbertson -- H.E.R.E.I.U. Welfare Fund
William Goss -- Cain Brothers
Glenn Hackbarth -- Independent Consultant
Jerome P. Kassirer, M.D. -- Tufts School of Medicine, Yale School of Medicine
Peter V. Lee, J.D. -- Pacific Business Group on Health
Dolores Mitchell -- Group Insurance Commission, Commonwealth of Massachusetts
Ralph W. Muller -- University of Pennsylvania Health System
Debra Ness -- National Partnership of Women and Families
Joseph Newhouse, Ph.D. -- Harvard University
Margaret E. O’Kane -- National Committee for Quality Assurance
Ellen Stovall -- National Coalition for Cancer Survivorship
John Tooker, M.D., MBA, FACP (Chair-elect) -- American College of Physicians
I. Steven Udvarhelyi, M.D. -- Independence Blue Cross


Insurance premiums are a poor gauge of health care costs, masked by market competition and plans’ability to negotiate provider discounts. Yet most employers and consumers choose a plan based on the lowest premium offered. A more accurate measure is the value a plan adds by delivering high-quality care while using the fewest possible resources in doing so.

HEDIS 2008

http://web.ncqa.org/Portals/0/HEDISQM/HEDIS2008/2008_Measures.pdf

US NEWS BEST HEALTH PLANS

Best Health Plans
Healthcare costs continue to rise, and most employees are getting no healthier. Employers are beginning to introduce wellness programs with teeth, rather than those that offer small perks like discounted gym memberships.

US NEWS BEST HEALTH PLANS

http://www.usnews.com/directories/health-plans/index_html/plan_cat+commercial/

Commercial

1. Harvard Pilgrim Health Care (HMO/POS)Maine, Massachusetts
Based on Consumer assessment, Prevention and Treatment

Medicare

1Fallon Community Health Plan (HMO)Massachusetts
Prevention, Treatment

Medicaid


1 Fallon Community Health Plan (HMO)Massachusetts
Consumer assessment, Prevention and Treatment

The 2007 Rankings Methodology
Let's select a managed care plan at random and conduct an inquiry. How good is it at encouraging members at risk of heart attack to get their bad cholesterol into safe territory and keep it there? If it's a Medicare plan, are physicians effectively steered away from prescribing certain antihistamines, muscle relaxants, and other drugs that could be dangerous to elderly patients? Are doctors alert for kidney disease in diabetic members? Are members happy with claims handling?

To someone trying to pick a health plan, answers to these kinds of nuts-and-bolts questions are useful. And November kicks off "open season," when millions of families decide whether to stick with their current plan or move to a different one.
So for a third year, U.S. News and the National Committee for Quality Assurance, managed care's leading accrediting and standards-setting body, have joined forces to rank health plans based on just such questions.
More than 500 HMOs and POS plans, including most large commercial, Medicare, and Medicaid plans and many smaller ones, have been evaluated, using data submitted annually to NCQA. Their performances in 50 measures for commercial plans, 28 for Medicare plans, and 35 for Medicaid plans were scored on a scale of 1 to 5 and converted to overall scores that determined their rankings.

Inside the measures. Some results came from a consumer survey asking members how satisfied they were, for example, with how well their doctors communicated with them and how quickly care was provided. The rest were medical, divided between prevention (such as whether members were screened for colorectal cancer) and treatment (such as whether asthmatic children from 5 to 9 years old got the right medication).
Plan performance in dozens of individual measures can be found at the Web address provided. It is the first time we've shown such fine detail; in the past, we displayed results only for some measures, although all of the data went into the final scores. The measures can be used to search, sort,and compare plans.
Health plans that couldn't be ranked because of insufficient data are grouped below ranked plans, with scores for measures they did submit. Plans that submitted no data at all, or did but refused to make it public, are listed at the bottom of the rankings. Sometimes there's a good reason—a plan is being phased out, say. Most of the time, however, that's not a place where you want to see your plan, or one that might interest you

HEDIS site

http://www.opm.gov/insure/health/hedis2002/9G.asp

HEDIS (Health Plan Employer Data and Information Set) is developed and maintained by the National Committee for Quality Assurance, a not for profit organization committed to assessing, reporting on, and improving the quality of health care. We present HEDIS results on managed care plans to:
allow consumers to reliably compare health plan performance, and
spur the health plans to make internal efforts at quality improvement.

