ACAP Opens New Pharmacy Bulletin Board
This week, ACAP launched a new bulletin board for ACAP-member plan staff dedicated to sharing best practices and common challenges around pharmacy. This includes formularies, 340B administration, and prescription drug carve-in/carve-out, among other topics.

ACAP's bulletin boards are an invaluable resource and knowledge base to many plan staff; the discussions engage hundreds of ACAP member-plan staff at all levels of service.

To see and use the roundtables, you'll need to log on to ACAP's Web site using your user ID and password; if you have issues logging on, contact Jeff Van Ness.

All ACAP plan staff are welcome to view and receive e-mail alerts from the pharmacy bulletin board--or any other board, for that matter. Manage your subscriptions by toggling the 'Subscribe to this forum' checkbox on the forum page in question.

Your Photo of the Month
ACAP teamed up with Medicaid Health Plans of America and the Menges Group to participate in the AIDS Walk Washington to benefit the Whitman-Walker Clinic in D.C. The group raised more than $1,100 -- and had a great time running and walking on a beautiful fall morning. Thanks to all who contributed!

Public Policy & Advocacy

"Grand Bargain" on Taxes, Spending Seen As Unlikely as Attention Shifts to Healthcare.gov Stumbles
As the country emerges from the latest completely-unnecessarily-damaging political showdown emanating from Washington, attention has turned to the implementation of the Affordable Care Act, and it hasn't been pretty. The troubled roll-out of the federal marketplace's healthcare.gov Web portal, combined with back-end problems in relaying data about the relatively few enrollees to health plans, has sent the Obama Administration and Congressional Democrats into a defensive posture and given Congressional Republican more fodder to attack the law.

House Committees controlled by Republicans have already scheduled a slate of hearings to understand the scope and origin of the enrollment problems.  Last week, the House Energy and Commerce Committee heard testimony from the private contractors responsible for most of the major elements of the website (the summary of the testimony: "my part works and I'm not responsible for how it all works together").  This week, HHS Secretary Kathleen Sebelius and CMS Administrator Marilyn Tavenner testified before the Energy and Commerce and Ways and Means Committee, respectively.

Concerns that Americans who are unable to register via the Web site could face tax penalties for not having coverage has led to calls among skittish Democrats for an extension of the open enrollment period (currently through March 31, 2014). Still, with the Administration's new healthcare.gov fix-it czar Jeffrey Zients saying that he believes that the Web site would be properly functioning by the end of November, any step toward delaying the individual mandate for a year or extending an open enrollment period are premature at this point.  It's also worth noting that such an action would not require Congressional approval and the Administration could make that decision unilaterally if it chose to do so.

Finally, this week will mark the first meeting of the conference committee to reconcile differences between the House Republican and Senate Democratic version of the budget.  With a seven-week deadline looming and both parties firmly ensconced in their respective positions, few observers anticipate anything substantive to emerge from this conference.  In fact, Senate Majority Leader Harry Reid has already declared a "grand bargain" -- one that involves entitlement cuts and changes to the tax code -- a dead letter.  Instead, most believe that the best that can be hoped for is a renegotiation of the discretionary spending levels under sequestration, or giving the agencies more flexibility to spend money under the sequestration limits. 

But the health care community does need to remain vigilant in these negotiations to ensure that the burden of sequestration is not shifted from the Defense Department to non-defense discretionary spending or that moderate changes in entitlements aren't made to relieve defense cuts. ACAP is closely monitoring developments.

ACAP Opens Nominations for Second Leadership in Advocacy Award
ACAP is pleased to announce the opening of nominations for its second annual Leadership in Advocacy Award. This award helps Safety Net Health Plans to show appreciation for their local Medicaid advocates--and at the same time allows ACAP to highlight the good working relationships our plans have with local advocates to those here in Washington.   

The winner of the Leadership in Advocacy Award will receive a plaque, a donation to charity in their name, and will be asked to join ACAP in Washington for an award ceremony during the February Fly-In.  The winner will also be highlighted in a future ACAP newsletter.  More information is available here; nominations must be submitted electronically to Kathy Kuhmerker no later than November 25, 2013. 

Excellence and Accountability

At AEH Innovations Summit, Meg Murray Talks Churn
On October 3, ACAP CEO Meg Murray was a featured panelist at the 2013 Innovations Summit hosted by America's Essential Hospitals.  

