NH Medicaid clients getting managed care notices

CONCORD, N.H. — Thousands of New Hampshire Medicaid clients are receiving letters notifying them to pick one of three managed care plans as the state rolls out its managed care system.

If Medicaid clients don't pick a plan, one will automatically be assigned to them beginning Nov. 12. If they aren't happy with their plan, they have 90 days to pick a different one. The plans take effect Dec. 1.

Meridian Health Plan, New Hampshire Healthy Families and Well Sense Health Plan are offering plans. The state is urging Medicaid clients to check to see which of their current medical providers are in a plan if they want to keep using them.

Letters will be sent to reach 120,000 Medicaid clients, Associate Commissioner Mary Ann Cooney said Monday.

New Hampshire is switching from a fee-for-service health care system to managed care to save money and try to provide Medicaid clients with better access to health care, especially those with chronic illnesses such as diabetes.

The three companies offering plans are offering extra benefits as incentives to sign up. Well Sense is offering clients a free dental kit including an electric toothbrush, free car safety seats and booster seats for infants and children and free bike helmets for kids. New Hampshire Health Families and Meridian Health Plan are offering SafeLink cellphones to some. All three offer programs to address obesity.

"Each one of the health plans has certain features that distinguishes it from the others, but overall, clients are going to get the services they've been provided," said Cooney.

A law was passed two years ago to move the state from fee-for-service to a managed care system for Medicaid clients, but efforts to implement the system stalled when health care providers refused to participate due to low state reimbursement levels for treating those patients, among other issues. The budget written by Republicans that same year cut state hospital aid for all but a handful of critical access hospitals. And the 10 largest hospitals sued over Medicaid rates, which complicated efforts to negotiate over managed care.

Lawmakers restored some aid in the budget adopted in June and required hospitals to participate in the managed care system to receive it. Since then, hospitals and other providers have agreed to participate, making it possible for the state to move ahead with its managed care system. The system will be implemented in phases. Switching to managed care is mandatory for most clients during the first phase, which covers medical care, such as doctors.

The developmentally disabled, clients in nursing homes and clients receiving long-term care services will be required to enroll in a plan in about a year during implementation of phase two of the system. Cooney said clients in nursing homes are required to select a plan for the doctors they see outside the nursing home during this enrollment period.

http://www.sunherald.com/2013/09/16/4955347/nh-medicaid-clients-getting-managed.html

Read more here: http://www.sunherald.com/2013/09/16/4955347/nh-medicaid-clients-getting-managed.html#storylink=cpy

Nonprofit health insurance company forming in Wis.

MILWAUKEE (AP) — Business leaders and community organizers in Milwaukee have formed a nonprofit health insurance company to provide coverage to small businesses and individuals.

Common Ground Healthcare Cooperative is one of 24 cooperatives being started nationwide with almost $2 billion in federal loans, the Milwaukee Journal Sentinel reported (http://bit.ly/1dBUJoc ).

Common Ground will focus on Milwaukee and eastern Wisconsin to start, selling coverage through the federally run online marketplace, or exchange, which opens Oct. 1.

The cooperative does not expect to have the lowest prices. Instead, Chairman Bob Connolly said it hopes to stand out by being a nonprofit run by its members.

"The difference is who we are, what we represent and what we stand for," Connolly said.

The cooperative is being started with up to $56.4 million in loans awarded under the Affordable Care Act. The money will go toward startup costs and meeting state requirements on reserves for insurance companies. It cannot be used for marketing, so the cooperative is relying on volunteers to get the word out by distributing fliers and talking to neighbors.

"How many people do you know that are going door-to-door telling their neighbors about health insurance?" Connolly asked a recent meeting of organizers.

The goal is to sign up 10,000 customers in the first year. Bob De Vita, Common Ground's chief executive officer, estimated the cooperative can break even with 20,000 to 30,000 customers.

Jim Wesp, owner of Kettle Moraine Hardwoods and vice president of Common Ground's board, said he was interested in the idea of a nonprofit because his company and five of its workers are paying about $50,000 a year for health coverage. He also liked the idea of a cooperative.

"As a member, I will have the ability to have some say in how the plan is run," Wesp said.

Common Ground is not the first nonprofit health insurance company in Wisconsin. Group Health Cooperative of South Central Wisconsin was started in the 1970s with a federal loan. It's former director, Larry Zanoni, was an early adviser to Common Ground.

"The best advice he gave us is to be persistent," De Vita said, "because people thought he was crazy."

___

http://www.sfgate.com/news/article/Nonprofit-health-insurance-company-forming-in-Wis-4835864.php

Owners of At Home VNA and their partner charged with scamming Medicare

A Natick man and his Everett business partner scammed more than $27 million from Medicare over six years, federal authorities allege in a sweeping indictment unsealed Friday.

Michael J. Galatis, 62, of Natick, and Janice Troisi, 64, of Everett, owners of At Home VNA of Waltham, are charged with health care fraud, money laundering, conspiracy and aiding and abetting, according to the U.S. District Court indictment.

Galatis was arrested at his home by federal authorities Friday at 6:48 a.m. It was unclear when and where Troisi was arrested.