DOH 2005

http://www.health.state.ny.us/health_care/managed_care/qarrfull/qarr_2005/supp05.pdf


Managed Care
Plan Performance
Report Supplement

Compares plans in very different ways.

REPORT ON EXAMINATION

http://www.ins.state.ny.us/exam_rpt/55107f03.pdf


REPORT ON EXAMINATION
OF
EXCELLUS HEALTH PLAN, INC.
AS OF
DECEMBER 31, 2003


Excellus Health Plan, Inc. is a not-for-profit health service corporation organized
and licensed under Article 43 of the New York Insurance Law. The Plan also holds a
Certificate of Authority under Article 44 of the New York Public Health Law as a health
maintenance organization. The Plan operates using two assumed names, Excellus Blue
Cross and Blue Shield and Univera HealthCare.
At the examination date, Excellus, Inc. was the sole member of Excellus Health
Plan, Inc. Excellus Inc. changed its name on January 23, 2004 to Lifetime Healthcare,
Inc. d/b/a The Lifetime Healthcare Companies. Excellus Health Plan, Inc. is the
surviving entity resulting from the mergers of the Blue Cross/Blue Shield Plans in the
Rochester, Central New York, and Utica-Watertown regions and HMOs in Central and
Western New York including HMO-CNY and Univera Healthcare of Central and
Western New York.


The Plan’s mission, as cited in its internal website, and as ratified by the
board of directors at its October 1, 2004 meeting, is quoted in part as follows:
“Being responsible stewards of our communities’ health care premiums
and health care resources.”

Within its strategy statement, also cited within the internal website, the Plan notes
the following as a value:
“Reducing unnecessary, wasteful expense is essential.”


As of December 31, 2003 health care services were provided to 1,890,430
members. The following chart shows annual membership changes by number and
percentage:
1998 1999 2000 2001 2002 2003
Members 1,909,220 1,858,024 2,293,291 1,893,224 2,001,806 1,890,430
Change % -2.7% +23.4% -17.5% +5.7% - 5.6%
It is noted that the increase during calendar year 2000 was due, in large part, to a
restatement of membership associated with the 2001 merger with Univera, Inc. The
subsequent decrease during 2001 was the result of a change in treatment of the Plan’s
minimum premium/premium credit business.

Parent company
Lifetime Healthcare, Inc.* non for profit but the company under area many for profit have about 25 division ? companies

SPECIAL REPORT ON EXAMINATION

http://www.ins.state.ny.us/exam_rpt/hnsr1203.pdf

SPECIAL REPORT ON EXAMINATION
OF
HEALTHNOW NEW YORK INC.
AS OF
DECEMBER 10, 2003


Conflict of Interest Procedures
The examination review revealed that certain directors were engaged in outside business
practices that have, at least, the appearance of potential conflicts with their roles as directors of
the Plan. During the examination period, conflict of interest statements were submitted to the
7
Plan’s internal audit section and reviewed in conformity with the Plan’s policy. However, not all
of the Plan’s potential conflicts of interest were identified or noted in the Board or Committee
minutes of meetings.
A review of the Plan’s existing Conflict of Interest forms, signed by the Plan’s board
members and officers indicates that such form should be enhanced to provide for additional
disclosure of conflicts including disclosure of a medical practice in New York State, disclosure
of family members that work for, or have a connection with providers of health care services,
disclosure of filer or family member of filer as a supplier of services to the Plan or member of
the HealthNow holding company system, and disclosure of filer or family member are owners of
a corporation whose aggregate sales to (1) hospitals, (2) licensed medical professions and (3)
facilities of health service, hospital service and medical expense indemnity corporations exceed
5% of its total sales.
It is recommended that HealthNow enhance its conflict of interest forms for its directors,
officers and key employees by including such additional disclosure items as indicated above or
other items as necessary. It is further recommended that the Plan enhance its review of such
conflict of interest statements and require more comprehensive documentation to support a
determination that conflicts do not exist.

Report of examination of Healthnow New York Inc Dec 31,2003

http://http://www.ins.state.ny.us/exam_rpt/55204c03.pdf


The Plan reported reserves and unassigned funds of $221,993,959 as of December
31, 2003. As of December 31, 2003, the Plan’s required to be maintained statutory reserve
of $222,134,436 was impaired in the amount of $140,477. Subsequent to this report date,
the Plan has filed quarterly and annual statements which indicate a removal of the
impairment.