The panel--entitled "What Does Health Reform Mean for Population Health?"--included Jennifer DeCubellis, Area Director of the Hennepin County (Minn.) Human Services & Public Health Department, and was moderated by Dr. Patrick Conway, Chief Medical Officer for CMS and Director of the Center for Medicare and Medicaid Innovation (CMMI).

Meg's presentation addressed the current state of "churn," shared the results of recent research from George Washington University policy experts detailing the extent of churn in states today and showed how continuous enrollment in Medicaid and CHIP leads to lower average monthly costs. She also discussed the barriers posed by churn to quality assessment and improvement, and discussed ACAP's proposals to address churn, many of which are embodied in H.R. 1698, the bipartisan Stabilize Medicaid and CHIP Coverage Act. She also discussed recent developments in the Senate and reminded attendees of the need to implement the Basic Health Program.

Select presentations from the Innovations Summit are available on AEH's Web site; and you may keep up to date on developments related to churn by reading ACAP's mini-site devoted to churn, coverageyoucancounton.org.

Welcome Tanara Blanchard to ACAP!
Recently, Tanara Blanchard joined ACAP as an Administrative Assistant.

Tanara comes to ACAP with 15 years of experience in the administrative and membership field, including 12 years' experience in the non-profit sector.  Prior to joining ACAP Tanara worked for the National Association for Conservation Districts, the National College Access Network, nine years at the American Insurance Association in the law department and two years at the National Association of Home Builders in the Builder Services department in administrative and membership capacities. Please join us in welcoming Tanara to ACAP! 

Commonwealth Fund Seeks Candidates for Fellowship Program
The Commonwealth Fund recently issued a call for applications for the 2014--15 Mongan Commonwealth Fund Fellowship Program in Minority Health Policy. The program trains physician leaders who are dedicated to creating high-performance health systems for vulnerable populations.

Up to five one-year, degree-granting fellowships are awarded per year. Fellows will complete academic work leading to a Master of Public Health (MPH) degree at the Harvard School of Public Health and be provided with core fellowship components such as seminars on leadership and health policy, practicum, forums, conferences, site visits, mentoring, journal club, and shadowing.  Alumni fellows have held leadership positions in 26 different states and a variety of health care delivery, government, and policy settings, including the U.S. Department of Health and Human Services, correctional health systems, the Indian Health Service, safety-net health systems, academic medical centers, and public health departments. 

Further details are available on this Commonwealth Fund blog post by Pamela Riley, a past Mongan fellow.

L.A. Care-Sponsored Free Clinic Comes Later This Week
Should you ever wonder about the pent-up demand for medical services, look no further than the annual Care Harbor event in Los Angeles, which is co-sponsored by ACAP member L.A. Care.

On Monday, thousands of uninsured and underinsured residents lined up to make appointments with doctors and dentists, and receive wristbands that would allow them entry into the event. Some had camped out since the previous Friday.

Fortunately, many of these patients will receive coverage under the Affordable Care Act come January. "For many of these folks, we hope it's the last time they're in this line," said L.A. Care CEO Howard Kahn in a Los Angeles Times article covering the wristband distribution. 

The clinic itself will take place later this week; we will cover it in the next issue of Community News. More coverage (video) of the wristband distribution is here.

Making a Difference Nominee: Polina Kogan of VNSNY CHOICE Health Plans
Since 2005, Polina Kogan has built the Pharmacy department at VNSNY CHOICE Health Plans from a single person to a staff of four pharmacists, and in the process launched several programs specifically designed for low-income populations to improve safe medication practices and reduce financial barriers to accessing needed medications. These efforts garnered Ms. Kogan a nomination for ACAP's 2013 Making a Difference Award.

In one such initiative, Ms. Kogan instituted new ways to educate dual-eligible and low-income members on financial subsidies offered by pharmacies and drug manufacturers to help members bridge financial barriers to needed medications.  She also designed and launched an interactive voice response system to members that features reminder calls in an effort to drive refills, improve adherence to medication, and reduce avoidable hospitalizations and physician visits. This program includes follow-up calls with case managers to assess and address contributing factors to medication non-adherence, including health literacy, access, or simple miscommunication. The program has resulted in measurably improved access, adherence and management of chronic conditions such as diabetes and hypertension.