According to the affidavit, Galatis and Troisi, along with a number of unnamed conspirators, worked together to defraud Medicare. The indictment said company nurses, under the orders of Galatis and Troisi, would run "wellness clinics" at senior housing centers and other types of assisted-living facilities with the goal of finding people on Medicare.

They would then arrange for home health care to be provided by At Home VNA, claiming that the patients were homebound so Medicare would pay. However, according to the indictment, the patients weren’t homebound. The scam began in January 2006 and continued through October 2012.

The indictment alleges that Galatis and Troisi falsified nursing visit reports to make it appear like the patients received skilled nursing services that were not needed or provided.

Galatis and Troisi also "discouraged" visiting nurses from discharging patients, even if the patients requested they stop. They would retaliate against nurses who recommended discharge and transfer the patient to another nurse, the indictment said.

In all, the company scammed millions from Medicare, the indictment said.

"In all, during the course of the conspiracy, AHVNA (At Home VNA) submitted more than $27 million in false and fraudulent home health claims to Medicare," the indictment said.

In addition, the indictment said Galatis laundered nearly $700,000 from his company to his own personal bank account, which he used to buy his home at 25 Indian Rock, Natick, and to pay off the mortgage for the home.

Authorities are looking to seize money in both Galatis' account and At Home VNA, the indictment said.

Both Galatis and Troisi appeared in federal court on Friday. Troisi was released on $25,000 bond. Galatis will be held in custody over the weekend because his $50,000 bond cannot be posted until Monday, a spokeswoman for the U.S. Department of Justice said.

Read more: http://www.metrowestdailynews.com/news/x1803293958/Natick-man-and-partner-charged-with-scamming-Medicare#ixzz2fiXrsDDF
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St. Luke’s on trial this week

What to know about the case brought by federal and state regulators, as well as Saint Al’s.

By AUDREY DUTTON — adutton@idahostatesman.com

Two of Idaho’s largest health care systems will commence a monthlong battle in federal court this week, with federal and state governments joining Saint Alphonsus Health System in a lawsuit to stop St. Luke’s Health System from owning a large physician practice that used to be independent.

The fight is more than a year in the making. It will determine the future of health care in Canyon County, and it also might be a game-changer for health care in Idaho, where St. Luke’s executives say they plan more growth and consolidation in the name of better health care, healthier people and lower costs.

WHAT CAUSED THIS FIGHT?

Boise-based St. Luke’s has been acquiring physician practices and hospitals for several years. It ramped up its buyouts under the leadership of CEO David Pate, a doctor and lawyer who moved to Boise from Houston four years ago to run the system. The system now includes seven hospitals, more than 70 clinics and medical offices, and about 11,000 employees in Idaho and eastern Oregon. Five years ago, St. Luke’s owned four hospitals and employed about 7,600 people.

But St. Luke’s isn’t being sued over growing too much. Though it is the dominant health care provider in places such as the Magic Valley — where the system’s legal opponents argue its dominance caused a spike in health care prices — its overall growth in recent years is just the background scenery for this lawsuit.

Instead, a single acquisition drew the scrutiny of the Federal Trade Commission and Idaho Attorney General Lawrence Wasden: a buyout of Nampa-based Saltzer Medical Group, which was the largest independent practice in the state.

Both Wasden and the FTC are in charge of enforcing federal and state antitrust laws that protect competition so that consumers can shop around.

Wasden’s office first asked, then warned, both businesses not to close on the deal until the FTC and Wasden had finished investigating whether St. Luke’s was breaking the law. St. Luke’s decided that might take years, so it pressed on.

Saint Alphonsus Health System and Treasure Valley Hospital, a small Boise surgical hospital, sued late last year to stop the Saltzer deal. The St. Luke’s competitors said the buyout would seriously harm their businesses. But Chief District Court Judge B. Lynn Winmill decided to allow the deal to close at the end of 2012, under a few conditions, including that both sides prepare for a full-blown trial.

The FTC and Wasden filed their own lawsuit earlier this year, saying data and paper-trail evidence show that the deal would position St. Luke’s to chip away at competition in Canyon County and to charge health insurers and patients more for services. The two lawsuits were then combined.

Before the lawsuits, Saint Alphonsus — owned by a national Catholic health-care company based in Michigan — made a competing offer to buy Saltzer. Saint Alphonsus now employs some doctors who defected from Saltzer during the negotiations. Saint Alphonsus also has acquired physician practices in recent years, but at a slower rate.

WHAT DO BOTH SIDES HAVE TO PROVE?

The main question is whether St. Luke’s owning Saltzer would substantially reduce competition for primary care in the market Saltzer serves. But there are a few other questions Winmill wants answered.

Where do patients go for health care?

This question is one of the most important, because it’s a sticking point for both sides. To figure out whether a merger is illegal, experts use a formula for how much of a certain “market” each business controls before the merger and after. In St. Luke’s case, the product market is “primary care” and the geographic market is up for debate.

St. Luke’s says Winmill shouldn’t think of Nampa as an island. St. Luke’s says Canyon County residents often make a half-hour drive to Meridian for health care, and patients choose primary-care doctors based on idiosyncratic factors, such as where the patients work.

