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Granite Healthcare Network and Cigna Launch Largest Accountable Care Program in New Hampshire Linking Doctors, Hospitals and Health Plan

Monday, July 30, 2012

Granite Healthcare Network and Cigna Launch Largest Accountable Care Program in New Hampshire Linking Doctors, Hospitals and Health Plan

Published: May 29, 2012
  • Consumers benefit from improved care coordination and greater emphasis on preventive care
  • Participating organizations rewarded for improving patient health and lowering medical costs
  • Program includes registered nurse clinical care coordinators

BLOOMFIELD, Conn. & CONCORD, N.H.--(BUSINESS WIRE)--May. 29, 2012-- Cigna (NYSE:CI) and the Granite Healthcare Network (GHN), a partnership among five independent charitable health care organizations in New Hampshire, have launched a collaborative accountable care initiative to expand patient access to health care, improve care coordination, and achieve the “triple aim” of improved health outcomes (quality), lower total medical costs and increased patient satisfaction. Collaborative accountable care is Cigna's approach to accomplishing the same population health goals as accountable care organizations, or ACOs.

The Granite Healthcare Network (Concord Hospital, Elliot Health System, LRGHealthcare, Southern New  ...

The Granite Healthcare Network (Concord Hospital, Elliot Health System, LRGHealthcare, Southern New Hampshire Health System and Wentworth-Douglass Hospital) and Cigna have launched an accountable care program to improve health and lower medical costs. (Photo: Cigna)

The Granite Healthcare Network comprises Concord Hospital, Elliot Health System, LRGHealthcare, Southern New Hampshire Health System and Wentworth-Douglass Hospital. Each member is an independent, integrated health care delivery system consisting of primary care doctors, specialists and hospitals.

Cigna's patient-centered collaboration with GHN is believed to be the largest accountable care program in New Hampshire that links doctors, hospitals and a single health plan.

The program will benefit more than 23,000 individuals covered by a Cigna health plan who receive care from among more than 900 GHN-participating health care professionals. Individuals who are enrolled in a Cigna health plan and later choose to seek care from a GHN-participating physician will also have access to the benefits of the program.

“Cigna has been a leader in accountable care, both here in New Hampshire and throughout the country, which is why we chose Cigna as the health plan for this initiative,” said Greg Baxter, M.D., chief medical officer for the Granite Healthcare Network. “We believe that this arrangement with Cigna offers the best opportunity for us to improve health care quality, lower medical costs and help our patients lead healthier and more productive lives.”

Each of the GHN-participating organizations will monitor and coordinate all aspects of an individual’s medical care. Patients will continue to go to their current physician and will not need to do anything to receive the benefits of the program. There also are no changes in any plan requirements regarding referrals to specialists. Patients most likely to see the immediate benefits of the program are those who need help managing chronic conditions, such as diabetes or heart disease.

Critical to the program’s benefits are registered nurses, employed by each of the five GHN health care organizations, who serve as clinical care coordinators and are integrated into the care delivery team to help patients with chronic conditions or other health challenges navigate their health care system. The care coordinators will enhance care by using patient-specific data provided by Cigna to identify patients being discharged from the hospital who might be at risk for readmission, as well as patients who may be overdue for important health screenings or who may have skipped a prescription refill. The care coordinators will contact these individuals to help them get the follow-up care or screenings they need, identify any issues related to medications and help prevent chronic conditions from worsening.

The care coordinators will also help patients schedule appointments, provide health education and refer patients to Cigna's clinical programs, such as disease management programs for diabetes, heart disease and other conditions; and lifestyle management programs, such as programs for tobacco cessation, weight management and stress management. This initiative is unique in using data and analytics at the health system level to focus health care professionals more fully on engaging patients to improve the coordination of their care as well as develop best practice clinical initiatives across the GHN member health systems.

“The five Granite Healthcare Network organizations share our vision for a patient-centered health care system that emphasizes prevention and primary care and rewards physicians for care quality and health outcomes,” said Donald Curry, president for Cigna in New England. “We believe that a system that’s focused on value rather than volume of care offers the best path to improved health and lower medical costs, which is good for individuals, families, employers and doctors.”

Cigna will compensate GHN for the medical and care coordination services its participating organizations provide. Additionally, the organizations may be rewarded through a “pay for performance” structure if they meet their targets for improving quality and lowering medical costs. Employers who sponsor health plans will benefit from lower health care costs or health care costs that increase at lower rates.

“The Granite Healthcare Network and Cigna are to be commended for this initiative that will benefit the citizens of New Hampshire,” said Paul Grundy, M.D., MPH, global director of healthcare transformation at IBM and president of the Patient-Centered Primary Care Collaborative. “This patient-centered collaboration is an excellent example of how health plans can work with physicians and hospitals to help create a health care system that works for everyone. Putting patients and their families at the center of care gives patients much better access to care, empowers them to communicate more effectively with their health care professional, gives physicians tools to better integrate and coordinate care, and helps improve the healing relationship between patients and their doctors.”

