Newsletter 92 September 2007
Contents
Facing the
Urgent Need to Reform Medicare Physician Payments
Malpractice Filings Against Health Care Providers, Jan 2001 – June 2007
2007-08 CLARK COUNTY
MEDICAL SOCIETY Committees
Southern Nevada
Health Officer Report
The Nevada Physician’s Guide to Congressional
Issues No. 22
Exclusive Offer! Group Health Insurance for CCMS Members
By Maureen Henkes, CIRS
St Mary’s health Plans
Saint Mary's Health Plans is proud to be selected as the
endorsed group health plan for the Clark County Medical Society. This benefit is exclusively for Clark County
Medical Society Members, the member’s families, the CCMS member’s employees,
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County Medical Society Members and their families from 15% to as much as 60% on
their health insurance premiums.
This program is preparing for a special year open
enrollment for members and member applicants that will begin November 1, 2007
and will close December 31, 2007 for an effective date of February 1,
2008. If you have not yet received a
quote, contact Clark and Associates for a rate comparison before the
deadline. The renewal will take place
June 1, 2008 and will renew every June thereafter.
Saint Mary's Health Plans, a member of Catholic
HealthCare West, is a fully insured PPO health plan. Competitively priced plans are offered with a
wide variety of deductible levels, co-insurance levels and physician office copays. Our Health
Choice PPO product provides access to Preferred Health Care Network (PHCN), a
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Our treatment emphasis is on preventive health, proactive and
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Saint
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H.S.A.'s are employee owned and
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For more information please contact the Clark County
Medical Society at 702-739-9989 or visit the CCMS website at
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You may also contact Saint Mary's Health Plans at
888-840-9080 or visit us at our website at: SaintMarysHealthPlans.com to find
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By joining this plan, CCMS saved more than $10,000 a year
on the staff’s health insurance benefit.
There is no better time to apply for CCMS membership than right now to
reap the savings of this group health insurance plan.
President’s Message - September
By Weldon (Don)
Congress’
unwillingness to address the flawed SGR formula (Sustained Growth Rate formula,
aka SGF) causes annual anxiety among the physician community where threats of
increasingly drastic Medicare reimbursement reductions hang on the whim of the
flawed formula. Each year for the last
several years, Congress has provided a band-aid allocation of funds to keep
reimbursements level. Finally, a
proposed SGR formula “fix” Bill has been introduced in the U.S. House of
Representatives. Congresswoman Shelley
Berkley is a cosponsor of this legislation which passed the House a couple
weeks ago. This SGF fix involves taking
funds from the Medicare Advantage/managed care programs and increasing the tax
on tobacco. You will find an article by
Congresswoman Shelley Berkley in this issue of the
When the
Bill was introduced in the
Proposed Sierra/United
Healthcare Merger
Many
physicians are concerned that the proposed Sierra/United Health merger will
create a practical monopoly in which the mega combined company will dictate the
terms and conditions of reimbursement contracts. Many physicians feel threatened their
economic survival will be difficult or impossible without acceding to the
contractual mandates of the mega-insurer.
Organized medicine is not alone in the concern for the deleterious
effect this merger may have on health care provided to
The
proposed Sierra/United Healthcare merger continues to vex many health care
providers. Please peruse these two
articles which address the most pressing public policy health issues of concern
to current southern
Facing the Urgent Need to Reform Medicare Physician Payments
By Representative
Shelley Berkley
Once again Congress is facing the issue of how to address
mandatory payment cuts that will soon hit doctors caring for Medicare patients
in
These cuts are the product of a flawed formula for
physician payments known as the SGR (Sustainable Growth Rate). This formula establishes a cumulative target
for Medicare spending growth over time. If spending exceeds the set target,
future payment levels are reduced.
Beginning in 2002, this flawed formula began requiring mandatory cuts in
reimbursement rates. Fearing the impact
that such a move would have on Medicare beneficiaries and doctors, Congress
blocked scheduled decreases in reimbursement rates in 2003, 2004, 2005, 2006,
and again this year.
That is one of the many reasons why I continue working in
Congress to address the need for real SGR reform, so that we do not continue to
see this issue reappear year after year.
I remain firm in my belief that physicians should not have to fear that
cuts in reimbursement rates will limit their ability to see and treat Medicare
beneficiaries who depend on them for care.
Congress has acted in the past to block payment cuts from
going into effect, but has yet to tackle the real issue of making long-term
changes to reimbursement rates, including long overdue increases to cover
higher costs. My goal has always been to
guarantee that doctors receive fair compensation for the services they provide
and to see that Medicare patients have peace of mind knowing they will not have
to find a new physician or be faced with a lack of access to care.
Earlier this year, I sought out--and was appointed to--a
seat on the powerful
As a member of the Committee on Ways and Means, I helped to
coauthor H.R. 3162, The Children's Health and Medicare Protection Act of 2007
(CHAMP). The House recently approved
this much needed legislation, which includes provisions to reform the SGR, on a
vote of 225 to 204. However, because the
House legislation containing the physician reimbursement rate adjustment has
yet to pass the U.S. Senate, the issue remains before Congress.
Rather than relying on a temporary one-year fix, as has
been done in the past, The CHAMP Act eliminates pending cuts in 2008 and 2009
and enacts an increase of .5 percent in both years. Utilizing this multi-year approach provides
for greater stability in reimbursements and ensures that
The House passed package also makes important and immediate
changes to improve the SGR formula by establishing six separate service
categories that will enable Medicare to more precisely track and adjust for
spending on physician services. In
addition, The CHAMP Act removes drugs from the target growth calculation,
enabling the SGR to better reflect actual growth in physician spending.
The bill also lays the groundwork for a long-term solution
to the physician payment system in several important ways. First, it establishes a new bonus for
efficient physicians and directs the Centers for Medicare & Medicaid
Services (CMS) to implement a mechanism to provide physicians with information
about how their practice patterns compare to their peers. Second, it gives the Secretary of Health and
Human Services additional tools to review and modify misvalued
services. Third, it provides for
additional analysis of the physician fee schedule to uncover further
refinements that need to be made.
Finally, The CHAMP Act invests in primary care and prevention by
providing additional resources for these services and testing strategies for
better coordination in Medicare.