The Plan is a non-profit health service corporation organized under the provisions
of the Membership Corporation Law and Article 43 of the New York Insurance Law.
The Plan was incorporated on September 26, 1939 and commenced business in 1940



As of December 31, 2003 health care services were provided to 669,699
members. The following chart shows annual membership changes by number and
percentage:
1998 1999 2000 2001 2002 2003
Members 674,183 679,463 616,961 622,664 649,875 669,699
Change % +0.1% -9.2% +0.1% +4.4% +3.1%


Different Corporate Structures ie.


HealthNow Holdings, Inc.
As of December 31, 2003, this entity was a wholly owned subsidiary of
HealthNow Systems Inc. and currently is the for-profit holding company for
HealthNow Foundation, New York Care Plus Insurance Agency, Inc. and HealthNow
Contractor Services, Inc., which are all subsidiaries of HealthNow Systems, Inc. The
shares of HealthNow Holdings were transferred to HealthNow New York Inc. in
April, 2004.


HealthNow Foundation (Not-for-Profit Corporation 501(c)(3))
HealthNow Foundation (Foundation) is organized exclusively for charitable
purposes in the United States and abroad within the meaning of Sections 170(c)(2)(B)
and 501(c)(3) of the Code. The sole member of the Foundation is HealthNow
Holdings, Inc.


HealthNow Contractor Services, Inc.
HealthNow Contractor Services, Inc. is a wholly owned subsidiary of HealthNow
Holdings, Inc. This entity was dormant as of December 31, 2003.


Blue Care New York Benefits Agency, Inc. (BCNYBA)
The Plan maintained a 16.67% controlling interest in Blue Care New York
Benefits Agency, Inc. (BCNYBA) as of December 31, 2003. The Plan, along with
four other New York Blue Cross and Blue Shield Plans, formed BCNYBA, then
known as New York Administrative Plan Services, Inc., in 1995 for the purpose of
providing insurance marketing services for said Plans.



New York Care Plus Insurance Agency, Inc. (NYCPIA)
The Plan, in 1997, formed New York Care Plus Insurance Agency, Inc. for the
purpose of operating as an accident & health and life insurance agency. As of the
date of this report, New York Care Plus Insurance Agency, Inc. has remained a
dormant operation.
The following is a description of the inter-company agreements in effect between
HealthNow New York Inc. and other members of the holding company as of the
examination date:


The above ratio is outside Department benchmark guidelines. The Plan
experienced positive underwriting results in the traditional product lines in 2002 and
2003, particularly in the Buffalo area.
The underwriting ratios presented below are on an earned-incurred basis and
encompass the October 1, 1999 to December 31, 2003 period covered by this
examination:
Amount Ratio
Claims incurred $5,147,699,017 86.1%
Claims adjustment expenses incurred 328,037,492 5.5%
Other underwriting expenses incurred 409,944,999 6.8%
Net underwriting gain 96,482,015 1.6%
Premiums earned $5,982,163,523 100.0%



As noted in the above schedule, the Plan exceeded the 12.5% administrative
expense limitation prescribed by Section 4309(b) of the New York Insurance Law for the
years 1999, 2000 and 2001.



Sales and Advertising
The Plan disseminated comparison benefit summary charts in 2004 which
contained instances of misleading and/or incomplete comparisons of other Plans’
benefits. A total of eight (8) such comparison benefit summary charts were found to have
been presented to employer groups and/or brokers. This is a violation of New York
Insurance Department Regulation 34 (11 NYCRR 215.11) which states:
“An advertisement shall not directly or indirectly make unfair or
incomplete comparisons of policies or benefits or comparisons of noncomparable
policies of other insurers, and shall not disparage
competitors, their policies, services or business methods, and shall not
disparage or unfairly minimize competing methods of marketing
insurance.”
It is recommended that the Plan comply with the requirements of Department
Regulation 34 (11 NYCRR 215.11) relative to its sales and marketing advertising.

Doctors for Better Health comments

Issues with medicaid and general reimbursement for providers.