The principles of the patient-centered medical home are the foundation of Cigna's collaborative accountable care initiatives. Cigna then builds on that foundation with a strong focus on collaboration and communication with medical organizations. Cigna is now engaged in 32 patient-centered initiatives in 17 states, including six multi-payer medical home pilots and 26 Cigna-only collaborative accountable care initiatives. The collaborative accountable care initiatives encompass more than 270,000 Cigna customers and more than 4,000 physicians.

In New England, Cigna has collaborative accountable care arrangements in Connecticut with ProHealth Physicians; in Maine with Eastern Maine Healthcare Systems, Kennebec Region Health Alliance, Penobscot Community Healthcare, plus two other physician practices that have not yet been announced; and in New Hampshire with Dartmouth-Hitchcock Clinic.

About Cigna

Cigna Corporation (NYSE: CI) is a global health service company dedicated to helping people improve their health, well-being and sense of security. All products and services are provided exclusively through operating subsidiaries of Cigna Corporation, including Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Life Insurance Company of North America and Cigna Life Insurance Company of New York. Such products and services include an integrated suite of health services, such as medical, dental, behavioral health, pharmacy and vision care benefits, and other related products including group disability, life, and accident coverage. Cigna has sales capability in 30 countries and jurisdictions, with approximately 70 million customer relationships throughout the world. To learn more about Cigna®, including links to follow us on Facebook or Twitter, visit

About Granite Healthcare Network (GHN)

GHN is a network of charitable organizations that are leading the transformation of healthcare delivery in New Hampshire by leveraging their collective intellectual and clinical resources to improve quality, cost-effectiveness and access beyond what any one of them could achieve individually. The member hospitals — Concord HospitalElliot Health SystemLRGHealthcareSouthern New Hampshire Health System, and Wentworth-Douglass Hospital — have joined forces to implement innovative initiatives focused on the triple aim of providing better health for communities and better care for patients at an affordable cost.

Photos/Multimedia Gallery Available:

Source: Cigna Corporation and Granite Healthcare Network

Media Contacts:
Mark Slitt, 860-226-2092
Granite Healthcare Network
Rachel Rowe, 603-415-1300

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Another View: The Medicaid program is a very good deal for New Hampshire

Monday, July 30, 2012

Another View: The Medicaid program is a very good deal for New Hampshire

In 2010, the states of Wyoming and Texas took a close look at Medicaid, wondering, as we do here in New Hampshire, what to do with a program that's become a major piece of the state budget.

Would it be cheaper to take the radical step of withdrawing from the federal-state partnership that pays for health insurance for people with disabilities, low-income children and seniors and leave them uninsured? The answer was no.

A clearer understanding of Medicaid reveals why.

New Hampshire Medicaid provides health insurance coverage to approximately 130,000 New Hampshire residents — 10 percent of our state's population. Essentially, Medicaid covers people that no other insurer will cover, largely because their health needs are too great and their incomes are too low to afford whatever private policies would be offered to them

Currently, New Hampshire pays for Medicaid by splitting the bill with the federal government. In fact, no matter what happens, the feds always pay at least 50 percent of costs — sometimes more, as is the case under the Affordable Care Act.

Medicaid makes financial sense for New Hampshire because access to the program reduces the number of people without insurance in our state. Reducing the uninsured takes pressure off hospitals and other providers of charity care, which in turn takes pressure off everyone's health care premiums, which have risen as uncompensated care costs have been shifted onto those paying for private insurance.

This is what Wyoming and Texas found. Ending Medicaid would not make the medical needs of their low-income citizens go away. It would just transfer the expense of uncompensated care to hospitals and providers (which ultimately shifts costs to those with private-pay insurance). At the same time, it would drain millions of dollars (the federal contribution) out of their respective state economies.

By splitting the cost of Medicaid with the federal government, we make sure New Hampshire's children get the immunizations and basic health care they need to grow and learn. We rest assured knowing that senior citizens will receive long-term care if they run out of assets. We know that people with disabilities will obtain services to enable them to remain independent and in their communities.

In 2014, under the new federal health law, approximately 30,000 to 50,000 additional New Hampshire residents will become eligible for Medicaid. The federal government will pay 100 percent of the costs for these Granite Staters for the first three years, eventually reducing its financial share to a permanent level of 90 percent by 2020. That means New Hampshire will be able to cover as many as 40 percent more people under Medicaid, but will never pay more than 10 percent of their costs, a health care bargain if there ever was one.

What makes no sense for New Hampshire is to change the financing structure of Medicaid to a block grant. Block granting Medicaid means that the federal government would send the state an annual fixed amount of money, which is not tied to health care inflation. Block grants pose two potential problems for our state: federal contributions would no longer be tied to actual costs, and the move would shift the risk of higher costs — due to the next inevitable economic downturn or public health crisis — solely onto New Hampshire.

If the state decides to make up for any loss of federal dollars by limiting Medicaid services and eligibility, uncompensated care costs and thus private market coverage costs will rise. In essence, people paying for private insurance will have to pay more to compensate for the charity care provided to the uninsured.

Block granting Medicaid does not address the underlying drivers of health care costs. It serves only to save the federal government money while shifting the financial risks entirely onto the states.