Ms. Kogan's commitment and efforts to improve quality and patient safety have benefited tens of thousands of VNSNY CHOICE members--especially the most vulnerable. She makes it a point to review alert data for drugs that are recalled, leads interventions to make members aware of potentially adverse drug interactions, and works with physicians to discontinue use of any medications that could be dangerous to senior citizens.

Above and beyond her primary duties, Ms. Kogan serves on the Pharmacy Quality Alliance advisory panel, which develops medication-related quality review criteria for CMS.

As noted by VNSNY CHOICE Health Plans President Christopher Palmieri in his nomination letter, "identifying and addressing prescription fulfillment barriers and improving quality for all our members have been at the heart of Polina Kogan's work… as a result of Polina's efforts, our members are safer."

We at ACAP applaud Polina Kogan's efforts in Making a Difference.

Safety Net Health Plan News

Christopher Gorton is Network Health's New President
Christopher "Kit" Gorton, M.D., was recently named president of ACAP member Network Health. 

Gorton was most recently CEO for Amerigroup Virginia, a Medicaid managed care organization that served nearly 57,000 members. Prior to Amerigroup, Gorton served as vice president of medical management and worldwide health care services at HP Enterprises Services and as chief medical officer and president of commercial programs at APS Healthcare Inc. He also served as Chief Medical Officer for the Pennsylvania Department of Public Welfare.

"Kit is an accomplished leader, with expertise in working with Medicaid and its managed care programs, health care analytics, and medical and behavioral health management," said Tom Croswell, president and COO of Tufts Health Plan. "He brings the breadth of experience we need to deliver on our goals and best serve our members." (Tufts Health Plan acquired Network Health in 2011.)

Gorton began his career as a practicing pediatrician in federally-qualified health centers, and taught at the Penn State College of Medicine. In addition to a B.A. from Dartmouth and a medical degree from Columbia, he holds a Master of Science in health administration from College of St. Francis in Illinois.

Two ACAP Plans Grow Their SNP Service Areas
As marketing season for Medicare Advantage is now under way with open enrollment soon to follow, two ACAP plans are growing their presence in the market to serve dual eligibles. 

Affinity Health Plan plans to expand its presence beyond New York City to five surrounding counties: Nassau, Suffolk, Westchester, Rockland and Orange.

And in Illinois, Community Care Alliance of Illinois, a wholly-owned subsidiary of ACAP member Family Health Network of Chicago, has received licensure from the State and approval from CMS to offer a SNP for dual eligibles in Chicago and the Rockford area; their service area includes Cook, Kane, Dupage, Will, Boone, Winnebago, McHenry, and Ogle counties.

More information is available in this Medicare Advantage News piece--note that it's behind a subscriber wall.

Family Health Network, Sinai Urban Health Institute Awarded Gold Honors by URAC for Asthma Program

As noted in the last issue of ACAP Community News, Family Health Network (FHN) of Chicago won Gold Honors for Health Care Consumer Engagement and Protection by URAC, a leading national health care accreditation organization. The award, which highlights best practices among health plan in advancing the role of consumers as active participants in health care, recognized the Asthma CarePartners program, a partnership between FHN and Sinai Urban Health Institute.  

The Asthma CarePartners program uses community health workers to educate asthma-affected individuals about the disease, its triggers, and proper management in their homes and over the phone.

"This is a great honor for FHN and SUHI," says Keith Kudla, Family Health Network's President and Chief Executive Officer. "It's a terrific example of how we work collaboratively with our medical providers to improve access to medical care and improve outcomes for the families and individuals we serve."

This is not FHN's first recognition for such partnerships: it has won three prior awards from URAC for its collaboration with PsycHealth in efforts to improve behavioral health care. 

More information about the awards is available on URAC's Web site, or FHN's press release.

Partnership HealthPlan Names Kisliuk Northern Region Exec. Director
Last week, Partnership HealthPlan of California (PHC) introduced Margaret Kisliuk as the Executive Director of its new Northern Region. Readers of ACAP Community News know that Partnership has dramatically expanded its service area in recent months into eight counties in northern California.

