Monday, November 16, 2015
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By Chris Bragg
Sunday, November 29, 2015
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BY Heidi Evans
NEW YORK DAILY NEWS
Sunday, April 5, 2015, 2:30 AM
Her hands trembling, and eyes brimming with tears, Patricia Almonte pressed a stethoscope to her ears and listened to her daughter’s heart beating in another little girl’s chest.
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By ANEMONA HARTOCOLLIS
MARCH 30, 2015
For a generation, doctors in New York’s economically depressed neighborhoods have been the ugly ducklings of the medical hierarchy. Many are foreign born and foreign trained, serve mostly minority and immigrant patients, and often run high-volume practices to compensate for Medicaid’s low rate of payment.
Now these doctors are in the vanguard of an experiment to transform New York’s health care services for the poor from a disorganized hodgepodge into coordinated networks of doctors, hospitals and other practitioners.
Medicaid officials hope to inspire these providers to work together and take a more active role in looking after their patients’ health, rather than simply waiting for them to show up when ill. The hope is that if they can do a better job of getting patients to, for example, quit smoking or manage their diabetes, doctors could reduce costly visits to hospitals and their emergency rooms.
Versions of this model, commonly called accountable care organizations, are appearing around the country for Medicare recipients, with mixed results. New York, which has the country’s largest Medicaid budget, is committing more than $1 billion a year for five years to the experiment. If it works, more could follow.
“If we succeed, patients will be more likely to get the right tests and medicine, doctors will benefit as we simplify the business side of their practices, and businesses will benefit as we hold down health-care cost growth,” Sylvia M. Burwell, secretary of the federal Department of Health and Human Services, said this month in New York City, during a visit to promote accountable care organizations.
At the start, doctors will still be paid as they are now, typically with a fee for every service — a payment model that has been blamed for the nation’s long increase in health spending. The doctors will be eligible for bonuses if their teams improve the health of the patients assigned to them, who generally have used them in the past.
In the future, if the experiment works, providers may be paid solely based on outcomes rather than volume of services, with better-performing groups earning more than those whose patients are in worse shape.
Given the amount of money involved, the New York State project, which goes by the ungainly name of Delivery System Reform Incentive Payment program, has created unlikely alliances, mainly between competing hospitals. In many cases, doctors and hospitals from different groups have served the same patients, and the jockeying over who would get to claim them — and the government money they would bring — was so fierce that the Medicaid inspector general had to step in to resolve territorial disputes.
Perhaps the most unusual alliance is one that brought together more than 1,000 primarily Hispanic doctors serving Upper Manhattan and the South Bronx and Asian doctors working in the Chinatowns of Manhattan, Brooklyn and Queens; and North Shore-Long Island Jewish Health System, a hospital chain that serves a largely middle-class population. The nonprofit venture they formed, called Advocate Community Providers, counts more than 770,000 patients, by far the most of the 25 groups taking part in the program.
The doctors are winning respect for the characteristics that once hurt them. “They have not turned their back on the Medicaid population; they have sort of embraced it,” Jason Helgerson, the state’s Medicaid director, said. “They speak their language. They understand their culture. They are based in the neighborhoods in which these people live.”
The force behind this group is Dr. Ramon Tallaj, a former health official in the Dominican Republic who moved to the United States in 1991. Dr. Tallaj, 59, turned an unrelated collection of small medical practices into a united force of 1,200 physicians called Corinthian Medical I.P.A.; they use their combined clout to negotiate with insurance companies and, in this case, the state.
Dr. Tallaj also is politically active. Since 2003, he has given at least $157,000 to Democrats, Republicans and the Latino Victory political action committee, including the maximum of $64,800 to the Democratic National Committee in 2013-14, according to campaign finance records. He has visited the White House at least five times, according to White House records, usually as part of large social or health care events, including the signing of the Affordable Care Act, and he has been photographed at least twice with President Obama at more intimate donor events.
But his path has not always been smooth. In 2008, a federal civil complaint accused Dr. Tallaj and a partner, St. Vincent’s Midtown Hospital, of using unlicensed foreign doctors at a clinic they ran on Academy Street in the Inwood section of Manhattan. In a settlement, the hospital said it was solely responsible for hiring and credentialing and agreed to pay $210,000; Dr. Tallaj said he did nothing wrong.