New Hampshire is better served by addressing the underlying drivers of health care cost growth. The state could do this by exploring alternative health care reimbursement models that reward outcomes rather than utilization, building infrastructure for widespread adoption and use of electronic medical records and requiring transparency in health care pricing. These make more sense than undermining Medicaid.

Medicaid is not New Hampshire's problem. Quite the opposite. Medicaid is a cost-effective means of providing insurance where private markets fail to do so.

Deborah Fournier is a policy analyst with the New Hampshire Fiscal Policy Institute.

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Hospitals create collaborative to crunch costs, improve care

Monday, July 30, 2012

Hospitals create collaborative to crunch costs, improve care

Doug Dean is the president and CEO at Elliot Hospital. (THOMAS ROY/SUNDAY NEWS)

Mike Green, right, president and CEO of Concord Hospital, speaks during a meeting of Granite Healthcare Network executives last week in Concord. Other hospital CEO members of the administrative services organization are, left to right, Greg Walker of Wentworth-Douglass Hospital, Tom Wilhelmsen of Southern New Hampshire Health System, Doug Dean of Elliot Hospital and Tom Clairmont of LRG Healthcare. (THOMAS ROY/SUNDAY NEWS)
CONCORD — Five hospital systems covering nearly half the state's population are embracing a data-driven approach to improving health care and reducing costs through their collaborative Granite Healthcare Network.

A key immediate focus is using predictive analytics to help the hospitals manage the health of the population they serve. Claims data from hospitals will be analyzed with a Verisk Health program to identify problem areas at GHN members Concord Hospital, Elliot Hospital, LRGHealthcare (Lakes Region General and Franklin Regional hospitals), Southern New Hampshire Health System (Southern New Hampshire Medical Center), and Wentworth-Douglass Hospital in Dover.

The business analytics software from Verisk also will help the hospitals prepare for a future in which payments by government and private insurers are expected to change to models based on performance and quality of care.

“Health care is changing and rather than being organizations that just treat the sick, the future is improving individuals' health status and then the population as a whole,” said Thomas Wilhelmsen Jr., president and CEO of Southern New Hampshire Health System in Nashua.

The move away from fee-for-service care would be harder for the hospitals to do on their own, but “collectively, as five organizations, covering a large geographic area ... we'll be able to achieve that goal better than any individual hospital could,” he said.

Spreading the cost of very expensive technology such as Verisk data analytics over a larger group will the help the hospitals reduce their future costs, Gregory Walker, president and CEO of Wentworth-Douglass Hospital, said.

Four of the hospitals are already benefiting from their December 2010 creation of Granite Shield Insurance Exchange LLC, through which they self-insure for professional and general liability for four of the GHN hospitals.

The partnership will reduce health-care costs by hundreds of thousands of dollars every year, the group said.

GHN has contracted with ARUP for reference lab services. By Sept. 1, all five hospitals will use ARUP saving more than $5 million over the next five years.


Despite their common participation in Granite Healthcare Network, each of the hospitals remains independent.

Savings are achieved through contracts negotiated by the organization, however the savings stay with each hospital. For example, for the laboratory work, Rowe said, the savings are spread over reduced pricing for each of the five hospitals.

GHN now has nine separate projects under way, including managed print services, data storage and linen service. By design, not every hospital will participate in every project. Hospitals participate based on their individual needs.

One current project, Medicare shared savings, is made up of just Elliot and Concord hospitals, which jointly cover about 20,000 elderly and disabled Medicare patients through their primary care networks.

“The goal is to demonstrate to the federal government that you can provide care at a lower cost at the aggregate level,” Green said.

“With 20,000 lives, we'll have the scale, with Verisk we'll have the data analytical capability, within our own EMRs and medical homes, we will have the infrastructure that we need to be able to manage the care for that population more efficiently with better outcomes,” he said.

Rowe said that by Elliot and Concord joining the Medicare project, all the hospitals will benefit from the their Medicare claims data being added to the data warehouse.

“The more data of different payers, the more we can learn from that,” she said. Hospitals have to enter into a risk-based or shared savings contract to get claims data from insurers, whether government or private.


The hospital CEOs met with counsel to learn the limits of their conversations to stay clear of antitrust concerns.

“When you get together, you can't just sit around and talk about everything you think you can,” Thomas Clairmont, president and CEO of LRGHealthcare, said.

Green said, “We never talk about pricing, we never talk about market domination or controlling any aspect of the market.”

GHN's focus is using the scale created by working together to reduce operating expenses, he said.

Targeting readmissions

As 10,000 Americans turn 65 every day and become eligible for Medicare, demand for health care is increasing. That trend will continue for nearly two decades, according to Pew Research Center.

“Demand for patient services over the next decade could potentially overwhelm the resources of hospitals in a lot of communities,” Elliot Hospital President and CEO Douglas Dean said. “We're the third oldest state in the country and the issue for us as hospital executives is to think very differently than we have over the last 20 or 30 years.”

Wentworth-Douglass President Walker said the predictive analytics will help reduce readmissions.