There is no question about the need to block scheduled
Medicare physician payment cuts, which will go into effect at the beginning of
next year.
Unfortunately, differences continue to exist over the best
path to achieving reform. Resolving
complexities surrounding the issue, including how to pay for a long term fix,
is a key step toward passage of a final package. Over the coming months, I will continue
working with my Ways and Means colleagues to reach out in hopes of enacting a
package that benefits physicians and families and addresses the issues with the
SGR that have led to the very problems we are dealing with today in Congress.
Clark County District Court Medical Malpractice Filings
2001 2002 2003 2004 2005 2006 2007
Jan 39 33 108 61 41 50 109
Feb 20 14 98 72 63 61
41
Mar 35 30 169 123 64 38
70
Apr 37 34 111 81 70 58
60
May 37 35 126 65 14 71
84
Jun 27 24 103 90 65 83
56
Jul 19 100 114 45 66 74
84
Aug 54 51 76 67 33 82
Sep 20 65 105 79 36 51
Oct 37 83 110 59 26 74
Nov 38 184 59 78 73 50
Dec 9 170 67 47 30 28
Sum 372 823 1246 867 581 720 420
Member News
Applicants to Go Before Credentialing Committee
John S
Anderson, MD - Radiology
Constantine
George, MD - Internal Medicine
John R Gosche, MD - Internal
Medicine
Yvonne L
Saunders, MD - Family Practice
Matthew W
Schwartz, MD - Radiation Oncology
Scott G
Shipley, MD - Otolaryngology
If you have any pertinent information about these
membership candidates, please contact:
For
information on becoming a member of the
2007-08 CLARK COUNTY
Bylaws,
Policies and Procedures Committee
(the Chairman serves as the parliamentarian of the BOT unless
otherwise designated by the President)
Staff person - Nancy Sommer
1.
2.
3.
4.
Building
Committee
Staff
person - Nancy Sommer
1.
Jerry Jones, MD - Chair
2.
3.
Jay Coates, MD
4.
5.
6.
7.
8.
Community
Health/Relations Committees
(the BOT Secretary is
the Chairman and the immediate Past President is a member)
Staff
person - Janice Poblete
1.
Annette Teijeiro, MD - Chair
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Credentials
Committee
Staff person - Janice Poblete
1.
Carol Vanderharten, MD - Chair
2.
3.
4.
5.
Mitchell Forman, DO
6.
Parker Kurlinski, M
7.
8.
9.
NSMA
Government Affairs Committee
Staff person - Dot Freel
1.
2.
3.
4.
John R. Thompson, MD
Membership
Committee
Staff
person - Janice Poblete
1.
Joseph Adashek, MD - Chair
2.
Noel
3.
4.
Archie Perrie, Jr., MD
5.
NSMA
Delegate Committee
Staff
person - Nancy Sommer
1. Mitchell Forman, MD - Chair
2.
3.
4.
5.
6.
7.
8.
9. Jerry Marty, MD
Nominating
Committee
Staff
person - Janice Poblete
1.
2.
3.
4.
5.
6.
7.
Alliance
By Wendy Agrawal & Estela Hansen, 2006-07 CCMS
Tuesday, September
18, 2007
Vitner Grill Restaurant in Summerlin
http://www.vglasvegas.com
Starters (Choice of one)
Treviso Caesar Salad wrapped in Prosciutto, Egg and Reggiano
Fresh Mozzarella with heirloom Tomatoes, aged Balsamic and micro Arugula
Entrees (choice of one)
Grilled Pesto Shrimp BLT with Nueske Bacon, Mache and Lemon Basil Aioli
Parpadelle Pasta with Basil Pesto, Pine Nuts and Mascarpone Cheese
Free-range half Chicken with Asiago-potato gratin and saffron pan reduction
Desserts (choice of one)
White Chocolate Cheesecake with Apricot Compote and Whipped Cream
Seasonal Fresh Fruit with Whipped Cream
Priced at $40 per person
Coffee and Hot or Iced Tea and soft drink are included
***********************************************************************************************************************************************************
When: Thursday, September 6th, 2007
Time: 9:30 AM
Place: Home of Shanila Choudhury
At 5761 O'Bannon Drive,
Who: New members and existing members
Please come join us for a New Member Welcome Brunch and Social
Please R.S.V.P. to Shanila at: 702-355-2019
CME CALENDAR
AHEC 318-8452
x 258
Online - "Domestic Violence and Medical Ethics."
Bechtel
NV Chapter AACE 434-8400
Pri-Med Institute (877)
4PRI-MED
Sierra Health
Services 242-7735
Sept 13 - “Medical Issues in Gay, Lesbian and Transgender Patients”
Oct 11 - “How to Document and
Southwest Medical
Associates 242-7735
Sept 5 - “Anesthesia Grand Rounds: Case Discussion” 1.5 CME Credits
Sept 7 - “Neurovascular Case Conference” 1.5 CME Credits
Sept 14 - “Targeting Atherothrombosis: A Common Denominator in ACS, PAD, and Stroke” 1.5 CME Credits
UMC 383-2604
Sept 7 - “Pediatric Management of Common Ear Diseases”
Sept 12 - “Current Management of Community-Aquired Pneumonia in Adults”
Sept 14 - “Use of Anti-Fungal Agents in the Setting of Bone Marrow Transplantation”
Sept 21 - “Open Abdomens”
Education Opportunities for Practice Managers 697-5471 ext 134
Call the NV Medical Group Management Association
Only CME Activities held at the Clark County Medical Society office are specifically endorsed by CCMS.
Testimony to the Insurance Commissioner from Assembly Speaker
Barbara Buckley regarding the Sierra/United HealthGroup merger
Dear Commissioner Molasky-Arman:
Re: Division of Insurance Hearing on the Acquisition of Health Plan of Nevada, Inc. by UnitedHealth Group, Incorporated
State of
Health
care is a basic necessity for every person.
It is no exaggeration to state that health care is often a matter of
life or death. Unfortunately,
- Not surprisingly, based on the foregoing data,
In such a challenged system, any alteration for the worse can have severe adverse impacts. For that reason, the proposed merger between Sierra Health Services (Sierra) and UnitedHealth Group (United) demands the closest scrutiny and exact compliance with applicable laws designed to protect the public health and welfare.