Looking tropical in a linen guayabera shirt, Dr. Tallaj rose to the podium in Albany last month to talk to a state Medicaid panel about his new coalition.
Where other groups gave PowerPoint presentations studded with jargon, Dr. Tallaj showed a video testimonial that cut from playground basketball to Asian and Hispanic doctors extolling their dedication in their own languages.
“We are the transformation that New York has been waiting for,” Dr. Tallaj said, first in Spanish and then in English, as if he were addressing a political rally. “We are different.”
When he was done, the panel burst into applause, and one member was so moved she proposed adding “bunches of points” to the score for Dr. Tallaj’s group, which could bring it millions of extra dollars.
For each group the state will set goals for a range of measures, such as how well the group manages diabetes cases — based on those patients’ eyesight, cholesterol readings, kidney function and other tests — and whether it can reduce preventable hospital admissions, such as those created by poor follow-up care. A group can get a bonus each year by making progress toward its goals.
But some of the Medicaid panel members questioned the logic of having such a large, diverse group of doctors and patients like Dr. Tallaj’s, without any obvious connections among them.
“What’s the glue that holds them together?” asked Stephen Berger, a panel member and investment banker. Mr. Helgerson suggested it was the loyalty of their patients.
The sheer size of the group could also make it complicated to track patients and determine who deserves credit for any improvements in their health. Patients may continue to see any doctor they wish, even if that doctor is not in the group.
“I think we’ve learned in New York City that no patient is an island,” Mr. Helgerson said. “They tend to migrate around.”
Likewise, Dr. Tallaj acknowledged that if his patients did well, he could reap the benefits even if he had not seen them, though he said that was not his motivation.
“One of my sons said: ‘Why are you doing this? Are you going to be making money?’” Dr. Tallaj recalled. He replied, “Because this is the right thing for our community, our patients.”
Dr. George Liu, another leader in the group and an endocrinologist with offices on Canal Street in Manhattan’s Chinatown, said it would be a cinch for the Asian community doctors to meet the hospital admission benchmarks because their patients already did not go to the hospital very often.
“People say, ‘You’re not providing the services, maybe that’s why your patients don’t go to the emergency room,’” Dr. Liu said, chuckling, in his office stuffed with knickknacks given to him by patients.
On the contrary, he said, “I frequently see patients until 3 o’clock in the morning.”
Accountable care organizations are still relatively new in health care, and New York’s experiment is one of many underway. One closely watched federal project that began in 2012 with 32 provider groups spread around the country produced overall savings and improved patients’ health, but some groups that did not save enough money have left, according to an analysis by the Brookings Institution. The government is now tinkering with that design.
Uwe Reinhardt, a health economist at Princeton, thought the idea was not as promising as some had hoped. “People thought there was maybe more waste than there actually really is,” he said.
Dr. Reinhardt was also dismissive of performance bonuses for doctors. “The idea that everyone’s professionalism and everyone’s good will has to be bought with tips is bizarre.”
But Mr. Helgerson said that the current model of paying for every test and procedure was not working, and that New York had to look for a new way.
“Is it easy and is it guaranteed?” he said. “The answer is no.” But he added, “At the end of the day, our belief is the current path, this fee for service path, is fraught with peril.”
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Provision would add 'skill' to VLTs
Measure could create some 100 jobs and increase education revenue
By Chris Bragg
Published 8:49 pm, Monday, March 30, 2015
A provision in the state budget gives New York's racinos the green light to offer an expanded array of electronic gaming featuring elements of "skill" at video lottery terminal facilities.
"The provision could include such games as certain types of electronic blackjack, three-card poker and other video lottery games where an element of skill and player interaction may be incorporated into games of chance," said state Gaming Commission spokesman Lee Park in an email. "In essence, it is simply codification of case law, for the avoidance of doubt."