“You can see patients that could have a disease like CHF (congestive heart failure) that are constantly coming to the hospital and being readmitted, but they aren't going to their primary care physician based off that claim, and it says certain diseases aren't being managed in the primary care office, they're using the hospital or higher-cost resources in the system.” Walker said.

“So they're looking at utilization on a high-risk patient basis, it's individual patients, or by certain disease entities, you can start drilling down the most cost-effective ways of managing these populations. They're unique; they're individuals or certain socioeconomic groups,” he said.

Limits to growth

“We've all been trained to think about how to appeal to more patients and get more volume,” Dean said. “The future of managing delivery will not so much be how to market to patients but how to care for the volume that will be coming our way, at a cost level that communities can afford.

“The burden on the business community, and the federal government and the state government, is such that we all recognize we have to do more with less but do a better job at it, and that's a challenge truly confronting the hospitals today,” he said.

Emergency-room demand levels in Manchester have exceeded anything he could have reasonably expected, Dean said.

“It's the result of the demographic shift of our community, particularly just south of our city,” he said.

Shifting business model

Outpatient care has become an increasingly large part of the hospital systems revenue base.

“Ten years ago, we all thought of ourselves as hospitals; today, we're health-care enterprises,” Green said.

“It used to be, 10 years ago, you looked at what was your inpatient census and your inpatient volume and that was a predictor of how you're doing. Today, 65 or 75 percent of revenue is outpatient-based.

“So you're looking at very different characteristics that will contribute to your success,” he said.

“A lot of it has to do with taking better care of an aging and growing population while consuming no more resources, and we think there is great promise in being able to do that,” Green said.


On the Net:

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Hospitals, patients should have been included in Medicaid hearings, judge says

Monday, July 30, 2012

Hospitals, patients should have been included in Medicaid hearings, judge says

A federal judge ordered the state's top Medicaid administrator to provide hospitals, Medicaid patients and the public a chance to comment on cuts the Legislature and governor have made to Medicaid reimbursement rates since 2008 — if the reduced rates remain in use.

U.S. District Court Judge Steven J. McAuliffe gave New Hampshire Department of Health and Human Services Commissioner Nicholas A. Toumpas 15 days to act under the preliminary injunction and order issued March 2.

While the judge wrote “it is not possible to turn back the clock” on the rate reductions, requiring DHHS to have a public comment session and explain its reasons for rate cuts would enforce state compliance with federal Medicaid rate-setting guidelines and allow health care providers and the public the right to voice their concerns.

“The rights being denied are the rights to participate and potentially influence an administrative decision of great importance to the plaintiffs and the public,” McAuliffe wrote in his 30-page order.

Medicaid is the state-federal health care program for the poor.

“It's a really strong ruling ... (The judge) is taking a very direct action to fix what are significant flaws with the way the state runs the program,” attorney W. Scott O'Connell said Monday.

“This state has benefited from lots of federal dollars that have not been used to reimburse providers and that has to stop. Let's use Medicaid dollars for Medicaid services and stop balancing the budget with it,” O'Connell said.

O'Connell represents 10 of the state's largest hospitals which filed suit against Toumpas, who administers the state's Medicaid program, seeking to block changes in Medicaid reimbursement rates that reduced hospital funding by more than $250 million in the 2012-2013 state budget.

The suit claimed the state did not follow proper guidelines when reducing Medicaid reimbursement rates. It also claimed the state cannot set Medicaid reimbursement rates based on budgetary reasons alone to hospitals. It asked the court for a preliminary injunction to bar enforcement of the cuts contained in the state budget.

Senior Assistant Attorney General Jane E. Smith said her office is reviewing the order with the governor, the Legislature and DHHS.

“We're still in those discussions and considering it,” Smith said. No decision has been made, she said.

The preliminary injunction gave Toumpas 15 days to decide whether he intends to continue with the reduced Medicaid rates. If so, Toumpas must give the public 30 days to comment.

After the public comment period, Toumpas must decide whether to retain the current rates and publish the methods and justifications used for setting them, the judge ordered.

The state's practice of cutting Medicaid reimbursement rates since 2008 so it can balance the state budget has shifted the burden of providing medical care from the state to hospitals and threatens equal access to quality medical care, McAuliffe wrote.

“The problem, of course, is that such a scheme threatens to render irrelevant other important factors that federal law requires (Toumpas) to consider, such as (the) requirement that rates be set at a level sufficient to assure both quality of care and that Medicaid beneficiaries have equal access to medical care,” he added.

O'Connell said plaintiff hospitals have been forced to limit, or shut down completely, access by new Medicaid patients to their primary care providers, eliminate some programs altogether and laid off more than 1,000 staff since July.

Smith noted the judge wrote it is “not inconceivable that the reduced rates still might have passed muster” had they been properly considered under federal guidelines.

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Hospitals buoyed by ruling in Medicaid reimbursement suit

Monday, July 30, 2012

Hospitals buoyed by ruling in Medicaid reimbursement suit

Tuesday, March 6, 2012

DOVER — A federal judge has handed a partial victory to Dartmouth-Hitchcock Medical Center and nine other New Hampshire hospitals in their lawsuit against the state health commissioner over reductions in Medicaid reimbursements, finding a "strong case" that the state's cuts failed federal mandates to provide minimal medical care for its neediest citizens.

