Tag: Medicaid Managed Care

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D.C. – Gray Accuses Colleagues of Medicaid Contract Steering

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Councilmembers in the district are accusing each other of corrupt handling of MCO contract awards.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

Ward 7 Councilmember Vince Gray accused fellow lawmakers of attempted contract steering in the latest chapter of the Medicaid managed care contract debacle. Councilmembers framed the debate during the June 29 legislative meeting as a struggle between disruption in medical coverage for Medicaid enrollees versus fidelity to contracting law.

In a letter sent to all D.C. councilmembers Monday, Gray wrote that a bill from Chairman Phil Mendelson and Councilmembers Robert White (At-Large) and Kenyan McDuffie (Ward 5) “is a thinly veiled attempt to steer a contract to Amerigroup,” which last year lost its bid to manage healthcare for some of the District’s Medicaid beneficiaries. In June of 2020, the Office of Contracting and Procurement awarded the $1.5 billion Medicaid contract to MedStar, CareFirst, and AmeriHealth.

The bill in question would require OCP to re-evaluate bids from all four companies as ordered by the Contract Appeals Board. Last December, the CAB, a quasi-judicial body that adjudicates government contract disputes, upheld a protest from Amerigroup and ordered OCP to re-evaluate, but the agency has been dragging its feet for the past six months.

In its re-evaluation, OCP must take into consideration the CAB’s ruling in another case. In August 2020, the CAB ruled that bidders’ proposals must include a plan for how they will subcontract with small local businesses. D.C. law says the subcontracting plan must be included in the initial proposal. OCP has previously admitted that it has violated the law for years and allowed subcontracting plans to come in later in the process. Medstar did not submit a complete subcontracting plan in its initial proposal, so a re-evaluation could replace Medstar with Amerigroup.

“Ethically, this is a path Council should never contemplate, let alone take,” Gray wrote in the letter. He argued that with MedStar removed from consideration in the Medicaid contract, the bill would disrupt medical coverage for about 65,000 people.

White, responding to Gray’s letter during the legislative meeting, called the allegation of contract steering a red herring. The issue, as White sees it, is about holding local agencies accountable when they violate the law.

“That is offensive and unnecessary,” White said to Gray’s accusation of contract steering. “I have such great respect for my colleague, and I hope he will contradict what he put in his letter because it was inappropriate.”

McDuffie was more pointed.

“It is disgusting to me that there would be allegations of contract steering by the Council, when in fact what [Deputy Mayor Wayne Turnage] and mayor are asking us to do is steer a contract,” McDuffie said Tuesday. “To retroactively fix a mess they created.”

Since the CAB ruling, the Bowser administration has repeatedly tried to avoid it. Like Gray, executive branch officials have said the re-evaluation will be disruptive to tens of thousands of Medicaid enrollees.

During Tuesday’s debate, At-Large Councilmember Christina Henderson questioned why the bill was still necessary. She pointed to a letter Turnage sent to members of the Committee on Health last week. The letter, according to Henderson, said the re-evaluation has already begun.

McDuffie was still was not convinced.

“Who is it coming from?” McDuffie asked. “Because if it’s coming from the same deputy mayor, then when I ask questions about procurement, he doesn’t seem to know the answers to those, but he conveniently has answers about procurement when it benefits what he wants to see happen in terms of who gets this contract.”

McDuffie pointed out that instead of hearing from OCP Director George Schutter, Mayor Muriel Bowser, and Gray, who chairs the health committee and has oversight in this area, the Council is largely hearing from Turnage.

“He’s saying they’re doing this. There’s no real indication to me that they are,” McDuffie said of Turnage. “Do you have any evidence they’ve started re-evaluation? Because in terms of credibility, I’m not willing to just stand on what he’s saying these days.”

In an email to Loose Lips following the Council debate, Turnage emphasized his commitment to truthfulness in his dealings with the mayor and the Council since he became director of the Department of Healthcare Finance in 2011.

“I have always been completely transparent and honest in my communications with the Mayor’s office and the Council,” Turnage wrote in the email. “That Councilmember McDuffie would, without the slightest justification, impugn my character in a public meeting, says a lot more about him than it does me.”

The bill passed 9-4. Gray, along with Councilmembers Brooke Pinto (Ward 2), Brianne Nadeau (Ward 1), and Mary Cheh (Ward 3), voted no.

 
 

Clipped from: https://washingtoncitypaper.com/article/521053/lucrative-medicaid-contract-prompts-finger-pointing-over-favoritism/

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Big Change To NC Medicaid System Takes Effect Thursday

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After years of effort and multiple political challenges, North Carolina HHS officials have brought managed care to the state for the first time.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

 
 

A map shows North Carolina’s managed care regions. The state is switching to a new Medicaid system Thursday.

Thursday is a big day for Medicaid in North Carolina.

The state is officially switching to a new Medicaid system called a “managed care” model.

That means 1.6 million Medicaid recipients will receive health care through plans managed by a small group of companies. Instead of paying doctors directly for their services, the state will pay companies that will then pay doctors who treat Medicaid recipients.

About 40 other states use this model, according to the Kaiser Family Foundation. The goal is to save money and improve care.