Letter sent to The Attorney General

Letter sent to attorney general

I went into medicine to help patients, not just focus on the finances of medicine. There seems to be a Healthcare DICTATORSHIP initiated by the Managed Care markets. There is an abuse of power with regards to managing patients, and problems with fee fixing below realistic measures. The fees are fixed in the HMO's favor. When an insurance company pays on a medical claim, the payment is considered a lost because their profits shrink. When a provider receives payment on a claim, more often than not, it is also considered a lost. Instead of being paid for services rendered, providers are paid for services "allowed." The vast difference between the HMO loses and the Doctors’ loses is that the HMO hold the reigns. Patients are being managed without choices. Providers are being forced into fixed contracts that are monopolized, either take it or leave it. This has become a huge problem. PLEASE HELP ADDRESS THESE ISSUES AND RECTIFY A REMEDY.

Department of Health Response

Vida Wehren Bureau of Program Planning and implementation division of managed Care and Program Evaluation state in her replied that numbers of specialists participating in medicaid managed care plans in Erie County increase by 123% between 2005 and 2007. Medicaid managed care enrollees in the Western NY region indicate levels of satifaction with their speciality care providers tha are consistent with statewide averages. Similarly, measure of satifaction with care received, timeliness of care, quality of care, customer service and overall satifaction with the health plan met or exceeded statewide averages.

Medicaid Issues

My name is Dr. Raul Vazquez, MD. I am board certified in Family Practice and have been in private practice for 12 years. I provide care to a large Medicaid population on the Westside of Buffalo. In 2003 I relocated my office from 778 Niagara Street to 564 Niagara. I purchased a piece of land and built a "State of the Art"12,000 square foot medical facility. My facility employs over 25 people. Most of the employees are bi-lingual and live right in the community. We have diversified the office to learn from the population and the modalities in order to increase revenue. We perform office services like spirometries, ekgs, holters, arterial dopplers, stress testing, cryotherapy, hair removal and laser services. Extender operations include ophthalmology, x-ray, cardiology, surgery, podiatry, physical therapy, durable goods, and pain management; all private practice model.

Every year it is becoming more and more difficult to sustain due to the decreases in Managed Care reimbursement. Managed Care has in some instances cut fees up to 66%. Over the last 15 years, I have noticed an increase in premiums but a decrease in service. It would seem that by this time, outcomes would be improved. There should be better management of chronic diseases and a reduction of costs. However, the costs are being controlled by reducing reimbursement to providers. Managed Care is in the business of managing costs NOT managing care for patients. As a primary care physician, it is my responsibility to refer patients to the appropriate specialists. However, it is gravely difficult to find specialists that even accept my Medicaid Managed Care patients. Moreover, the providers that once accepted these patients are now declining them. It is simply insulting to expect providers to work for free. We have to provide malpractice and quality care to all of our patients, ill-respective of their medical insurance.

In this area the fees are so low that most providers are leaving, or in the process of leaving, which is what prompted this letter. Today Ophthalmologist, Dr. Rafael Medina, who has been in my facility for 5 years, told me that he would be leaving next month due to reimbursement decline. It is no longer feasible for him to manage this population.

I know that the county is concerned with the welfare of all its citizens; And you as a businessman can appreciate the struggles of another business entity. I have been able in the past 12 years to show improved outcomes on chronic diseases. Asthma, Diabetes and Hypertension is very prominent in this community, However, my asthmatic patients are admitted less than 1% with a 0% morbidity/mortality. My diabetics are controlled at an average HGA1C of <8. Nationally, diabetics are averaging HGA1c's of 9. My hypertensives, and my depressed patients are also well managed and improved. We receive no federal, state, county or city funding. I am simply asking the County and the State to look at the present problems. I do not want to abandon my patients; I feel that I am providing a necessary service. I have some suggestions for improving care and managing populations NOT solely managing costs.

I would be honored to sit down with the elected officials and brainstorm an alternative to the status quo. Insurance companies are concerned with patients accessing emergency rooms for routine care that could be performed by their primary care doctor at a fraction of the costs. Well, if current trends continue, more patients will be forced into the ER's due to a decline in the number of providers that will accept them. This type of segregation creates a cast system that I am sure New York State would not be proud of. Healthcare has become desensitized and patients with substandard coverage are being ostracized by the entire industry, including the pharmacies, the doctors, the extenders and the insurers.

Sincerely,

Dr. Raul Vazquez, MD, FAAFP