In a pair of sharply worded rulings on Friday, U.S. District Judge Steven J. McAuliffe ordered the state to properly notify the public and hold hearings about reimbursement rates that were dramatically lowered in 2008. The notice must be given within 15 days from Friday's ruling, to be followed by a 30-day comment period.

"The state violated federal law," said Scott O'Connell, vice chair of litigation department for Nixon Peabody LLC, the firm representing the 10 hospitals. "It's got to run a transparent process and follow federal law. They didn't do any of that, and instead tried to do it in a stealth way."

In his notification, Nicholas Toumpas, commissioner of the state Department of Health and Human Services, must articulate the rates the state will pay to hospitals, the precise methodologies used to set those rates and justifications for those rates, McAuliffe wrote in a preliminary injunction. Within 15 days of the end of the comment period, Toumpas must decide whether to employ the rates and must restate the methods and justifications.

But McAuliffe did not block the state from enforcing the reimbursement rates, saying that to do so would risk undercutting the commissioner's authority to set rates and the federal Health and Human Services secretary's authority to review and approve them.

Messages left for Toumpas on his home and mobile phones were not returned. A spokeswoman for DHHS did not return a message Friday night.

Calls to Nancy Smith of the N.H. Attorney General's Office were not returned Monday.

"We thought that it was a very positive ruling for our patients," said Frank McDougall, vice president of government affairs at Dartmouth-Hitchcock Medical Center. "I think the language in the decision is very strong language" saying that the state erred in how it set Medicaid reimbursement rates and informed the public about those rates.

The state cut reimbursement rates in 2008 to keep the state's Medicaid obligation in line with the state budget. The 10 hospitals filed suit last summer, asserting they would provide $131 million in uncompensated care and pay another $135 million in a state Medicaid enhancement tax used to leverage more federal funding. Several of the state's largest hospitals, including DHMC, said those measures were to blame for increasing costs and forcing layoffs of workers last year.

Hospitals which participated in the suit include Dartmouth-Hitchcock Medical Center, Elliot Hospital in Manchester, Catholic Medical Center in Manchester, Lakes Region General Hospital in Laconia, Southern New Hampshire Medical Center in Nashua, St. Joseph Hospital in Nashua, Cheshire Medical Center in Keene, Wentworth-Douglass Hospital in Dover, Frisbie Memorial Hospital in Rochester and Exeter Hospital.

In addition to ordering the state to follow the federal notification and comment protocols, McAuliffe put the state on notice that its methods for setting its rates were flawed and are unlikely to pass muster with federal regulators who manage Medicaid the federal-state program that provides health care for the poorest citizens.

"Substantively, the providers and beneficiaries make a strong case that the reduced Medicaid reimbursement rates implemented by the Commissioner are far below the actual cost of providing care, inconsistent with the state's legal obligation to set Medicaid rates at a level that at least minimally supports their ability to deliver medical care to the most needy, and the product of a rate-setting process completely untethered from the methods and standards the State is obligated to apply in setting rates," McAuliffe wrote in his 31-page order.

In their lawsuit, the hospitals contended the state's Medicaid reimbursements didn't satisfy federal requirements to provide sufficiently for patient care, an issue McAuliffe addressed, but did not act upon.

"As is likely self-evident, arbitrary reductions in Medicaid reimbursement rates, implemented solely to accommodate state budgetary preferences, necessarily collapse multiple rate-setting factors into just one state prerogative," McAuliffe wrote. "It is equally self-evident that if rate-setting based strictly on state prerogative were permissible under (federal law), then the purpose and objectives of the federal-state program could be completely undermined by participating states, in direct contravention of Congressional intent."

McAuliffe noted that "courts have rejected Medicaid rates set solely on the basis of state budget considerations."

In their lawsuit, the hospitals argued that federal requirements trumped state law under the Constitution's Supremacy Clause. The U.S. Supreme Court declined to address this issue in a decision last month about a similar Medicaid case in California, and McAuliffe took note, writing that "a critical legal question remains unanswered."

But the hospitals have another remedy available to them, one they are already pursuing. There has thus far been no review of the state's Medicaid rates by the federal Health and Human Services secretary.

"We would welcome that, very much so," McDougall said.

He and James Weinstein, DHMC's chief executive, were in Washington to meet with federal officials earlier this year.

"There haven't been any state plan amendments filed" for federal review, McDougall said.

In a further attempt to resolve the Supremacy Clause questions and to determine whether the federal administrative process is working, McAuliffe ordered lawyers on both sides to submit new arguments on those points within the next 45 days.

Foster's Daily Democrat Reporter Laurenne Ramsdell contributed to this report.

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Hospitals Sue New Hampshire for Medicaid Millions

Monday, July 30, 2012

Hospitals sue New Hampshire for Medicaid millions

MANCHESTER -- Ten New Hampshire hospitals brought suit in federal court Monday seeking to block the state from enacting a current two-year budget they say unlawfully cuts Medicaid reimbursements while forcing them to pay more than $250 million in new taxes.