The opponents say Winmill should ignore that argument, because St. Luke’s hasn’t really defined a better “market” boundary and evidence shows that people in Nampa want health care close to home.

Does St. Luke’s hoard patients by keeping referrals in-house?

St. Luke’s says it encourages doctors to make their own decisions about where they send patients and gives them no reason to keep patients in the St. Luke’s system. The governments and competing hospitals say that’s not what they’ve seen in the data. The competitors say referrals drop when a doctor goes on the St. Luke’s payroll, though the reason for that drop-off is in dispute.

Would St. Luke’s raise prices if it owns Saltzer for good?

Idaho health insurers think it would, according to court documents. The state and federal governments have mined data and found a steep price increase in the Twin Falls area, where they argue that St. Luke’s owns almost the entire market for primary care. Their lawyers say St. Luke’s might reduce competition and raise prices, and that just this possibility is enough to break the law. St. Luke’s attorneys say that if the merger survives, St. Luke’s would lower prices through a contract it penned last year with Utah-based health insurer SelectHealth — a deal that St. Luke’s says can succeed only if it owns plenty of doctors in Nampa.

WHO STANDS TO GAIN FROM THIS? WHAT IS THE PAYOFF?

If St. Luke’s loses, Saint Alphonsus would maintain a larger share of the Nampa market, where it has a hospital and medical plaza. Saint Alphonsus and Treasure Valley Hospital also would keep the patients they think St. Luke’s would siphon away, as well as the money they make from those patients.

If St. Luke’s wins, it will have a foothold in Canyon County, where it currently has no hospital. Its attorneys and executives say it could fully execute a plan to provide lower-cost care by paying doctors for high-quality, efficient work.

For everyone else, what it means is unclear. Both sides argue that if they win, consumers will have lower-cost medical care, Idahoans with Medicaid will have more access to physicians, and people at their organizations won’t lose their jobs.

WHO WILL TESTIFY?

Both sides gave the judge a road map of their arguments, with testimony and evidence they might bring up in the trial.

The people who provide testimony — some of whom will take the stand — include executives and doctors from the two health systems and their hospitals, Saltzer Medical Group, consultants, economists, health care experts, and the directors of the Idaho Department of Health and Welfare and the Idaho Department of Insurance. They also include executives from Blue Cross of Idaho, Regence BlueShield of Idaho and SelectHealth insurance.

St. Luke’s opponents have subpoenaed their first witnesses: Lance Coleman, senior medical director for Blue Cross of Idaho; Jeff Crouch, vice president of provider services for Blue Cross of Idaho; Linda Duer, executive director of the Idaho Physicians Network, a statewide independent health care provider association; Patrick Otte, the vice president of human resources for Micron; and David Peterman, president of Primary Health Medical Group, an independent chain of clinics in the Treasure Valley.

http://www.idahostatesman.com/2013/09/22/2774971/st-lukeson-trialthis-week.html

Read more here: http://www.idahostatesman.com/2013/09/22/2774971/st-lukeson-trialthis-week.html#storylink=cpy

HBR: Redefining the Patient Experience with Collaborative Care

HARVARD BUSINESS REVIEW: by Leonard L. Berry and Jamie Dunham  |   9:30 AM September 20, 2013 

It’s a common patient complaint about the people involved in their care: “Sometimes the left hand doesn’t seem to know what the right hand is doing. I don’t feel everyone is working together.” To address this issue, nurses at ThedaCare employed lean techniques to create a patient-centered, team-based model that’s producing solid results.

Based in Appleton, Wisconsin, ThedaCare is a five-hospital health system with 26 clinics, other allied services, and more than 6,000 employees. It has been a pioneer in applying lean methodology in health care in order to tackle quality and cost issues. It began its lean journey in 2003 and has made considerable progress. For example, its accountable-care-organization partnership with Bellin Health, a health care system in Green Bay, Wisconsin, presently has the lowest cost per Medicare beneficiary among 32 pioneer ACOs, and the ThedaCare Physicians group was ranked first in quality performance statewide in 2013 by Consumer Reports.

ThedaCare opened its first “collaborative care” hospital unit in a medical-surgical unit at Appleton Medical Center in 2007 after 18 months of interdisciplinary planning led by nurses. A second was introduced in a medical-surgical unit at Theda Clark Hospital in Neenah in 2009, and a third in another medical-surgical unit at Appleton Medical Center in 2010. By 2013, all eight medical-surgical units in the two hospitals had been converted to the collaborative-care model.

The results to date show that the inpatient-care model is succeeding in improving safety, efficiency, and effectiveness. For the first three units, costs and length of stay declined, and quality and patient and nursing satisfaction improved. Some metrics improved immediately (within the first month); others over a period of six to nine months. A new process that required the pharmacist, rather than a nurse, to be responsible for “admission medication reconciliation” (a process that ensures that the patient’s list of medications that he or she is taking at home is accurate and can be used as a baseline for prescribing medication during his or her hospital stay) reduced the errors per patient admission to zero from between 1.25 and 1.5.