Ms. Kisliuk was previously at the Marin County Department of Health and Human Services as the Chief Assistant Director, Director of Public Health Programs and the Director of Mental Health & Substance Abuse Programs. (Yes, all three at once!) Her previous health plan experience includes service as the CFO and Assistant Executive Director at MetroPlus Health Plan in New York. She is set to begin on November 11.

Gold Coast Health Plan's New Web Site Garners Awards
ACAP member Gold Coast Health Plan (GCHP) recently won two notable awards for its recently-redesigned Web site.

GCHP was presented with the Merit Award in the website category of the health systems division in the 15th annual Web Health Awards program. The GCHP Web site was chosen from nearly 600 entries by a panel of distinguished experts in the digital health media.

The GCHP Web site was also honored with an American Graphic Design Award by Graphic Design USA (GDUSA), a news magazine for graphic designers and other creative professionals. Among more than 8,000 entries, only 15 percent were recognized and received awards.



ACAP Meetings

There's Still Time to Register for ACAP's Medicare and Quality Meetings in Scottsdale
Registration is now open for two key ACAP meetings set to take place in Scottsdale, Arizona in mid-November.

ACAP's Fall Medicare and Managed Long-Term Care meeting is scheduled for Tuesday and Wednesday, November 19 and 20. It will be followed immediately by ACAP's Fall Quality Meeting, which will take place on Wednesday and Thursday, November 20 and 21.    

You can now register for either meeting, or both, here.  

The Meetings will take place at:
Hyatt Regency Scottsdale Resort and Spa at Gainey Ranch
7500 E. Doubletree Ranch Road
Scottsdale, AZ  85258
(480) 444-1234
Reserve your hotel rooms here. 

Don't miss this great networking opportunity -- mark your calendars today.  As always, there is no registration cost for ACAP members to attend the meeting.  Please visit ACAP's Web site for periodic updates about this meeting and other ACAP resources. 

October 24: Navigating Commercial Risk Adjustment: Is Your Health Plan Set for Success? hosted by Verisk Health
This presentation discussed the latest risk adjustment techniques and best practices to ensure accurate reporting of your members' health. It explored ways to quantify population risk, optimize data compliance and revenue integrity, and ensure quality improvement. 

Other topics covered include Edge Server management techniques to ensure data integrity; improving data compliance and associated revenue by identifying undocumented conditions; multi-faceted approaches to efficiently capture risk through member and provider engagement; and effective care management initiatives featuring targeted member outreach.

October 22: The Value of PBM Oversight hosted by Solid Benefit Guidance
This presentation provided examples of potential audit issues; ways to identify and address fraud, waste, and abuse; and an outline of PBM contract issues and the impact they have on PBM financials.

October 15: Chronic Care Opportunities and Challenges for Medicaid Managed Care Under the Affordable Care Act hosted by PPSV
This Webinar addressed new ACA requirements related to serving the Medicaid population, including essential health benefits and alternative benefit plans; Medicaid eligibility expansion; Medicaid managed care for long-term services and supports; new Medicaid long-term care initiatives; management of pharmacy benefits and 340B programs; and lessons to be learned from Medicare, including shared savings models and special-needs plans.

CTG to Offer ACAP Members Special Pricing on Medical Analytics Packages

ACAP Preferred Vendor CTG has prepared an exclusive offer for ACAP-member plans: discounted pricing on its financial and medical claims analytics software packages--Medical Informatics Suite of Solutions and Technologies (MISST) and Comprehensive Claims Integrity Audit (CCIA). CTG's software solutions, coupled with its consultants' backgrounds in medical coding and billing, data analytics, and state and federal regulations, collect and analyze large amounts of claims data and trends, leading to meaningful, actionable results.

CTG has developed flexible and comprehensive healthcare informatics software based on its extensive experience in the provider and payer markets. Drawing on more than 600 healthcare engagements in the past 25 years, CTG's consultants have deep experience in developing data-driven solutions to the issues faced by its clients. These customizable, powerful solutions focus on actionable findings with goals of improving patient care and decreasing the amount of unwarranted claims.

CTG's Medical Informatics Suite of Solutions and Technologies (MISST) is a software-as-a-service (SaaS) that can reduce expenses for healthcare organizations related to hospital readmissions, among other areas.

CTG's proprietary Comprehensive Claims Integrity Audit (CCIA) software enables ACAP members to reduce unwarranted medical spending. Findings from CCIA include recoverable claim payments and errors, waste, and abuse recoveries.