Legislative Directives on Insurance
As far back as 1971, the Legislature declared that the purposes of the Nevada Insurance Code are to:
NRS 679A.140 Purposes;
construction.
1. The purposes of this Code are to:
(a) Protect policyholders and all having an interest under insurance policies;
(b) Implement the public interest in the business of insurance;
(c) Provide adequate standards of solidity of insurers, and of integrity and
competence in conduct of their affairs in the home offices and in the field;
(d) Improve and thereby preserve state regulation of insurance;
(e) Insure that policyholders, claimants and insurers are treated fairly and
equitably;
(f) Encourage full cooperation of the office of Commissioner with other
regulatory bodies, both of this and other states and of the Federal Government;
(g) Insure that the State has an adequate and healthy insurance market
characterized by competitive conditions and the exercise of initiative;
(h) Prevent misleading, unfair and monopolistic practices in insurance
operations; and
(i) Continue to provide the State of Nevada with a
comprehensive, modern and adequate body of law, in response to the McCarran Act
(Public Law 15, 79th Congress, 15 U.S.C. §§ 1011 to 1015, inclusive), for the
effective regulation and supervision of insurance business transacted within,
or affecting interests of the people of this state.
2. The provisions of this Code shall be given reasonable and liberal
construction for the fulfillment of these purposes.
We and our legislative colleagues are determined that these public policy principles will be strictly observed in the review of the proposed merger. Our purpose today is to highlight areas of concern regarding the merger and emphasize to the Commissioner particular issues that demand rigorous analysis.
Nevada Revised Statutes (NRS) 692C.256 provides that the Commissioner may issue an order relating to an acquisition if the effect of the acquisition may substantially lessen competition in any line of insurance in this State or [even] tend to create a monopoly. In determining whether to issue such an order, the Commissioner shall consider the standards set forth in the Horizontal Merger Guidelines issued by the U.S. Department of Justice and the Federal Trade Commission.
Overview of Merger Guidelines
We
want to call attention to several important aspects of those Guidelines. Under 15 U.S.C. § 18 (1988), mergers are
prohibited if their effect “may be substantially to lessen competition, or to
tend to create a monopoly.” This is
essentially the same standard
The Guidelines note that:
·
Mergers are
motivated by the prospect of financial gains.
The possible sources of the financial gains from mergers are many, and
the Guidelines do not attempt to
identify all possible sources of gain in every merger. Instead, the Guidelines focus on the one potential source of gain that is of
concern under the antitrust laws: market
power.
·
The
unifying theme of the Guidelines is
that mergers should not be permitted to create or enhance market power or to
facilitate its exercise. Market power to
a seller is the ability profitably to maintain prices above competitive levels
for a significant period of time.
- The result of the exercise of market power is a transfer of wealth from buyers to sellers or a misallocation of resources.
- Market power also encompasses the ability of a single buyer (a “monopsonist”), to depress the price paid for a product to a level that is below the competitive price and thereby depress output. The exercise of monopsony power has adverse effects comparable to those associated with the exercise of market power by sellers. In order to assess potential monopsony concerns, the regulator will apply an analytical framework analogous to the framework of the Guidelines.
- Sellers with market power also may lessen competition
on dimensions other than price, such as product quality, service, or
innovation. Again, this is an area
of particular concern to many
- The Guidelines reflect the congressional intent that merger enforcement should interdict competitive problems in their incipiency.
The
potential for monopsony as a result of this merger is
a grave concern for many of
The overview instructions to the Guidelines provide:
·
The Guidelines describe the analytical
process that the regulator will employ in determining whether to challenge a
horizontal merger. First, the regulator
assesses whether the merger would significantly increase concentration and
result in a concentrated market, properly defined and measured.
·
Second, the
regulator assesses whether the merger, in light of market concentration and
other factors that characterize the market, raises concern about potential
adverse competitive effects.
·
Third, the
regulator assesses whether entry would be timely, likely, and sufficient either
to deter or to counteract the competitive effects of concern.
·
Fourth, the
regulator assesses any efficiency gains that reasonably cannot be achieved by
the parties through other means.
·
Finally,
the regulator assesses whether, but for the merger, either party to the
transaction would be likely to fail, causing its assets to exit the
market. The process of assessing market
concentration, potential adverse competitive effects, entry, efficiency, and
failure is a tool that allows the regulator to answer the ultimate inquiry in
merger analysis: whether the merger is
likely to create or enhance market power or to facilitate its exercise.
Defining Appropriate Markets for Purposes of Competitive Analysis
One of the key analytical concepts is the identification of the appropriate market. The regulator evaluates the likely competitive impact of a merger within the context of economically meaningful markets, i.e., markets that could be subject to the exercise of market power. In this respect, the Guidelines provide:
·
A market is
defined as a product or group of products and a geographic area in which it is
produced or sold such that a hypothetical profit-maximizing firm likely would
impose at least a “small but significant and nontransitory”
increase in price. A relevant market is
a group of products and a geographic area that is no bigger than necessary to
satisfy this test.
·
Once
defined, a relevant market must be measured in terms of its participants and
concentration. Participants include
firms currently producing or selling the market’s products in the market’s
geographic area. In addition,
participants may include other firms depending on their likely supply responses
to a “small but significant and nontransitory” price
increase.
·
Specifically,
the regulator will begin with each product (narrowly defined) produced or sold
by each merging firm and ask what would happen if a hypothetical monopolist of
that product imposed at least a “small but significant and nontransitory”
increase in price, but the terms of sale of all other products remained
constant.
·
The
regulator generally will consider the relevant product market to be the
smallest group of products that satisfies this test.
·
In
attempting to determine objectively the effect of a “small but significant and nontransitory” increase in price, the regulator, in most
contexts, will use a price increase of 5 percent lasting for the foreseeable
future. However, what constitutes a
“small but significant and nontransitory” increase in
price will depend on the nature of the industry, and the regulator at times may
use a price increase that is larger or smaller than 5 percent.
·
Although
discussed separately, product market definition and geographic market
definition are interrelated. In
particular, the extent to which buyers of a particular product would shift to
other products in the event of a “small but significant and nontransitory”
increase in price must be evaluated in the context of the relevant geographic
market.