The lawsuit filed in U.S. District Court in Concord claims the state budget illegally eliminates the so-called disproportionate share funding system of Medicaid reimbursement, essentially forcing hospitals to pay the state more than they receive for caring for the state's neediest citizens.

This not only threatens Medicaid recipients' access to care, but also could force hospitals to lay off staff, cut programs and services and possibly lead to closures as hospitals scramble to make up for millions they will lose, hospital officials say.

“There will be hundreds of people who will lose their jobs, not just in Manchester but many hundreds in the state,” Catholic Medical Center President and Chief Executive Officer Alyson Pitman Giles said.

The suit filed against New Hampshire Commissioner of Health and Human Services Nicholas A. Toumpas seeks a preliminary injunction to stop the state from imposing the rate cuts, then a full hearing to determine if the cuts are legal, said Manchester attorney W. Scott O'Connell, who represents the plaintiffs.

Toumpas' agency referred media inquires to the state Attorney General's Office.

“We are reviewing it and we have 60 days to respond and we will respond within that time frame,” Deputy Attorney General Ann M. Rice said.

Hospital officials say the state's decision was budget-driven and unilaterally imposed in violation of the federal Medicaid Act, which requires Medicaid rate cuts to be approved by the Center for Medicaid Services, a division of the U.S. Department of Health and Human Services.

The state's actions also violated federal law because they were enacted without giving hospitals notice or opportunity to comment on the impact they would have, O'Connell said.

The state Medicaid program is a state-federal partnership designed to ensure the poor, elderly and disabled have access to adequate medical care.

Colin Manning, spokesman for Gov. John Lynch, said the lawsuit does not come as a surprise to the corner office.

“The budget proposed by the governor was very different from the one passed by the Legislature,” Manning said. “The governor took a balanced approach that did not propose such a drastic cut to hospitals. That is one of the reasons that the governor did not support the Legislature's budget and now we have another major issue that will have to be addressed by the courts and an action the Legislature may have to reconsider.”

House Speaker William O'Brien said the state budget is preferable to the alternative of tax increases for New Hampshire.

“We had to make some very difficult choices,” O'Brien said. “We're confident that we made a correct choice and the court will uphold it.”

Under the current budget, CMC must find a way to make up for the $12 million the state will tax it this year alone, Pitman Giles said. Previously, the state simultaneously reimbursed hospitals with a disproportionate share payment equivalent to the tax, but those payments were eliminated in the budget, she said.

“This is a new tax,” she said.

Elliot Health System must take immediate steps to make up for the approximate $17 million it will lose in Medicaid reimbursements this year, its President and Chief Executive Officer Doug Dean said.

“We don't have the luxury of waiting until August, September or October to see if we are going to be incurring these types of operational losses,” Dean said.

“As soon as possible, we will be taking steps to reduce the costs of operating Elliot Hospital,” Dean added. He would not elaborate.

“This devalues all of the good work that these hospitals have done over the decades to take care of the state's poor,” Dean said.

Dartmouth-Hitchcock faces a $40 million tax on top of the $60 million it loses in under-compensated care provided to state Medicaid patients, a hospital spokesman said.

Dartmouth-Hitchcock Board of Trustees Chairman Wayne Granquist said the state budget threatens the hospital and the people who rely on it for their health care.

“This lawsuit comes after we have exhausted all other avenues to express to the state legislature the impact of these draconian budget cuts,” he said in a statement.

New Hampshire, which has one of the lowest Medicaid reimbursement rates in the nation, reimbursed Dartmouth-Hitchcock $28 million of the $88 million in care it provided patients in fiscal year 2010, a hospital spokesman said.

Other hospitals who joined the suit are Wentworth-Douglass Hospital in Dover, Exeter Hospital in Exeter, Southern New Hampshire Health System and St. Joseph Hospital in Nashua, Cheshire Medical Center in Keene, Frisbie Memorial Hospital in Rochester and Lakes Region General Hospital in Laconia.

New Hampshire Union Leader staff reporter Dan Tuohy contributed to this report.

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Draconian treatment for mental patients

Monday, July 30, 2012


Draconian treatment for mental patients

Mike Bradley, Hillsboro

As a direct result of ill-advised budget cuts foisted on the state by the Republican Legislature and a dogmatic, antiquated refusal to look at alternative revenue sources, a situation exists in our hospitals which can only be described as draconian.

Available placements at our state mental hospital, for both adults and kids, have been dramatically reduced. Patients in need of hospitalization are spending - no exaggeration - days in the local emergency room, waiting for availability. Let me get a little graphic. Imagine you, or someone you care about, has a serious mental illness, is suicidal or psychotic. You are placed in an ER cubicle or exam room, sitting on one of those small cots. There is no shower. You are not allowed to walk around the department because of confidentiality considerations. A mental health worker checks in with you every 12 hours, but otherwise you receive no treatment. A bagged lunch is brought in at mealtimes. That's it - you wait in what amounts to solitary confinement for 24, 48 or 72 hours. Longer stays of up to eight days have occurred.