Team Care at the Bedside

The collaborative-care model replaces inconsistent, fragmented hospital care. A bedside-care teamcomposed of a physician (“medical expert”), nurse (“care-progression manager”), pharmacist (“medication expert”), and discharge planner (“transitional-needs coordinator”) collaborates — with patient and family input — to develop a single care plan that is continuously updated in daily team huddles. On admission, the team gathers the patient history, performs a physical assessment, determines an anticipated discharge date, and works backward from this date to build a coordinated plan of care.

Using evidence-based guidelines linked to the electronic medical record, the nurse manages the patient’s care progression, and the bedside pharmacist contributes to optimizing management of the medication. The physician leads the clinical assessment and planning process but as a team member/partner. The discharge planner assists the team in devising the best transition plan post hospitalization.

This patient-centered approach minimizes duplication of effort, puts people in roles that leverage their skills and accelerates clinical learning as teammates teach each other. Staff use “tollgates” — purposeful timeouts that are a lean concept — to analyze the patient’s status and remove obstacles in delivering care.

Struggles — and Lessons — from the Journey

Despite the progress, the collaborative care model has had its challenges and remains a work in progress. For example, program designers learned belatedly that the new model requires a different kind of unit leader: a team-builder, coach, and mentor. A “collaborative-care spread team” consisting of clinical experts in the model, a project manager, organizational development specialists, and others guide the nurse managers through their unit’s preparation and implementation phases, supporting their leadership development every step of the way.

One challenge that’s currently being addressed is how to both maintain essential standard work across units and accommodate the requirements of clinical specialties. Some adaptation for certain patient types, like the short-stay surgical patients, has been needed to continue to meet the model goals. As with the original design, these adaptations were made using lean tools for ongoing process improvement.

Another ongoing challenge is getting private-practice physicians who use ThedaCare hospitals to fully engage. To help address this issue, hospital medical directors meet with independent physician groups to share essential elements of the model and determine how they can be applied to doctors’ workflows. (Garnering the full participation of ThedaCare-employed physicians has gone more smoothly.)

ThedaCare’s experience with collaborative care offers salient lessons:

Start from scratch. ThedaCare started by designing a new delivery process rather than adding to the existing process. Starting fresh sparks uninhibited creativity; it encourages “why can’t we” instead of “we can’t” thinking.

Follow a methodology. The design team fully used lean methods such as rapid-improvement events, value-stream maps, and visual-management concepts. That ThedaCare turned to hospital nurses to lead the program design reflects the lean tenet of asking people closest to the work to improve it. (For more information on how to apply lean techniques in health care, see this article.)

Fully use the talent. Collaborative care addresses one of health care’s greatest sources of waste and defects: the underutilization of skilled labor. Too often, highly trained staff work below their scope of expertise — for example, doctors doing what nurses not only can do but also probably do better. Nurses coordinating patients’ care progression and pharmacists managing medications represent big wins for patients and other stakeholders.

Involve the patient. The voice of the patient was a critical input in developing the collaborative-care approach. Patients participated in rapid-improvement events and were members of the development team. Patients anxious to know when they would likely go home were the impetus to providing a discharge goal on admission and focusing on the course of care needed to meet that goal. Patients voicing distrust because they were asked the same question multiple times by different clinicians during their admission laid the foundation for an admission process conducted jointly by the care team.

Invest in intentional thinking. Another lean tenet is assessment before action. Two examples: the 18 months that ThedaCare spent planning the new model and the care team huddles before, during, and after patient visits to assess and reassess the patient’s care plan.

Support strategy with infrastructure. Changes in the hospital facility were made to implement the new approach. They included converting semi-private patient rooms to private rooms and replacing the traditional nursing stations with decentralized alcoves located just outside of the patient rooms, where teams can huddle  before and after visiting patients. A whiteboard was put in the patient’s room so staff could summarize the care plan, timeline, and other relevant information for patients and families. And the supply server was redesigned so it could be restocked outside patient rooms but would be easy for care providers to access medications (kept in locked compartments) and other things. This reduces the time that it takes for nurses to gather supplies, allowing them to spend more time with patients.

Communicate quality. In general, patients have basic expectations about their hospital experience — they want reassurance that providers care about them, communicate with one another, and are competent. Involving the patient in care planning, summarizing the plan on the in-room whiteboard, and following work standards that provide reliable outcomes communicate to patients that they are receiving quality care.

The progress to date of ThedaCare’s collaborative care model is evidence that patient-centered teamwork can improve the quality and lower the cost of care.

Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us athealtheditors@hbr.org, and sign up to receive updates here.

http://blogs.hbr.org/2013/09/redefining-the-patient-experience-with-collaborative-care/

Kaiser Permanente's Medicare Plans Are No. 1 Again

Kaiser Permanente Medicare plans hold top five spots in rankings; all Kaiser Permanente Medicare and Private plans are highest-ranked in the markets they serve

By Kaiser Permanente

OAKLAND, CALIF., SEPT. 19, 2013 — /PRNewswire/ -- Kaiser Permanente Medicare plans continue to demonstrate that they are the best in the nation, ranking No. 1 in a published report by the National Committee for Quality Assurance for the third year in a row.