·
The
regulator will first define the relevant product market with respect to each of
the products of each of the merging firms.
For each product market in which both merging firms participate, the
regulator will determine the geographic market or markets in which the firms
produce or sell. A single firm may
operate in a number of different geographic markets.
Why
is this discussion important? Because
determining the relevant product market and the appropriate geographic market
may require analysis of distinct products such as health maintenance
organizations (HMO) and participating provider options to be evaluated
separately and may require them to be compared county by county rather than statewide. The determination of the relevant markets
will have a decisive impact on determining accurate levels of market
concentration, i.e., monopoly power. The
regulator normally assesses competition in each relevant market affected by a
merger independently and normally will challenge the merger if it is likely to
be anticompetitive in any relevant market.
Concentration and Market Shares
Market shares will be calculated using the best indicator of firms’ future competitive significance. This analysis has particular importance when looking at the ability of potential competitors to offset the merging entity’s market power. Small firms with limited market presence, even if there are several of them, may not be able to effectively compete with a large, dominant firm.
In this
respect, the Guidelines provide:
·
Market
concentration is a function of the number of firms in a market and their
respective market shares. As an aid to
the interpretation of market data, the regulator will use the Herfindahl-Hirschman Index (HHI) of market
concentration. The HHI is calculated by
summing the squares of the individual market shares of all the
participants. The HHI reflects both the
distribution of the market shares of the top four firms and the
composition of the market outside the top four firms. It also gives proportionately greater weight
to the market shares of the larger firms, in accord with their relative
importance in competitive interactions.
·
The
regulator divides the spectrum of market concentration as measured by the HHI
into three regions that can be broadly characterized as unconcentrated
(HHI below 1,000), moderately concentrated (HHI between 1,000 and 1,800), and
highly concentrated (HHI above 1,800).
·
The
regulator regards markets with a post-merger HHI between 1,000 and 1,800 to be
moderately concentrated. Mergers
producing an increase in the HHI of less than 100 points in moderately
concentrated markets post-merger are unlikely to have adverse competitive
consequences and ordinarily require no further analysis. Mergers producing an increase in the HHI of
more than 100 points in moderately concentrated markets post-merger potentially
raise significant competitive concerns.
·
The
regulator regards markets with a post-merger HHI above 1,800 to be highly
concentrated. Mergers producing an
increase in the HHI of less than 50 points, even in highly concentrated markets
post-merger, are unlikely to have adverse competitive consequences and
ordinarily require no further analysis.
Mergers producing an increase in the HHI of more than 50 points in
highly concentrated markets post-merger potentially raise significant
competitive concerns. Where the
post-merger HHI exceeds 1,800, it will be presumed that mergers producing an
increase in the HHI of more than 100 points are likely to create or enhance
market power or facilitate its exercise.
Data
have been cited in some submissions to you indicating that United has a 13
percent share of the Las Vegas Metropolitan HMO market and that Sierra controls
81 percent. Assuming these figures are
accurate, an acquisition would remove the single largest competitor to
Sierra—by merging it with the dominant market participant! Such a result would effectively terminate the
one existing market participant with any creditable ability to compete with
Sierra. It is hard to see how such an
outcome can do anything but “substantially lessen competition,” by further
concentrating market power, in direct contravention to the statutory mandate in
NRS 692C.256.
Similarly,
figures provided to you in other submissions indicate the Medicare coverage
percentages in
Additional Analysis Necessary—Sufficiency of Entry of Potential New Competitors
The Guidelines note:
·
However,
market share and concentration data provide only the starting point for analyzing
the competitive impact of a merger.
Before determining whether to challenge a merger, the regulator also
will assess the other market factors that pertain to competitive effects, as
well as entry, efficiencies, and failure.
·
A merger is
not likely to create or enhance market power or to facilitate its exercise if
entry into the market is so easy that market participants, after the merger,
either collectively or unilaterally could not profitably maintain a price
increase above premerger levels. Such entry likely will deter an
anticompetitive merger in its incipiency, or deter or counteract the
competitive effects of concern.
·
However,
entry, although likely, will not be sufficient if, as a result of incumbent
control, the tangible and intangible assets required for entry are not
adequately available for entrants to respond fully to their sales
opportunities. Once again, this is a
subject of acute concern for
Additional
Analysis Necessary—Efficiencies
The Guidelines note that
one of the primary justifications for mergers is increased efficiencies. Not surprisingly, the proponents of the
present merger have advanced efficiencies in support of the transaction. However, the Guidelines observe that claims of increased efficiency must be
carefully evaluated:
·
Competition
usually spurs firms to achieve efficiencies internally. Nevertheless, mergers
have the potential to generate significant efficiencies by permitting a better
utilization of existing assets, enabling the combined firm to achieve lower
costs in producing a given quantity and quality than either firm could have
achieved without the proposed transaction.
Indeed, the primary benefit of mergers to the economy is their potential
to generate such efficiencies.
·
The
regulator will consider only those efficiencies likely to be accomplished with
the proposed merger and unlikely to be accomplished in the absence of either
the proposed merger or another means having comparable anticompetitive
effects. These are termed
merger-specific efficiencies.
·
But
efficiencies are difficult to verify and quantify, in part, because much of the
information relating to efficiencies is uniquely in the possession of the
merging firms. Moreover, efficiencies
projected reasonably and in good faith by the merging firms may not be
realized. Therefore, according to the Guidelines, the merging firms must substantiate
efficiency claims so that the regulator can verify by reasonable means the
likelihood and magnitude of each asserted efficiency; how and when each would
be achieved (and any costs of doing so); how each would enhance the merged
firm’s ability and incentive to compete; and why each would be merger-specific. Efficiency claims will not be considered if
they are vague or speculative or otherwise cannot be verified by reasonable
means.
·
The greater
the potential adverse competitive effect of a merger, as indicated by the
increase in the HHI and post-merger HHI, the greater must be cognizable
efficiencies in order for the regulator to conclude that the merger will not
have an anticompetitive effect in the relevant market. When the potential adverse competitive effect
of a merger is likely to be particularly large (as appears to be the case
here), extraordinarily great cognizable efficiencies would be necessary to
prevent the merger from being anticompetitive.
·
Efficiencies
almost never justify a merger to monopoly or near-monopoly.
