Portland-area competitors try working together to cut costs for Oregon Health Plan

Published: Wednesday, April 04, 2012, 4:24 PM     Updated: Wednesday, April 04, 2012, 6:47 PM

By Nick Budnick, The Oregonian

A new push to reshape health care in greater Portland is reminiscent, its biggest booster says, of the race to land a man on the moon.

Erstwhile health care competitors hope to set aside their differences to care for the region’s 200,000 Oregon Health Plan members, says Legacy Health CEO George Brown. The task is happening in a timeline — Brown snaps his fingers — “that’s like that long. It’s a moon shot for sure. What we’re trying to do, to my knowledge, has not been attempted any place in the country.”

While the space analogy might seem a stretch, it’s no exaggeration to say Brown’s effort faces steep challenges. He leads a loose group of medical and mental health providers from Clackamas, Washington and Multnomah counties that earlier this week notified the state of plans to join efforts to better manage Medicaid spending.

The group aims to have a more detailed application in to the state by the end of the month. However, several members of the group, such as Tuality and Providence, have also sent their own letters to the state, saying they will set up their own care organizations if this group does not come together as planned. In all, 68 private companies and nonprofits have notified the state of their desire to qualify under Oregon’s reforms.

The obstacles are many. In Portland, the goal of operating by August is a tight one. Other care organizations formed under the state law won’t have as many competitors joining up. Federal funding has not materialized either locally or statewide. And the goal – to use new concepts to save money and improve health for low-income people in the region – has not been applied on so grand a scale.

One obstacle the new coordinated care organization won’t have to face is the U.S. Supreme Court. While headlines lately have focused on a challenge to the new federal law focused on Medicare and commercial insurance, Oregon’s law is different, pushing providers into better coordinated care for state Medicaid recipients.

The carrot? A cut of whatever savings the new Oregon health provider groups can find by moving away from traditional fee-for-service care. There’s possible federal funding as well as access to a potentially lucrative market in the future: public employees. Over time, Gov. John Kitzhaber envisions the new coordinated care organizations as serving teachers and state workers.

Though managed care groups already operate in Oregon, the new ones may be larger. The Portland area group calls itself the TriCounty Medicaid Collaborative and includes Providence Health & Services, Oregon Health & Science University, Tuality Healthcare, Kaiser Permanente, Adventist Health, federally funded community health clinics and health departments of Clackamas, Multnomah and Washington counties.

The region’s largest Medicaid provider group, CareOregon, hopes to join the new group, though it won’t cast a final vote until later this month. “It’s an unproven area, and it’s scary,” says CareOregon CEO Dave Ford. “But it’s exciting. It’s going to be an unfolding drama”

In contrast, a competing provider network of 1,500 doctors and nurse practitioners that has participated in discussions expects to go its own way. “The darn thing is so nebulous you really don’t know what they’re doing,” says Jeff Hetherington of FamilyCare.

The would-be collaborative expects to hear any day on a $34-million grant it requested in federal startup funds. The grant application promises focused efforts on those eligible for both Medicare and Medicaid, meaning they are not only poor but elderly or otherwise disabled, about 16,000 in all. The group will encourage healthy lifestyles among all Oregon Health Plan members, not just those most in need of care.

Other money could become available, too. Oregon hopes to hear by August whether it will receive $2.5 billion in federal funds to support its reforms.

Brown says the ongoing discussions, conducted in private, could lead to a federally sanctioned nonprofit.

The new group is dominated by health plans. In theory, their hospitals have the most to lose fiscally from a healthier population. Does it make sense to put them in charge of the new reforms?

“I know that cynical view,” Ford says. “This is more than rhetoric. These guys are activating their organizations in ways I haven’t seen before.”

Brown, for his part, says serving Medicaid patients is not a profit center for hospitals, moreover, participants are setting aside self-interest. “It just absolutely is surprising to me. The greater good has been held out as the right thing to do and the path to follow.”

Nick Budnick

Surcharge for smokers on Medicaid

Bill seeks surcharge for Utah smokers on Medicaid

By Brian Passey, USA TODAY

ST. GEORGE, Utah – If private health insurers can add a surcharge for smokers, why not Medicaid?

  • By Victor R. Caivano, AP

    Utah Republican Rep. Paul Ray is proposing that the state impose a higher co-pay on Medicaid residents who use tobacco.

By Victor R. Caivano, AP

Utah Republican Rep. Paul Ray is proposing that the state impose a higher co-pay on Medicaid residents who use tobacco.

That’s the argument behind a bill Utah Republican Rep. Paul Ray has proposed that could become a first-in-the-nation state law imposing a higher co-payment for tobacco-using residents enrolled in Medicaid.