The "NCQA's Health Insurance Plan Rankings 2013–2014" report is published annually and ranks health plans — Medicare, Medicaid and Private (Commercial) — in three categories, including customer experience, prevention and treatment. For the third year in a row, a Kaiser Permanente Medicare health plan is No.1 in the nation: Kaiser Permanente Southern California, which has been the nation's top Medicare plan for two years running. In 2011, Kaiser Permanente Northern California was top-ranked.

In addition, Kaiser Permanente Medicare plans hold the top five spots in the 2013-2014 rankings; Kaiser Permanente Northern California was No. 2, followed by Kaiser Permanente Northwest, Kaiser Permanente Colorado, and Kaiser Permanente Hawaii. These five regions account for 8.2 million of Kaiser Permanente's more than 9.1 million members. All eight Kaiser Permanente Medicare plans were in the top 16, which means all eight Kaiser Permanente plans are in the top 4 percent out of the 405 plans that were ranked.

In the Commercial rankings, Kaiser Permanente has three plans among the top 10 nationally for the second year in a row, including the second-highest ranked plan in the U.S., Kaiser Permanente Northwest. Also in the Top 10 were Kaiser Permanente Northern California (No. 7) and Kaiser Permanente Ohio (No. 10). All eight Kaiser Permanente Commercial plans are among the top 25 plans and therefore among the top 6 percent of the 484 ranked national plans.

All Kaiser Permanente plans ranked highest in both Medicare and Commercial in the regions or states they serve.

Kaiser Permanente Hawaii, for the third year in a row, retained its position as the No. 2-ranked Medicaid plan in the nation.

"We are proud to again have the highest-rated health plans in the markets that we serve," saidJed Weissberg, MD, senior vice president, Hospitals, Quality and Care Delivery Excellence, Kaiser Permanente. "Our consistently excellent performance in the rankings reflects Kaiser Permanente's commitment to helping our members get healthy and stay healthy. We have dedicated physicians and care teams who use best practices and cutting-edge tools to provide coordinated, compassionate care, creating a better, safer patient experience."

Kaiser Permanente's Commercial plans in Colorado and the Mid-Atlantic States and its Medicare plan in Colorado were also honored as "Best Value" plans, a new designation added to the rankings for the first time this year by NCQA. A "Best Value" plan, according to NCQA, is a plan that is "getting higher quality of care" and "avoiding costly care." Many health plans in the nation — including most from Kaiser Permanente — chose not to collect or report the necessary data that would determine whether they were a "Best Value" plan, and therefore were not eligible for that designation.  

Now in its eighth year, the "NCQA's Health Insurance Plan Rankings" is based on combined scores for health plans in Healthcare Effectiveness Data and Information Set®, commonly called HEDIS; the Consumer Assessment of Healthcare Providers and Systems®, or CAHPS; and NCQA Accreditation standards scores. Consumers and employers assess plans prior to annual enrollment periods.

In the Medicare category, with 405 plans nationally ranked, Kaiser Permanente had the following rankings:

• Kaiser Permanente Southern California — 1st
• Kaiser Permanente Northern California — 2nd
• Kaiser Permanente Northwest — 3rd
• Kaiser Permanente Colorado — 4th
• Kaiser Permanente Hawaii — 5th
• Kaiser Permanente Mid-Atlantic States — 8th
• Kaiser Permanente Ohio — 11th
• Kaiser Permanente Georgia – 16th

Kaiser Permanente Hawaii was the only Kaiser Permanente plan eligible for the Medicaid rankings. The Hawaii plan ranked second in the nation out of 131 plans. Other Kaiser Permanente regions are not required to report data on the full set of measures used to calculate Medicaid rankings and were therefore unranked in this category.

Out of 484 nationally ranked Commercial plans, Kaiser Permanente had the following rankings:

• Kaiser Permanente Northwest — 2nd
• Kaiser Permanente Northern California — 7th
• Kaiser Permanente Ohio — 10th
• Kaiser Permanente Colorado — 13th
• Kaiser Permanente Mid-Atlantic States — 16th
• Kaiser Permanente Southern California — 17th
• Kaiser Permanente Georgia — 20th
• Kaiser Permanente Hawaii — 25th

"Our high ratings recognize Kaiser Permanente's superb physicians and care providers," said Amy Compton-Phillips, MD, associate executive director for Quality at The Permanente Federation, the national umbrella organization of more than 17,000 physicians who provide care to Kaiser Permanente's more than 9.1 million members. "This recognition, however, is not merely about rankings. These scores demonstrate that at Kaiser Permanente improving the health of our members is our calling. We continuously strive to improve and provide better care to the more than 9.1 million Kaiser Permanente members we serve."