·
Experience
has shown that certain types of efficiencies are more likely to be cognizable
and substantial than others. Those
relating to procurement, management, or capital cost are less likely to be
merger-specific or substantial, or may not be cognizable for other reasons.
United’s
General Counsel indicated at the first hearing that one of the principal merger
benefits will be economies of scale, citing in particular more efficient and
effective procurement. Yet this is
exactly the kind of efficiency the Guidelines
view as suspect. Testimony already received by you from participants in
Concerns About United’s Market Conduct
We are also particularly concerned about the conclusions reached by Mr. Nestor J. Romero in his market conduct analysis of United for the Insurance Division. Mr. Romero noted United has been involved in at least 69 regulatory actions in the past five years. These actions involved a significant number of complaints regarding claims handling and payment. Fines of up to $1.25 million have been assessed so these are not inconsequential actions.
By contrast, according to Mr. Romero, Health Plan of Nevada, Sierra’s subsidiary, has NOT had significant regulatory issues in the past five years. He recommends that if the merger is approved, you require United to utilize Sierra’s market conduct compliance systems, claims payment, complaint handling, and customer service functions.
While such a stipulation appears highly appropriate given United’s history, we are concerned about the long-term efficacy of such a directive. Although key Sierra personnel reportedly will remain with the merged company, what assurance do we have that this arrangement will continue or that the Sierra staff will not be overridden by the new parent company? Given the regulatory problems identified by Mr. Romero and the resignation less than a year ago of United’s CEO, William McGuire, for a stock-option scandal, how can Nevadans be sure this corporate culture will not infect the new local operations? A mere directive may be too feeble a prescription for such virulent circumstances. Please recall that one of the declared purposes of the Nevada Insurance Code is to “provide adequate standards . . . of integrity . . . in the home offices . . . and the field.”
Concluding
Remarks
Given the importance of health care for Nevadans and the systemic problems currently plaguing the market here, great care should be exercised in discharging your duties under the Nevada Insurance Code. The Legislature has declared that the purposes of that Code are to:
·
Implement
the public interest;
·
Ensure fair
and equitable treatment of consumers;
·
Ensure that
the State has an adequate and healthy insurance market characterized by
competitive conditions and the exercise of initiative; and
·
Prevent
misleading, unfair, and monopolistic practices in insurance operation.
The final legislative directive in this regard
is: “The provisions of this Code shall
be given reasonable and liberal construction for the fulfillment of these
purposes.” We urge you, Madam
Commissioner, to closely scrutinize this proposed merger with these public
policy mandates clearly in mind.
Southern Nevada Health District Report
By
Southern Nevada Health
District
A recent investigation into three cases of pertussis in infants and school-age children in
While it is not unusual for a small number of cases to be
reported to the Southern Nevada Health District (SNHD) throughout the year, it
is important that we respond aggressively in order to mitigate the possibility
of a widespread community outbreak. The potential for a small number of cases
to mushroom into a large-scale outbreak is clearly illustrated through the
experiences of the state of
In response to our local cases, health district staff completed an intensive contact investigation with the cooperation of the families involved, and offered onsite Tdap immunizations for children attending the school where cases were reported.
Additionally, the health district has released a technical bulletin in order to request the assistance of the health care community in the prompt identification and reporting of pertussis cases.
Pertussis is a highly communicable respiratory disease caused by Bordetella pertussis that is typically manifested by paroxysmal spasms of severe coughing, whooping and posttussive vomiting. Adults and adolescents have a more variable presentation, from asymptomatic to classic presentation, and often times are the source of infection for younger children and infants who are most at risk for serious disease complications. It is for this reason the Centers for Disease Control and Prevention (CDC) is recommending the following:
- Adolescents 11-12 years of age should receive a single dose of Tdap instead of TD.
- Adolescents 13-18 years who have not received Tdap should receive a single dose Tdap as their catch-up booster instead of Td if they have not completed the recommended childhood DTaP/DTP vaccination series.
- Adults 19 through 64 years of age should receive a single dose of Tdap to replace a single dose of Td for booster immunization against tetanus, diphtheria and pertussis.
It is important for adults who have close contact with infants, including child care and health care professionals, to have the booster immunization.
Laboratory testing is another important tool in our efforts to identify and mitigate the effects of the illness. Culture is the most specific of the available tests and considered the gold standard, however, it may take as long as two weeks, limiting the usefulness of the results in a clinical setting. Polymerase chain reaction (PCR) testing is more sensitive and provides faster results. The CDC currently recommends PCR testing be performed in addition to, not instead of, culture. Detailed information on the proper collection and transport of clinical specimens required for testing is contained in the health district technical bulletin found on the SNHD website: http://www.southernnevadahealthdistrict.org/physician/download/tb-072607.pdf.
Post-exposure prophylaxis is effective against pertussis and should be administered to all close contacts, regardless of age and vaccination status. When administering prophylaxis it is important to ensure patients complete the full course of therapy to ensure complete eradication of the organism.
Cases of pertussis are managed primarily through supportive care, however, antibiotics are of some value as this therapy eradicates the organism from secretions, limiting communicability and possibly modifying the course of the illness. It is important for patients to complete the full course of treatment to prevent bacteriologic relapse. Since the disease is toxin-mediated, symptoms may persist after treatment is completed.
In order to ensure cases of pertussis are appropriately tracked it is important for health care providers to report all known or suspected cases of the illness to the health district per Nevada Administrative Code 441A. Cases should be reported to the Office of Epidemiology at (702) 759-1300, option #2. This number is available 24-hours, seven days a week.
For more information on specimen collection, laboratory treatment, prophylaxis and the recommended antimicrobial treatment access the health district website at www.SouthernNevadaHealthDistrict.org or contact the Office of Epidemiology at (702) 759-1300, option #2.
Minutes
MINUTES
SYNOPSIS June 19, 2007
The
meeting was called to order by Dr. Jameson at
II. Action Items
A. Minutes from the
B. Financial report was presented by Dr.
Steinberg:
§
General Revenue – Actual for 11 months of Fiscal
Year 2006-07 is $433,114.00 compared to $409,897.36 in Fiscal Year 2005-06 for
an increase of $23,216.64 over last year at this time.