The measure — included in the Revenue budget bill introduced over the weekend — was meant to guard against legal challenges asserting these types of games involving some degree of "skill" were unauthorized. VLTs, popularly known as video slot machines, are purely games of chance.
James Featherstonhaugh, a prominent lobbyist who is an owner of the Saratoga Casino and Raceway, said he plans to provide the new skill-based games to his customers as soon as possible.
"We think our customers are looking forward to it," Featherstonhaugh said. "We can't wait."
The Hotel Trades Council union, which represents racino works and made passage of the provision its top budget priority, said it will create more than 100 new jobs at facilities represented by the HTC, as well as added tax revenue for education.
"This language helps protect hundreds of millions in gaming revenue that flows to the state, adds $20 million a year to the budget and creates good middle class jobs," said Josh Gold, the union's director of political and strategic affairs.
The Gaming Commission maintains the provision would bring in $20 million in its first year, and $40 million in subsequent years. But critics of the gaming industry say the northeastern market is growing saturated and doubt its long-term business prospects.
New York has VLTs at its nine racinos, but the change would apply to only six, according to Park: Saratoga Casino and Raceway as well as Resorts World Casino New York City in Queens, the Empire City Casino at Yonkers Raceway, Monticello Casino and Raceway, Tioga Downs and Vernon Downs. Three others would be excluded from the provision because they lie in the Seneca Nation's gaming exclusivity zone.
Gov. Andrew Cuomo included the provision in his budget proposal. Former Speaker Sheldon Silver removal from his post earlier this year amid corruption charges meant a well-known opponent of the gambling industry was removed from leadership of the chamber. At the same time, two new gambling parlors that would benefit from the added gaming options are set to open on Long Island, a stronghold of Senate Republicans, which is represented in part by Senate Majority Leader Dean Skelos.
Other interests that pushed for the provision included the Malaysian gaming giant Genting, which operates Resorts World, the Nassau Regional Off-Track Betting Corp., and Yonkers Racing Corp., according to lobbying disclosures.
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Oversight panel swoons over doctor-led network
Friday, February 20, 2015
Advocate Community Partners was the highlight of yesterday’s meeting of the panel tasked with reviewing the DSRIP project scores for 25 Performing Provider Systems. The group is the only physician-led PPS of the bunch.
DSRIP Project Approval Oversight Panel member William Ebenstein called the network the most exciting and innovative the oversight body had reviewed. He heralded the use of community physicians as the key to reducing avoidable hospitalizations. That tactic, he said, differed from other PPS networks that had underutilized doctors in their plans.
Panelist Judy Wessler, who is critical of academic medical centers applying for DSRIP funds, was impressed by the application. She said it fully addresses cultural competence, the issue of how providers will address health disparities in their community and improve understanding of the health care system among residents.
Dr. Ramon Tallaj, chief executive and medical director of AW Medical, presented on behalf of the PPS. He emphasized the importance the network has placed on primary care and treating patients in their communities with providers who are capable of speaking to them in their native languages.
ACP had the largest patient attribution in the state, at 769,089 New Yorkers.
“There is a tremendous amount riding on their success,” state Medicaid Director Jason Helgerson said of the network.
The PPS spans Manhattan, Brooklyn, Queens and the Bronx. AW Medical, the PPS lead entity, represents 2,500 providers, including 2,000 physicians, who are members of eight independent practice associations and three accountable care organizations.
North Shore-LIJ, which has five hospitals in the PPS’ service area, partnered with AW Medical and will provide a number of administrative functions for the PPS.
Panelist Stephen Berger offered the only skepticism, questioning how the governance structure will be “the glue” that will hold a broad network of physicians together.
The panel awarded an additional 3.92 points to Advocate's score across various sections—the greatest increase for any of the 17 networks reviewed so far. Based on Mr. Helgerson’s estimate that a single point could be worth about $1 million to $3 million in funding to a large PPS, the panel’s adjustment could be worth as much as $12 million.
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On Tuesday, the State of New York took a baby step—or maybe a giant leap!—toward making the United States of America something more closely resembling a modern democracy: Governor Andrew Cuomo signed a bill joining up the Empire State to the National Popular Vote (N.P.V.) interstate compact.
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