The rankings and methodology are posted on the NCQA's website at www.ncqa.org and on theConsumer Reports website. The rankings and an article about health plans will appear in the November issue of Consumer Reports magazine.

http://www.heraldonline.com/2013/09/19/5226568/kaiser-permanentes-medicare-plans.html

Read more here: http://www.heraldonline.com/2013/09/19/5226568/kaiser-permanentes-medicare-plans.html#storylink=cpy

More charges filed against cancer specialist Fata

Rochester Hills, Mich. (WXYZ) - A grand jury hands down 13 new charges on a Detroit-area cancer specialist accused of giving unnecessary treatments to patients.

The new charges against Dr. Farid Fata include fraud, conspiracy to receive kickbacks and fraud during the citizenship process. Dr. Fata has been in custody for six weeks  A judge will consider lowering his bail at an Oct. 2 hearing.

7 Action News spoke with a patient's wife who believes they were victims of the kickback scheme.

Two days before 66-year-old Larry Hicks died from lung cancer, Dr Fata threatened to stop treating him said his wife Donna Hicks.

“I was in a state of shock.  I couldn’t believe a doctor would do that, especially in the presence of a dying patient,” said Donna.

Donna moved out of state after her husband died in 2010.  She said she they told Dr. Fata they wanted to use Hospice of Michigan, but Dr. Fata would not hear it, and wanted them to use the services Guardian Angel Home Care.

“He said, well you should have gone with guardian angels because they know him.  And he said, well, if this what you want, then I can’t be his doctor anymore,” said Donna.

According to federal authorities, Dr. Fata referred patients Guardian Angel Home Care, Inc. in exchange for kickbacks on three separate occasions totaling $3,000 dollars.

“False.  100 percent false,” said Ziad Kassab, Vice President of Guaridan Angel Home Care, Inc.

7 Action News spoke with Kassab at the company’s headquarters in Rochester Hills.   

“We are hurt.  These allegations are not true at all.  Please don’t believe what you’re hearing,” said Kassab.

Kassab refuted all of the allegations in the indictment and said that Dr. Fata was one of about a dozen medical directors.  He only held the position for maybe one year and patients could choose to go where they wanted for home care services.

“We’re surprised as everyone else.  We didn’t know anything about his practices or allegations until we saw it on TV,” said Kassab.

The kickback allegations are just one portion of the new charges.  The federal government said that at least four of Dr. Fata's patients being treated for cancer did not have cancer.

The government said one patient who did not have cancer had 155 chemotherapy treatments.

Federal authorities from the beginning have said that Dr. Fata misdiagnosed patients and ordered unnecessary treatments to make money off of Medicare and other insurance programs.

Fata could lose his U.S. citizenship if the government proves he was committing health fraud when he applied in 2008.

Dr. Fata's attorney Mark Kriger would not talk on camera about the charges but told 7 Action News by phone, “I do not believe it is appropriate to comment on pending cases. I believe the appropriate forum is the courtroom."

Attorney's for victims of Dr. Fata and families of victims have an open meeting at the Concorde Inn in Rochester HIlls Thursday from 5 pm-8 pm.

Read more: http://www.wxyz.com/dpp/news/more-charges-filed-against-cancer-specialist-fata#ixzz2fLr6Sx00

Community-Oriented Pediatric Medical Homes

Dr. Genevieve Daftary, Pediatrics Department | 9/15/2013, noon

A pediatric patient and his mother talk with a medical assistant at Codman Square Health Center. CODMAN HEALTH SQUARE

A Special Advertorial Section

What does a patient centered medical home (PCMH) look like within primary care pediatrics? What is needed from a pediatric- centered medical home within the context of an urban community health center like Codman Square? Our health center achieved the highest tier of recognition from the National Committee for Quality Assurance in 2012, reflecting our commitment and organizational capacity to provide care that is coordinated, patient centered and responsive to health of the population.

The process of achieving PCMH recognition was a reminder that children are not little adults. Our pediatric population struggles with the affects of asthma, obesity, sickle cell disease and attention deficit disorders, all considered chronic medical conditions within children. However, the management of these conditions and the more common issues affecting children and young adults of language delay, school and learning problems, high risk sexual behaviors, drug use and mood disorders do not typically fit well in the model of chronic disease management and episodic health care encounters that has been used in adult settings. If our aim is to be patient centered, how do we design a medical home that addresses these very important needs of the youngest members of our community?

It is interesting to revisit this question when one considers that the American Academy of Pediatrics (AAP) released one of the earliest concepts of patient centered medical home in its 1992 policy report on Medical Home. “The AAP believes that the medical care of infants, children and adolescents ideally should be accessible, continuous, comprehensive, family-centered, coordinated and compassionate.”

This initial policy statement grew out of almost 30 years of work by the AAP on addressing the care of children with special health care needs (CSHCN) and went on to inform more contemporary versions of this concept. This concept of the medical home was revised and expanded on by a coalition of the AAP, the American Academy of Family Physicians, the American College of Physicians and the American Osteopathic Association in 2007 and released as the Joint Principles of the Patient Centered Medical Home. Ultimately the Agency for Healthcare Research and Quality definition emerged and has largely been used to make decisions about accreditation.

While PCMH emerged from pediatrics and the care of CSHCN, the large majority of pediatric patients, both in our population and more broadly, do not have complex medical needs but do have complex social, developmental and psychological needs that have a large impact on their overall wellness now and in the future.