§
Operating Expenses – Actual for 11 months of Fiscal
Year 2006-07 is $337,424.44 compared to $286,453.30 for an increase of
approximately $50971.14 over last year at this time.
§
Overall,
revenues exceeded our expenses by $95,689.56.
The bank balance for the end of May was $490,091.70 compared to
$396,214.92 last year at this time.
III. Committee Reports
A.
Membership Count
Janice
Poblete provided the Membership Reports.
§
As
of
§
There
are 75 new members and 10 reinstatements for the Fiscal Year 06-07.
§
A
motion passed to pay $40 to Janice Poblete for each past due membership paid
prior to
B. Credentials
Committee
New
Member Applicants were presented to the board and was unanimously approved:
Applicant Name Specialty
Damon
I. Masaki, MD Maternal
Fetal Medicine
New
Student Member Applicants from
Applicant Name Applicant Name
Kenneth
R. Anderson Shaun P. Brancheau
David
J. Byun Tanya
H. Dam
Megan
Do Geoffrey
G. Graham
Matthew
L. Jenkins Ling Jing
Saima Khalid Kasie M. Kudrewicz
Babak Mahgerefteh M. Brigid
Maruszak
Courtney
H. Morrow Scott A.
Moulton
Rochelle
S. Orr Carol B. Orzga
Anna-maria Schuster Jonathan
D. Schwartz
Brent
L. Treadaway Lisa
C. Underwood
C.
Community Health/Community Relations
Committee
Dr.
Jones presented the report.
§
§
Dear
Doctor – Dr. Alexander is still moving forward with the project.
§
West
Care – Will start as early as this Friday (June 22) giving pre-natal care to
incarcerated.
D.
Building Committee
Dr.
Nowins presented the Building Committee report.
§
Dr.
Havins, Dr. Jameson and Dr. Nowins visited three locations for the future home
of CCMS.
o
The
Shea at Sunset building. There is a
possibility of obtaining 4,000 square feet for the price of 3,000 square
feet. The location is most central
(Sunset/Pecos), and is most likely the best deal.
o
IND/MLAN
office building. Fabulous office
complex, however it is cost prohibitive.
o
After
much discussion, ranging from whether the membership should be polled regarding
the sale of the building, to what location is most feasible for CCMS, to what
size building is really needed, to asking what price to set for the sale of the
building, a motion was approved to place the building up for sale in the amount
of $850,000.
o
Another
motion passed stating that the Realtor selection will be decided at the first
Building Committee meeting under the chairmanship of Dr. Jones.
IV.
Wendy Agrawal presented the
§
Wendy
Agrawal stated that their first meeting will be in August.
§
Current
membership with the
§
The
§
The
Internet Safety program for children will be launching this year with pilot
programs being conducted at a couple of the local schools.
V.
County Health Officer Report (in packets)
Dr.
Sands was not present, therefore no report was given.
VI.
Dr.
Lenhart presented the UNSOM report.
§
Legislative
update: We did not receive funds for
administration, however, we were awarded $90MM for a new building ($60MM comes
to
§
Finished
consultation with Nevada Hospital Association (ECG, Touro and UNSOM) to
determine the growth of the area hospitals.
§
VII.
Dr.
Foreman presented the Touro Report after the Committee Reports
§
Pursuing
individual GME programs with local hospitals, particularly with Valley. We will have the first ophthalmology program
in the state.
§
Currently
in negotiations with an associate Dean who has promised to jump start the first
cardiology fellowship in the state, perhaps in 2008.
§
We
are beginning clinical rotations in rural areas in July.
§
Selected
as recipients of scholarships for 10 Touro students. The recipients have been identified and will
be guests of the Installation Dinner.
VIII.
Scholarship Fund Report
Dr. Ellerton was not present. Therefore no report was given.
IX. NSMA Report
Dr.
Kingsley presented the NSMA Report.
§
Dr.
Kingsley thanked all those who participated in the Legislative Core Group and
especially to Larry Matheis and our lobbyists.
§
The
Group followed 236 bills, had a very successful legislative session.
§
Dr.
Kingsley will be traveling to the North several times/year to keep the
connection going.
IX.
AMA Report
Dr.
Horne and Dr. Nelson were not present.
Therefore no report was given.
XI. NBME Report
Dr.
Rodriguez presented the NBME report.
§
Received
some bad press regarding our discipline statistics.
§
The
numbers are compiled in 3 year increments and it is projected that the numbers
will be much better on the next reporting period.
§
The
Board eliminated the $100,000 budget line item for advertising.
XII. President’s Report
§
United/Sierra
Merger – Larry Matheis gave a synopsis on the status of the merger. He sent an update after the hearing last
week. Five additional public hearings
with at least two in
§
The
Governor was instrumental in delaying the merger by requiring the additional
meetings.
§
Many
legal issues will have to be addressed to the satisfaction of the state
entities.
§
Larry
stated that we are on the front edge of the next major health care battle and
advised that the AMA has made this a major priority.
XIII.
Administrative Report
Dr.
Havins stated there would be no Administrative Report.
XIV.
New Business
None to report.
XV.
Old Business
None
to report.
XVI.
Future Meetings
Next
meeting is scheduled for Tuesday,
XVII.
Adjournment
Meeting
adjourned at
MINUTES
SYNOPSIS July 17, 2007
I. Call To Order:
The
meeting was called to order by Dr. Havins at
II. Action Items
A. Minutes from the
B. Financial report was presented by Dr.
Steinberg:
§
General Revenue – Actual for 12 months of Fiscal Year
2006-07 is $454737.07 compared to $440,395.59 in Fiscal Year 2005-06 for an
increase of $14,341.48 over last year at this time.
§
Operating Expenses – Actual for 12 months of Fiscal
Year 2006-07 is $366,843.57 compared to $322,989.75 for an increase of approximately
$43,853.82 over last year at this time.
§
Overall,
revenues exceeded our expenses by $87,893.50.
The bank balance for the end of June was $487,428.76 compared to
$390,696.77 last year at this time.
C.
2007-08
Budget
§
The
proposed budget was presented by Dr. Havins.
Legal expenses for Mr. Balto (United merger)
and the American Child Care litigation were included. The budget projects a $2,000 net profit.
§
Dr.