Although Medicaid recipients in Utah do not pay premiums, some are required to pay up to $5 co-payments for prescriptions or doctor visits.

According to the American Lung Association, smokers enrolled in Medicaid smoke at a rate 60% greater than the general population. Ray said smokers on Medicaid cost Utah $104 million annually. “If they’re paying $7 a day for a pack of cigarettes, they should be able to pay a $2 to $3 co-pay,” Ray said.

Ray said he believes his proposal is unique among state Medicaid programs. Alper Ozinal, a spokesman from the Centers for Medicare & Medicaid Programs, said his agency is not aware of other states that have considered similar legislation

Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, a health industry trade association, said many health insurance providers have chosen to implement surcharges on smokers because of the broad recognition that smoking increases health complications and resulting health care costs.

The American Lung Association opposes the proposed co-payment. There is no evidence that it would encourage smokers to quit, said Jennifer Singleterry, the association’s manager of cessation policy. Instead, low-income smokers on Medicaid would just have to pay more. “We feel that this is a punitive measure for smokers,” she said.

Gary Nolan, U.S. director for the Citizens Freedom Alliance, a property rights and smoker advocacy organization that also opposes the proposed law, added that legislation that affects smokers is easy to pass because smokers do not represent a large voting demographic.

The bill went before the Utah House Government Operations Committee on Thursday. It is being modified to include a wellness aspect with a smoking cessation program. Ray said he plans to bring it back before the committee next week. He said he does not expect much opposition within the heavily Republican House and Senate.

Ray said he would like to eventually extend the idea to an entire wellness program that would include obesity and alcohol use.

“I’m not trying to do this to punish people,” he said. “I’m doing this to encourage people to be healthy.”

Contributing: Passey also reports for The Spectrum in St. George, Utah

Dentist uses paper clips in Medicaid Root Canals

Dentist pleaded guilty, paper clip used in root canals
Updated 1d 1h ago
NEW BEDFORD, Mass. (AP) – A former dentist in Massachusetts has pleaded guilty to Medicaid fraud for using paper clips instead of stainless steel posts in root canals.

A former dentist in Massachusetts has pleaded guilty to Medicaid fraud for using paper clips instead of stainless steel posts in root canals.
ext Monday after pleading guilty last week in New Bedford Superior Court to a variety of charges, including defrauding Medicaid of $130,000 assault and battery, illegally prescribing prescription drugs and witness intimidation.
Prosecutors say the 53-year-old Clair was suspended by Medicaid in 2002, but continued to file claims from August 2003 to June 2005 by using the names of other dentists in his Fall River practice.
Authorities say instead of stainless steel posts for root canals, he used sections of paper clips — which can cause pain and even infection — in an effort to save money.

American Medical News story about Ohio Medicaid Plan

Ohio governor proposes Medicaid shared savings

Gov. John Kasich also wants a single care manager and benefits access point for people eligible for both Medicare and Medicaid.

By Doug Trapp, amednews staff. Posted Jan. 20, 2012.

Ohio Gov. John Kasich has begun a dual effort to transform the state’s Medicaid program to pay based on the quality and coordination of care provided to enrollees.

In early January, the Ohio Governor’s Office of Health Transformation announced that it was seeking public and stakeholder input on a proposal to create a single point of benefits administration for Ohioans who are eligible for both Medicare and Medicaid. The state also is rebidding its Medicaid managed care contracts to emphasize quality beginning in 2013. The Ohio Legislature endorsed these and other goals in a budget bill adopted in 2011.

“In Ohio and across the country, we must do a better job of meeting the health needs of individuals and creating a healthy and productive work force at a price that is affordable for businesses, governments, individuals, and other payers,” said Greg Moody, director of the governor’s health transformation office.

Kasich proposed creating a single point for benefits administration for the 190,000 Ohioans eligible for Medicare and Medicaid. Typically, Medicare pays for doctor and hospital visits and prescription drugs for these dual-eligible beneficiaries. Medicaid mostly pays for their long-term care, including nursing home stays.

The Kasich administration’s draft dual-eligible proposal — called an Integrated Care Delivery System — would assign each beneficiary to a care manager to ensure seamless care transitions. The program also would include periodic home visits with enrollees, aggressive reviews of hospital admissions and nursing home placements, and a centralized record for each beneficiary.

Ohio’s proposal is based on its application for one of 15 federal grants of up to $1 million to design dual-eligible care programs. In April 2011, the federal Centers for Medicare & Medicaid Services awarded the grants, which were made available through the national health system reform law. Ohio was not an awardee.