At Codman Square Health Center we have begun to structure a broader community-oriented perspective on patient-centered medical homes for children. We have done this internally using group visit models for children between birth and one year that emphasize shared community and parenting experiences and allow more time with providers to focus on anticipatory guidance. Additionally, we have incorporated the Project LAUNCH program into our support services for families most in need.

This federal grant has allowed us to have a family resource specialist and an early childhood development specialist available within the health center to support those families and children we identify as being most in need of parenting support, behavior coaching, child care resources and developmental assessments and support. These specialists have performed home and school visits, coordinated resources for families whose children are being evaluated for autism and helped coach young families struggling with homelessness, unemployment and single parenthood.

Externally, we have cultivated strong relationships with schools, recognizing that after early childhood, schools become not just the places where children spend most of their waking hours but also micro-communities that serve as a way to engage with students and parents around a variety of health and wellness topics. We enjoy being a resource for consultation on school health policies and programs, a referral resource for health services and an on-site provider of care.

Our longest and strongest partnerships have been with Tech Boston Academy, where one of our nurse practitioners runs a school-based health center, and Codman Academy Charter Public School, the first and only co-located school within a health center in the country. These relationships with schools fit into a belief that integrating education and health care can achieve real community wellness through the reversal of the effects of systemic poverty. As we work with these and other school partners, we are looking to build systems to promote the growth of healthy children who will go on to be leaders of healthy communities. It is a vision for a new patient-centered approach that we are excited to be a part of building.

Codman Square Health Center

637 Washington St, Dorchester, MA 02124

617-825-9660 | codman.org

http://baystatebanner.com/news/2013/sep/15/community-oriented-pediatric-medical-homes/?page=2

Gentiva® Health Services to Acquire Harden Healthcare

- Increases Focus on Dual Eligible Population

- Combines Leading Home Health, Hospice and Community Care Providers

- Company To Host Call Today at 9:00 a.m. ET

ATLANTA, Sept. 19, 2013 /PRNewswire/ -- Gentiva Health Services, Inc. (NASDAQ: GTIV) ("Gentiva" or "the Company"), the largest provider of home health and hospice services in the United States based on revenue, and Harden Healthcare Holdings, Inc. ("Harden"), a leading provider of home health, hospice and community care services, announced today that they have entered into a definitive merger agreement whereby Gentiva will acquire Harden.    

Under the terms of the merger agreement, Gentiva will acquire Harden's home health, hospice and community care businesses. Harden's existing shareholders will retain the company's long-term care business.   The purchase price to be paid by Gentiva is approximately $408.8 million, consisting of $355 million in cash and approximately $53.8 million in Gentiva common stock.  Gentiva expects to fund the cash portion of the purchase price through available cash and a new credit facility.  The Company expects to raise a new $855 million term loan facility to fund the transaction and refinance its existing term loans.      

Founded in 2001 and based in Austin, Texas, Harden operates in 13 states and has a large presence in Texas and several other south central states.  Excluding its long-term care business, Harden's 2012 consolidated revenue was approximately$476.0 million.  

Based on results from continuing operations for the respective companies' 2012 fiscal years, we anticipate the combination of Gentiva and Harden will create a company with revenue comprised of 49% home health revenue, 41% hospice revenue and 10% community care revenue.  The percent of combined company Medicare revenues for the full-year 2012 would have been 72%, down from 86% for standalone Gentiva, thereby reducing the Company's Medicare exposure.

As part of the transaction, Gentiva will become a preferred provider for Harden's 49 skilled nursing and assisted living facilities in Texas.

"This transaction is a great strategic fit for Gentiva and we believe it will provide significant long-term value for our shareholders," commented Gentiva Executive Chairman Rod Windley. "I consider the Harden transaction a milestone in the continued Gentiva growth story.  The increasing healthcare needs of an aging population and ongoing rate pressures will fuel industry consolidation and Gentiva is positioned to be a leader in this effort.  Additionally, I am pleased to announce that current Harden Chairman Steve Hicks will be joining the Gentiva board at the completion of the merger."

"We are excited to welcome the Harden employees to the Gentiva family," said Gentiva CEO Tony Strange.  "Harden is recognized as a leader in the post-acute care continuum for seniors and shares our commitment to quality outcomes, customer satisfaction and employee engagement, all done in an environment of compliance.  In addition to further strengthening our core home health and hospice businesses, this acquisition expands Gentiva's service offerings into the dual eligibles, which is one of America's most frail populations and a key priority for federal and state governments as they seek better coordination of care, reduced costs and improved outcomes.  We believe the combination of these two companies uniquely positions us to provide pre- and post-acute care services in the markets we serve."

Harden CEO Lew Little added, "This merger represents an exciting opportunity to bring together two complementary companies that share a commitment to providing compassionate care and we look forward to better serving our patients and their families with the expanded resources of the combined company."

The transaction was approved by the Board of Directors of each company and by Harden's shareholders. The transaction is scheduled to close in the fourth quarter of 2013 and is subject to customary closing conditions. 