Examples of how CTG's software can be used by healthcare payers and providers include:

• Providing evidence for reducing emergency admissions/readmissions for various chronic conditions; these analytics can focus on high-cost, high-impact conditions like chronic kidney disease (CKD) and congestive heart failure (CHF), and are expandable to other areas.

• Creating a Risk Registry and early detection of diseases (preconfigured for CKD and CHF) that identifies potential intervention points for diseases beyond CKD and CHF.

• Offering an option for clinical outreach services to maximize the impact of these analytical results. This option is coordinated with the health plans' clinical staff to capitalize on analytics results. 

• Generating a retrospective snapshot of paid claims to determine if any additional actions should be taken to recover erroneous payments

What type of investment is involved?
CTG will provide MISST through a combined software as a service (SaaS) consulting engagement, with a special discount per member, per month for ACAP plans beyond normal market rates. In addition, multi-year licensing discounts will be applied.

For CCIA services, CTG will bundle this offering in parallel with the MISST offerings and will not charge any separate set up or initial licensing fees. CTG will deliver CCIA services for a fee of 25 percent (which is a discounted rate) of recovered savings and 10 percent of prospective savings for the next 12 months as negotiated with each ACAP plan client. The prospective savings amount is the payment that CTG has identified that can be avoided for future payments through medical policy changes, billing policy changes, benefit changes, claim edits, administrative policy changes, and provider reimbursement contract changes.

For more information, contact John Hoben at 585-370-0847 (email) or Rich Romanski at 321-544-3839 (email).

ACAP STRATEGIC ALLY
Health Integrated | about the Strategic Alliance

ACAP PREFERRED VENDORS
340(b) Drug Pricing: PerformRx
Actuarial and Data Services: Cirdan Health Systems and Consulting
Analytics, Business Intelligence and Performance Management: CTG, MedeAnalytics, The Menges Group
Behavioral Health: Beacon Health Strategies, PerformCare
Business Process and IT Services: TriZetto
Business Process Outsourcing: TMG Health
Care For High Risk Members: Optum, The Menges Group
Care Coordination/Management Technology Solutions: Altruista Health, CaseTrakker
Compliance Software: Compliance 360
Dental: Avesis
Disease Management: Accordant Health Services, a CVS Caremark company
Executive Search and Recruitment: Morgan Consulting Resources
Fraud, Waste and Abuse: Verisk Health
Group Purchasing: CommonWealth Purchasing Group, LLC
Health Literacy/Plain Language Software: Health Literacy Innovations
Health Management Solutions: Health Integrated
Hearing: Avesis
HEDIS Compliance and Reporting: Verisk Health
HIPAA/HITECH Compliance Software & Consulting: Clearwater Compliance
IT Consulting Services: InfoArch Consulting, Inc.
Legal Services: Epstein Becker Green, Powers Pyles Sutter & Verville
Management Consulting: HTMS, an Emdeon company
Marketing: DeltaSigma, LLC
Member Assessments: MedXM, Optum
Member/Provider Communications Consulting and Software: Cody Consulting Services
Network Development: Creative Health Concepts/WeiserMazars
Non-Emergency Medical Transport Management: Coordinated Transportation Solutions
Patient Communication Services: CommonWealth Purchasing Group, LLC
PBM Solutions: Excelsior Solutions, The Pharmacy Group, Solid Benefit Guidance
PCMH Transformation Support: Discern Consulting
Pharmacy Benefit Managers: Catamaran, MedImpact, Navitus Health Solutions
Quality Measurement/Payment Reform: Discern Consulting
Radiology Benefits Management: Care to Care
Reinsurance Services: RBS Re, Summit Re
RFP Strategy and Response: DeltaSigma, LLC, The Menges Group
Risk Adjustment: Altegra Health, PopHealthMan, Verisk Health
Specialty Formulary Management: CDMI
Specialty Pharmacy: Accordant Health Services, a CVS Caremark company; Amber Pharmacy, Welldyne, Inc.
Strategic Consultants: DeltaSigma, LLC
Strategic Government Business Solutions: ClearStone Solutions
Subrogation: First Recovery Group
TPL Subcontractors: HMS
Vision: Avesis, Block Vision
Web Portals/SaaS: Health X