This is inhumane treatment of our most vulnerable neighbors, and also is illegal, since law requires immediate placement of patients being involuntarily admitted (because of danger to self or others). Is this the New Hampshire Advantage? Is this what you voted for?



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Laconia Citizen Editorial: Holding Toumpas’ feet to the fire

Monday, July 30, 2012

Laconia Citizen Editorial: Holding Toumpas’ feet to the fire


June 6, 2012

The state is being called to task on its abandonment of its obligations to the poor and elderly. The Centers for Medicare and Medicaid Services (CMS), the federal agency that administers Medicare, Medicaid, and the State Children's Health Insurance Program, has given Nick Toumpas and the NH Department of Health and Human Services 30 days to provide the information it has been seeking for four months to prove that the budget cuts New Hampshire has been making are not violating the requirements of the law.

CMS wants to be sure that New Hampshire is continuing to operate within its approved plan for providing access to health care as well as meeting the requirements of section 1902(a)(30)(A) of the Social Security Act. The testimony it has been receiving indicates the state has not.

The letter to Toumpas that CMS made public on Monday specifically cites LRGHealthcare's decision to notify 3,000 Medicaid beneficiaries that they needed to find an alternative source of primary care, as the professional group associated with Lakes Region General Hospital would no longer be participating as a Medicaid provider due to the reduced reimbursements from the state. Likewise, CMS cited the testimony provided in the Federal District Court of New Hampshire in the case of Dartmouth-Hitchcock v. Toumpas which raised issues about current and future access to physician services, inpatient and outpatient psychological services, and hospital-related home health services. CMS further cited the sub-acute care facilities' reductions in the number of beds available to ventilator-dependent beneficiaries under the home health benefit.

The documentation CMS is seeking would identify access problems and have the state develop a plan for corrective action to make sure access standards are being met.

We have some sympathy for Toumpas who is trying his best to work within the budget that the NH Legislature has provided while meeting the federal requirements associated with Medicaid and Medicare funds. Perhaps the threat of federal action will cause the penny-wise and pound-foolish legislators to rethink their approach to spending if not force them to acknowledge that they are New Hampshire's "death squad" — abandoning the state's most at-risk individuals with their actions.

After years of diverting federal funds intended to help the sick and elderly, it is time for New Hampshire's leadership to face up to its obligations and do the right thing.

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Health Care in Need of Immediate Medical Attention

Monday, July 30, 2012

Sunday, June 10, 2012

Health care in need of immediate medical attention

It’s time for everyone involved in perpetuating a broken and confusing health care economy to work together to fix it.

For decades, hospitals, insurance companies, regulators and the government have participated in payment schemes that delivered tremendous increases in both the cost of care and the price of health insurance.

Instead of building an affordable and equitable system, we have created a burdensome financing model on the backs of employers and individuals who purchase their own health insurance. If we do nothing, the system will collapse.

As a hospital administrator, I acknowledge our role in the problem of escalating cost and state our willingness to be part of the solution. Before we start talking about solutions, we need a common understanding of the problem.

We hear a lot about the need for more competition in health care; more competitors will drive down price. In a free market, that is a sound economic principle. In a free market, prices are set competitively, and customers cover their tab.

Health care does not work that way. While the price (or charge) for a health care service is the same to each individual, the amount paid differs and rates set by governmental payers are below costs. This makes it different than a free-market business.

Imagine that the rules changed for auto dealers. Suddenly, car sellers are required to be open 24/7, and every customer who walks through the door must leave with a car regardless of his or her ability to pay. The first few sales might look something like this:

A customer enters the showroom and gives the dealer a Medicaid insurance card, and the dealer provides the car for about half the actual cost.

The second customer walks in with a Medicare insurance card. Again, the dealer turns over the keys and is paid about three-quarters of what it cost for the dealership to purchase the vehicle.

The third customer arrives and presents a private insurance card. How much does the dealer need to receive for that car in order to cover the costs of doing business around the clock and providing cars to the first two customers?

The amount is shocking. If each car cost the dealer $20,000, the third car has to be purchased for $35,000 to just cover the losses of the first two cars, and that amount will increase to cover other costs of running the business.

Obviously, we would not accept these rules, which would destroy the auto industry and make car buying prohibitive for “commercially insured” customers. Yet, this is precisely what we have allowed to occur in health care.

All hospitals required to accept Medicare, Medicaid and patients without insurance shift costs to the insured patients. This practice drives up the cost of health insurance premiums.

Between now and November, politicians will be asking for our votes. If they truly want to earn our vote, the candidates must understand this complicated health care issue and be willing to work toward a real solution to the problems created by the way we pay for health care today.

Beware the magic cure. If anyone claims to have a trouble-free fix, then that person should be dismissed.

We need legislators who are willing to tackle the problem earnestly and be full partners in the solution. They must have their eyes on sustainable, long-term answers to address the enormous challenge we face.

The car dealership scenario is why common tests and procedures are less expensive to receive from a provider that refuses to treat Medicaid, Medicare and uninsured patients. Community hospitals do not have that option. Nor do we seek it.