The Company expects the acquisition to be accretive to adjusted income per share, exclusive of one-time costs, within the first 12 months following closing. Assuming the transaction closes in the fourth quarter of 2013 as expected, the Company expects combined 2014 revenues to be in the range of $2.1 billion to $2.2 billion and Adjusted EBITDA to be in the range of $210.0 million to $220.0 million, excluding the impact of equity-based compensation expense.

Edge Healthcare Partners, LLC, a division of Edge Corporate Finance, LLC, is acting as financial advisor to Gentiva.  Greenberg Traurig, LLP is acting as legal advisor to Gentiva.  Barclays and BofA Merrill Lynch have provided committed financing for the transaction.  

Barclays is acting as financial advisor to the Board of Directors of Harden.  Alston & Bird LLP is acting as legal advisor to Harden.

Non-GAAP Financial Measures

The information provided in this press release includes a non-GAAP financial measure, Adjusted EBITDA. Adjusted EBITDA excludes charges related to restructuring, legal settlements, acquisition and integration activities and other special items.  Management uses Adjusted EBITDA to compare operating results with other companies in the healthcare industry.  Adjusted EBITDA should not be considered in isolation or as a substitute for the comparable GAAP measure.

A reconciliation of Adjusted EBITDA to net income attributable to Gentiva shareholders, the most directly comparable GAAP measure, is not accessible on a forward-looking basis without unreasonable effort due to the inherent difficulties in predicting the costs of restructuring, legal settlements and merger and acquisition activities and the impact of any future acquisitions or divestitures, which can fluctuate significantly and may have a significant impact on net income.

Conference Call and Webcast Details

The Company will comment further on this transaction during a conference call and live webcast to be held Thursday, September 19, 2013 at 9:00 a.m. Eastern Time. To participate in the call from the United States, Canada or an international location, dial (973) 935-2408 and reference call #68479531. The webcast is an audio-only, one-way event. Webcast listeners who wish to ask questions must participate in the conference call. Log onto http://investors.gentiva.com/events.cfm to hear the webcast. A replay of the call will be available on September 19 and will remain available continuously through September 26. To listen to a replay of the call from the United States, Canada or international locations dial (800) 585-8367 or (404) 537-3406 and enter the following PIN at the prompt: 68479531. Visit http://investors.gentiva.com/events.cfm to access the webcast archive. This press release is accessible at http://investors.gentiva.com/releases.cfm and a transcript of the conference call will be posted on the Company's website.

About Gentiva Health Services, Inc.

Gentiva Health Services, Inc. is the nation's largest provider of home health and hospice services based on revenue, delivering innovative, high quality care to patients across the United States. Gentiva is a single source for skilled nursing; physical, occupational, speech and neurorehabilitation services; hospice services; social work; nutrition; disease management education; help with daily living activities; and other therapies and services. GTIV-G

Forward-Looking Statements

Certain statements contained in this news release, including, without limitation, statements containing the words "believes," "anticipates," "intends," "expects," "assumes," "trends" and similar expressions, constitute "forward-looking statements" within the meaning of the Private Securities Litigation Reform Act of 1995. Forward-looking statements are based upon the Company's current plans, expectations and projections about future events. However, such statements involve known and unknown risks, uncertainties and other factors that may cause the actual results, performance or achievements of the Company to be materially different from any future results, performance or achievements expressed or implied by such forward-looking statements. These factors include, among others, the following: economic and business conditions; demographic changes; changes in, or failure to comply with, existing governmental regulations; the impact on our Company of healthcare reform legislation and its implementation through governmental regulations; legislative proposals for healthcare reform; changes in Medicare, Medicaid and commercial payer reimbursement levels; the outcome of any inquiries into the Company's operations and business practices by governmental authorities; compliance with any corporate integrity agreement affecting the Company's operations; effects of competition in the markets in which the Company operates; liability and other claims asserted against the Company; ability to attract and retain qualified personnel; ability to access capital markets; availability and terms of capital; loss of significant contracts or reduction in revenues associated with major payer sources; ability of customers to pay for services; business disruption due to natural disasters, pandemic outbreaks, terrorist acts or cyber-attacks; availability, effectiveness, stability and security of the Company's information technology systems; ability to successfully integrate the operations of acquisitions the Company may make and achieve expected synergies and operational efficiencies within expected time-frames; ability to maintain compliance with its financial covenants under the Company's credit agreement; effect on liquidity of the Company's debt service requirements; and changes in estimates and judgments associated with critical accounting policies and estimates. For a detailed discussion of certain of these and other factors that could cause actual results to differ from those contained in this news release, please refer to the Company's various filings with the Securities and Exchange Commission, including the "Risk Factors" section contained in the Company's annual report on Form 10-K for the year ended December 31, 2012.

Financial and Investor Contact:

Eric Slusser
770-951-6101
eric.slusser@gentiva.com

or

John Mongelli
770-951-6496
john.mongelli@gentiva.com

Media Contact:

Scott Cianciulli
Brainerd Communicators
212-986-6667
cianciulli@braincomm.com

http://www.prnewswire.com/news-releases/gentiva-health-services-to-acquire-harden-healthcare-224377691.html