Colletti raised the issue of the CEO Expense Account and made a motion to
delete the restrictions to the use of the account. After much discussion, a new motion was made
to allow for staff lunches as part of the $9,000 annual Exec. Dir expense
account, limited to $1,500 per year. The
motion was unanimously approved.
§
Bank
Signature Cards – Signatures of the new officers were gathered for banking
purposes.
III. Committee Reports
The
list of committees were distributed to the BOT members. A motion was made and passed to
approve
the committee members. Dr. Kline and Dr.
Steinberg requested to be added to the Building
Committee. With Dr. Jones concurrence,
the two doctors were added.
A.
Membership Count
Janice
Poblete provided the Membership Report:
§
As
of
§
There
were 78 new members and 10 reinstatements in the Fiscal Year 06-07.
§
Seven
renewals were obtained by Janice Poblete’s
efforts. She will be paid $40 for each
past due membership she was successful in receiving.
B.
Credentials
Committee report.
§
Dr.
Havins stated that Dr. Van der Harten will chair the committee and said she
will be attending some of the BOT meetings.
E.
Community Health/Community Relations
Committee
Dr.
Teijeiro presented the Building Committee report:
§
The
Juvenile Justice Center and West Care are now on the website.
§
Meetings
will begin in September, and all are welcome.
F.
Building Committee
Dr.
Jones presented the Building Committee report:
§
The committee’s
next step is to identify/engage a Realtor.
§
A
geographical area needs to be defined for the CCMS facility that will be
central to all physicians. This will be
discussed at the first meeting on August 7.
IV.
Estela Hansen presented the
§
Membership
is down from 170 to 45. A membership
drive is being developed for September.
Details will be forthcoming.
§
The
X.
County Health Officer Report (in packets)
Dr.
Sands was not present, therefore no report was given.
XI.
Dr.
Lenhart presented the UNSOM report:
§
New
residents began classes July 1 with a very strong pediatric group.
§
The
Vice Chancellor recruitment is ongoing; however, details cannot be made public
at this time. The candidate will be
selected by July 31.
XII.
Dr.
Foreman presented the Touro Report:
§
Touro
is in the process of building out a section of the school for a clinical
research center with several expanded programs in Health & Human Services,
including a doctorate in nursing, ultrasonagraphy and
physical therapy.
§
Touro
is continuing to grow their student body with134 students accepted at the
current cost and they are continuing to work with Valley to expand the
residency program.
§
Touro
is In the process of hiring an Associate Dean for academic programs. He is a cardiologist who runs a fellowship in
§
Touro
is looking to expand the Graduate Medical Education program. Meetings have been conducted with several of
the hospitals in the community. Without
these programs, the residents will not stay in the
XIII.
Scholarship Fund Report
Dr. Ellerton was not present;
therefore, Dr. Havins gave comments.
§
Dr.
Havins stated that 6 students from UNSOM and 8 students from Touro attended the
Installation Dinner as the guests of CCMS.
§
Scholarship
monies awarded are as follows: $10k to
Touro, $10k to UNSOM, $3k to NSC, $3k to CCSN.
$3k waiting for UNLV and will be released when the administration fee
issue has been resolved in writing.
IX. NSMA Report
Larry
Matheis presented the NSMA Report:
§
The
NSMA is In the process of naming all the commissions for next year. One of the major ones will be a commission to
develop the legislative strategy for the next session.
§
The
website is being revised.
§
NSMA
is working with the
§
The
Division of Insurance will be conducting three hearings next week. NSMA has been coordinating with the AMA legal
team, SCIU and their national legal team in preparation for the meetings. The Commissioner’s decision is expected
within the next month.
§
Dr.
Colletti asked if CCMS has retained Mr. Balto as our
attorney. Dr. Havins stated that CCMS
will be contracting with him for up to $10k of services. Larry Matheis stated NSMA are also utilizing
his services and will also contract with him.
Mr. Balto has already submitted a white paper
on the merger to the Insurance Commissioner.
§
Dr.
Brill stated that he was unimpressed with the NSMA meeting, and felt that the
Friday/Sunday sessions were not a good use of time. Larry Matheis thanked Dr. Brill for his
feedback and welcomed any suggestions from the group to help improve the annual
meetings. Dr. Brill was unable to attend
the Saturday session where most of NSMA’s annual meeting substantive work
occurs.
XIV.
AMA Report
Dr.
Horne presented the report.
§
Three
resolutions were presented at the AMA meeting:
§
Advance
Directive Resolution – This resolution was referred to the Board of Trustees to
implement.
§
The
most controversial resolution was over the use of physician prescribing
information. They have made changes
making it easier to opt out. They have
put it on the front page of the AMA website, however,
it is not prescription data you are opting out of, but rather data
reporting.
§
The
third resolution was accepted, however, they will leave it to each state to do
the survey of how sufficiently fee based physicians are available to ER’s.
XI. NBME Report
Dr. Rodriguez was not present. Therefore, no report was given.
§
Dr.
Havins advised that the next NBME meeting will be September 14 & 15.
XII.
President’s Report:
Dr.
Havins announced the birthdays for the month of July: Dr. Colletti and Dr.
Horne. Cake was
served to celebrate the birthdays. Each of the birthday boys received a lovely
CCMS tie and a magnificent CCMS coffee
mug.
XIV.
Administrative Report
Dr.
Havins stated there was no Administrative Report.
XVIII. New Business
2008
Installation Dinner - Dr. Jones encouraged more BOT members to attend the event.
XIX.
Old Business
None
to report.
XX.
Future Meetings
Next
meeting is scheduled for Tuesday,
XXI.
Adjournment
Meeting
adjourned at
The Nevada
By Larry Matheis
NSMA Executive Director
Congress Passes Bills on SCHIP &
Medicare: Difficult Conference Committee Process Expected
Last week saw contentious battles in Congress over 2 issues of importance to physicians: payment for Medicare patient services &, coverage for uninsured children..
The House of Representatives passed H.R.3162 (Children's Health & Medicare Act) addressing both Medicare payments & SCHIP reauthorization. It passed on nearly a straight party-line vote with 5 Republicans voting for the bill & 10 Democrats voting against it. Representative Shelley Berkley voted for the bill & Representatives Dean Heller & Jon Porter voted against it.