But as long as Medicaid and Medicare do not cover the cost of services provided to patients enrolled in those programs, health care will be financed through the hidden taxes on our employers and paying individuals in the form of increased health insurance costs.

There are things everyone involved can do to improve our chances of finding a solution.

Hospitals must be relentless about reducing cost and eliminating waste.

Legislators need to understand that lowering payments to doctors does not lower the cost of the service – it just shifts the cost to others.

Patients need to accept responsibility for the impact their choices have on the cost of health care.

And insurers need to design products that place fewer burdens on employers and provide meaningful incentives to improve health.

With a shared understanding of the problem we face, the conversation can change from finger-pointing to meaningful ideas about how to fix a broken system and achieve sustainability.

The people we serve – patients, clinicians, voters, employers, employees, etc. – are depending on it.

Scott Westover is the senior vice president for strategic management at Southern New Hampshire Medical Center in Nashua.

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Medicaid Calls State to Task

Monday, July 30, 2012

Medicaid calls state to task

Lawmakers' cuts to payments at issue

Federal Medicaid officials are threatening action against the state if it cannot show within 30 days that Medicaid patients still have access to health care given that lawmakers drastically reduced Medicaid payments to the state's hospitals last year.

The $230 million cut in state and federal money forced several hospitals to lay off staff and some to say they could no longer afford to treat Medicaid patients. Ten of the state's 13 largest hospitals are suing the state in federal court over the cuts.

The judge overseeing that case concluded in a ruling issued in March that the state was "highly likely" to have violated federal Medicaid rules in the way it cut reimbursement rates to hospitals. The case is still pending.

The May 23 letter from the Centers for Medicare and Medicaid Services to Health and Human Services Commissioner Nick Toumpas echoes concerns raised in the lawsuit. It follows months of seemingly unsuccessful negotiations between the two.

"While this is a short time frame, (the center) and the state have been talking about these issues for four months, and we requested the data when we met in March," wrote Cindy Mann, director and deputy administrator of the Centers for Medicare and Medicaid Services.

Mann's letter did not specify what penalties the state could face, and a center spokesman declined to say whether federal officials were considering withholding the $600 million in federal Medicaid money New Hampshire receives each year.

In response to media calls yesterday, Toumpas made public his response to Mann. Contrary to claims from hospital officials, Toumpas said, his office has no proof that Medicaid patients cannot find doctors and hospitals to treat them.

Toumpas accused Mann of misrepresenting the level of cooperation his office has given to federal officials since they began meeting in January. He said the state has provided much of the information federal officials have requested. In fact, Toumpas added, federal officials have been unwilling to review some of it.

He used the Lakes Region General Hospital as an example.

This fall, that hospital notified 3,500 patients that the Medicaid reimbursement cuts meant it could no longer afford to treat Medicaid patients at some of its primary care practices. In his letter, Toumpas said only 1,000 of those patients were on Medicaid, and of those 1,000 patients, 600 had received care elsewhere.

Toumpas said that left 400 Medicaid patients "potentially" in need of a new primary care provider. Their needs could be met, Toumpas said, by four other primary and family care clinics "in close proximity" to the hospital.

He told Mann he had provided her similar information about other hospitals that had alleged their Medicaid patients would go without care.

"This information," Toumpas wrote, "clearly demonstrates that there has not been, currently is not, nor will be any evidence of a barrier to access to Medicaid recipients in New Hampshire."

At issue is a tax that has long been imposed on the hospitals to raise money in order to secure matching federal funds.

That tax generates about $115 million from the state's hospitals each year. The state turns that into $230 million by using the federal Medicaid dollar-for-dollar match. In year's past, the state returned some of the matching money to the hospitals to compensate them for unpaid Medicaid treatment.

Last year, the Republican-controlled Legislature eliminated the payment to hospitals and instead used the money to balance the state budget. Dartmouth-Hitchcock Medical Center, one of the 10 hospitals suing the state, is losing about $100 million a year, said Frank McDougall, vice president of government affairs at Dartmouth-Hitchcock. Concord Hospital, which did not join the federal lawsuit, is losing between $13 million and $18 million.

"I think this (letter from the center) is very significant," McDougall said. "When you hear from a federal judge that the (Medicaid) program is below standard and broken and then you hear it from a . . . federal agency, I think they validate each other. And they validate what we have been saying."

Henry Lipman, a vice president with Lakes Region General Hospital, agreed. "I think they've said to the state, 'You haven't been able to satisfy us either. If you can't, you run the risk of compliance action.' "

Michael Green, president and chief executive officer of Concord Hospital, was reluctant yesterday to interpret the seriousness of the letter from federal officials.

"I see this as somewhat of a delicate dance between the state Department of Health and Human Services and Medicaid (officials)," he said. Green questioned the likelihood that federal officials would withhold Medicaid money if their goal is to, instead, ensure Medicaid patients have access to care.

"I hope and I do anticipate that the state and federal government will resolve this before the federal government seriously considers withholding payment," Green said. "I don't see how that is constructive."

(Annmarie Timmins can be reached at 369-3323 or or on Twitter @annmarietimmins.)

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