The Ohio dual-eligible proposal would solicit bids from outside organizations to provide care to the beneficiaries. It requires federal approval, but CMS has outlined two paths states can take regarding such programs, according to Ohio Medicaid director John McCarthy A dual-eligible managed care program — Ohio’s choice — would allow state and federal health officials to set program capitation rates in advance to achieve a savings target. A fee-for-service program would not include a maximum budget but would share savings generated in the previous year through care coordination and other efforts, he said.

McCarthy said physician- or hospital-directed accountable care organizations could bid to care for dual eligibles, but that the work will not be easy. “Setting capitation rates and measuring risk isn’t going to be straightforward in this population,” he said.

McCarthy said the state does not want to achieve savings by reducing Medicaid physician fees, but wants physicians to benefit from gains in quality and efficiency by sharing in the savings.

The governor’s office has listened to physicians while crafting the proposals, said Tim Maglione, senior director for government relations for the Ohio State Medical Assn. “We feel that we have the opportunity for meaningful input on the development of this program.” The state began two months of public input meetings on Jan. 12, McCarthy said.

Nationwide, 9 million people are eligible for both Medicare and Medicaid, according to CMS. These beneficiaries account for a disproportionate share of the $300 billion in annual Medicare and Medicaid spending. More than 2.1 million people are enrolled in Ohio’s Medicaid program. Seven managed care plans serve more than 1.6 million Medicaid enrollees, including 125,000 aged, blind and disabled people, and 37,000 children with special needs, according to Kasich’s office.

The Ohio State Medical Assn. has not adopted formal positions on either proposal, but the state’s emphasis on quality and administrative simplification are good goals, Maglione said, adding, “I do think they’re on the right track.” Maglione also said he believes the state will hold managed care plans accountable for their quality performance.

Many Ohio physicians continue to see Medicaid patients even though state fees sometimes do not cover physicians’ costs, Maglione said. Ohio Medicaid physician fees are between 65% and 70% of Medicare rates, although some Medicaid managed care plans pay more to ensure adequate networks.

More information about the Ohio reform plans are available online from the governor’s Office of Health Transformation (healthtransformation.ohio.gov/). Information also is available from the Catalyst for Payment Reform website (www.catalyzepaymentreform.org/).

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Copyright 2012 American Medical Association. All rights reserved.

Aetna CEO says inidividual Mandate Doesn’t Matter

Healthcare Individual Mandate Too Weak to Matter, Aetna CEO Says

from Insurance Journal

Wall Street’s concern about the U.S. Supreme Court’s looming decision on President Obama’s healthcare overhaul is overblown because the provision at the heart of the law already has little teeth, the top executive at Aetna Inc. said.

The court in March will hear arguments on the part of the law that requires Americans buy insurance or pay a penalty, known as the individual mandate. A ruling is expected by the end of June.

Some insurers have argued that a strong individual mandate is critical for the stability of the insurance pool by ensuring that healthy people buy insurance in addition to sick patients.

Investors are concerned that a ruling that eliminates the individual mandate but continues to require insurers to enroll people with pre-existing health conditions would hurt profits.

“Even as it exists today, the individual mandate is weak and still presents problems because the penalty is so low,” Aetna Chief Executive Mark Bertolini said in an interview on Wednesday. “If you get rid of it, I don’t know that it makes all that much of a difference.”

The Supreme Court decision, Bertolini said, “presents more of an opportunity for us to revisit how healthcare reform is structured than actually undoing the underlying dynamics or fundamentals of what they put in the bill.”

Bertolini said that the parts of the overhaul law that have already been implemented are “not going anywhere.”

“What we should be thinking about is if we do get an opportunity to change the bill, which we think we will, then what would we suggest?” he said.

As part of its authority under the new law, the U.S. Health and Human Services Department last week rebuked a privately held insurer, Trustmark Life Insurance Co,. for what the agency called unreasonable premium increases. The law requires insurers to disclose and justify health premium increases of more than 10 percent.

Bertolini said Aetna has not yet begun to see the impact of rate review because market trends have led the company to requests for lower increases.

“The 10 percent threshold has not caused us to ask for rates lower than 10 percent,” he said. “The market has, because the trend has been so low.”

Health insurers have reported very low levels of healthcare claims over the past year as patients delay doctor visits and procedures during the weak economy.

Bertolini spoke as Aetna, the No. 3 U.S. health insurer, launched a new branding campaign, designed to underscore its change from an insurance carrier to a “health solutions” company.

The branding campaign reflects changes the company has been making for the past several years, Bertolini said.

With consumers bearing an increasing amount of healthcare costs, he said, “we’re going to have to position ourselves in the eyes of the consumer as being somebody who, one, is helpful and, two, gives them a lot of ways of accessing the system and understanding the system better.”

(Reporting By Lewis Krauskopf; Editing by Tim Dobbyn)

    Copyright 2012 Reuters. Click for restrictions.