What does CHAMP do for Medicare physician payments? It's a 500 page bill affecting most of the Medicare program, so this is just a gloss. According to an AMA analysis, it prevents the 10% cuts in physician payments in 2008 as well as the projected 5+% 2009 cuts, providing instead for .5% increase in each year. The bill finally deals with the underlying error (the "sustainable growth rate" formula), which it replaces with 6 separate targets (starting in 2008 with primary care/preventive services, other E&M services, imaging services, major procedures, anesthesia services, minor procedures, & some others). Growth would be measured by the GDP (GDP+2.5 for primary & preventive services). It freezes payment updates in 2013. It also drops physician-administered outpatient prescription drugs from target calculations.
It repeals the $1.35billion Physician Assistance & Quality Initiative (which would pay the 1.5% bonuses for quality measure reporting, but allow voluntary reporting to continue. (Most of the payment cuts are paid for by transferring this fund). It extends the floor on the GPCI for another 2 years. It provides for a 5% Medicare bonus payments for physicians practicing in counties in the lowest 5th percentile of per capita spending under Parts A & B. It sets up 3 Medical Home demo projects. It changes payment localities (mostly in CA). It continues the bonuses for physicians in "scarcity counties". It funds a "bundling" study. It requires implementation of comparative data system by which the DHHS measures resource use on a per capita & episode basis & provides confidential feedback to physicians by Medicare on how practice patterns compare to other physicians nationally as well as in the same locality. It requires accreditation of imaging facilities, but not office based physician use although it reduces by 50% the technical component for imaging services involving contiguous body parts & provides for global billing. (That's a $.4billion cut over 5 years.) It eliminates the hospital exception to the prohibition on physician self-referrals. Basically, it bans physician ownership of specialty hospitals (That's a $.7billoion cut over 5 years).
The part that has the health plan lobbyists doing a lot of heavy breathing deals with the Medicare Advantage Plans. It establishes a level playing field between original Medicare fee-for-service by phasing-out overpayment to the MA plans over a 4-year period to 100% of regular Medicare fee-for-service. It takes measures to curb illegal & misleading marketing practices by the MAs. It limits out-of-pocket costs for any service to no more than the cost sharing in original or direct Medicare. It prohibits the auto-enrollment of Medicaid beneficiaries into MA plans and provides for continuous open enrollment for full Medicaid dual eligibles & qualified Medicare beneficiaries meeting income requirements. In a provision almost as painful to the health plans as the cuts in their bonuses is a requirement that information on MA plans including Medical loss ratio must be publicly posted annually prior to open enrollment period. It creates standard for Medicare Loss Ratio & failure to meet ratio results in reductions & ultimately exclusion from MA program. It requires development of measures to assess disparities in the amount & quantity of health services provided to racial & ethnic minorities & HHS would issue reports on findings. HHS would be required to audit risk adjustment data submitted by MA plans & confers enforcement authority to address shortcomings in submissions. HHS would be required to evaluate the adequacy of the MA risk adjustment system with a particular focus on beneficiaries with chronic diseases. Physicians & providers would not be allowed to extra-bill or balance bill plan members by 15%. And, just in case you missed the overall tenor of the House attitude to the MAs, the Medicare Advantage program would be renamed the Medicare Part C program.
The Senate isn't ready to address the Medicare payment mess (although the leaders on both sides swear that they will fix it). The Senate did pass S.1893 (The Children's Health Insurance Reauthorization Act of 2007). 31 Senate Republicans, including Senator John Ensign, voted against the bill. This bill would authorize the program for 5 years & add $35 billion to the current $25 billion to increase coverage of children.
So what do the Senate CHIP & the House CHAMP bills do regarding the SCHIP program? Both reauthorize the program (which sunsets on 9-30-07). The Senate bill reauthorizes it for 5 years while the House bill removes the sunset provision. The Senate bill would cover 3.3 million uninsured children (& raise the eligibility standards from the current 200% of federal poverty level or below to 300% of the current FPL or below & reduces the federal match from 60% to 50% or the Medicaid match percentage) & continue coverage for the 6 million children already enrolled. The House bill extends coverage to 5.1 million children (the estimated number of uninsured that are currently eligible but not enrolled so the eligibility standards stay the same, but it would permit state waivers for some persons with higher incomes) to the currently enrolled 6 million children. The Senate bill provides $35billion in new funding for 5-years over the current $25billion baseline. This is paid for by increases on tobacco products. The House provides $50billion in new funds paid for by a smaller tobacco tax increase & using most of the MA savings discussed above. Both permit covering pregnant women if the State Medicaid program covers them up to 185% of poverty. The Senate continues the ban on adults without SCHIP eligible children while the House bill allows the option. Both require parity between mental & physical health benefits & the Senate sets up a demonstration project for dental coverage, while the House bill provides for the coverage. Both crate State bonuses for effective outreach. Both encourage, but in different ways, premium assistance for working families.
What's the bottom line? The impending physician payment cuts have to be stopped & SCHIP must be reauthorized. CHAMP has a lot in it & some of it is painful, but (for the 1st time in the 7 years this problem has been repeated) it fairly deals with the short & long term issue of the basic physician fee schedule. Both bills continue & enhance the important children's coverage program.
Contact
The
All
physicians, medical students &
· Ask each if they will vote for legislation to eliminate the proposed 10% cut in health professional payments for Medicare schedule to start on 1-1-08.
· Ask each if they agree to the offset this action from the bonuses paid to Medicare Advantage Plans. If they say that they don't, ask them specifically, where the money to avoid the erroneous cuts will come from in the Medicare budget?
·
Ask each if they will vote for legislation to
reauthorize the SCHIP program (Nevada CheckUp and Nevada CheckUp Plus)? If they
do not support the CHAMP bill approach, for what approach will they vote? If
SCHIP is not reauthorized, 30,000
Send a summary of your conversations to Larry Matheis (lmatheis@nsmadocs.org) including, with whom you spoke, & how the member responded to the key questions above. Thank you.
Classifieds
Perinatologist: The UNSOM
Department of OBGYN is seeking a candidate to join the Division of
Maternal-Fetal Medicine. Experience teaching medical students and residents preferred. Research
interests desirable. For information go to: www.unrsearch.edu.
AA/EOE. Women/under-represented groups are encouraged
to apply.
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