But it will likely be a bumpy transition. Very few people in North Carolina have chosen their own health plan, according to state data, and many likely don’t even know the change is happening.

An advocacy group called North Carolina for Better Medicaid surveyed 170 Medicaid beneficiaries and found that 43% of them knew “very little” or “nothing” about the switch to managed care. Dave Richard, the head of NC Medicaid, said that’s not surprising.

“We tried to do everything we could — reach out with social media, with radio and television media, direct mail-outs to beneficiaries,” Richard said. “But people’s lives are complicated and a lot of things are going on.”

Becca Friedman with the Charlotte Center for Legal Advocacy said she is particularly worried about problems with the mail.

“There’s definitely been a lot of notices that have gone out to beneficiaries that we’re nervous aren’t getting to them,” Friedman said.

She said a lot of Medicaid beneficiaries have moved or changed their addresses during the pandemic and the state may not have their updated mailing information.

Medicaid recipients had until May 21 to pick their own new health plan or the state would automatically assign one. According to Richard, only about 15% of people signed up, which he said is in line with what other states saw when they changed systems.

NCDHHS

“We would love to have had it higher,” Richard said. “But in consultation with other states who had gone live with managed care … it’s well within the norms that they experienced.”

Richard said the state based its health plan assignments for the other 85% of Medicaid recipients around people’s primary care doctors so that people could theoretically continue to see the same provider. He admits there will be problems with the auto-assignments.

For example, he said, the primary care doctor that the state has on file for someone might be outdated and not match the doctor that they have actually been seeing. Or their new plan might not include a specialist that they need.

“If you have heart disease … your primary care provider is really, really important. But your cardiologist is probably more important to you,” Richard said. “You may not have been assigned to a plan where your cardiologist is enrolled.”

Richard said he and his staff are bracing for a flood of phone calls and emails in the coming weeks and the state has planned for some hiccups. If a Medicaid recipient shows up for an appointment and the doctor isn’t on their new plan, that doctor can still bill Medicaid for the next 60 days.

“We have a rapid response team that’s ready, prepared to do this,” Richard said. “Our health plans are all ready for that. Our enrollment broker will continue to be there to address beneficiary issues.”

Recipients have until Sept. 30 to change their managed care plan for any reason.

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Clipped from: https://www.wfae.org/health/2021-06-30/big-change-to-nc-medicaid-system-takes-effect-thursday

 
 

 
 

 
 

 
 

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Medicaid rebid stripped from Ohio budget. Other actions unclear

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The requirement to ensure a local plan wins contracts has been removed from the latest Ohio budget bill.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

The full implications of this week’s budget negotiations for a redesign of the Medicaid managed-care system seemed unclear Tuesday.

The Toledo Blade reported that language that would have required the Ohio Department of Medicaid to re-do a massive redesign and procurement in its managed-care system was stripped from the version of the state budget that was passed Monday. But the package was said to retain special considerations for Medicaid managed-care companies that are headquartered in Ohio.

Advocates following the issue closely said they were still studying the matter. The office of Gov. Mike DeWine declined to comment.

Two Northwest Ohio lawmakers, Senate President Matt Huffman, R-Lima, and Sen. Theresa Gavarone, R-Bowling Green, had inserted language requiring that the Medicaid system rebid the work after Paramount Advantage, a subsidiary of Toledo-based ProMedica, lost out badly in the original procurement earlier this year. Paramount said the process was biased against it.

The loss of the business, ProMedica has said, will cost the region 600 jobs. The company didn’t respond to a request for comment Tuesday.

Gavarone told The Blade that she was disappointed that language that would give Paramount another shot was stripped out during conference-committee negotiations. She was a member of the committee.

Critics of the attempted do-over said it threatened the launch of OhioRISE, a program that would create wraparound services to up to 60,000 kids with complex behavioral needs. Such children are currently in the care of multiple agencies and in some cases, parents have to surrender custody to county health officials so that they can get the services they need. The program is a major priority of DeWine’s.

Also, rebidding the work threatened to at least delay restructuring the way the $29 billion-a-year Medicaid system purchases most of its prescription drugs. Managed-care providers currently hire pharmacy middlemen who work behind a veil of secrecy and have been shown to mark up generic drugs by hundreds of millions of dollars on Ohio.

The Medicaid redesign takes that work away from managed-care companies and gives it instead to a separate pharmacy middleman, or benefit manager, who would work directly for the state. The idea is to give state officials a window onto pricing and reimbursement data, as well as decisions regarding which drugs get preferred treatment.

Perhaps most significantly, when the budget conferees apparently eliminated language requiring that Medicaid managed-care business be re-bid, they upheld the philosophy of competitive procurement. Some critics expressed fears that if the re-bidding requirement stayed in the budget, it would have sent the wrong message to future disappointed bidders: If you lose out initially, all you have to do is lobby and litigate your way back into the game.

 
 

Clipped from: https://ohiocapitaljournal.com/2021/06/30/medicaid-rebid-stripped-from-ohio-budget-other-actions-unclear/

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Pa’s Medicaid is so valuable that Aetna, Centene, Gateway sue to run it

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MCOs that lost their contracts years ago have made a lot of money while the protests drag on for years.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

Pennsylvania is trying for the third time since 2015 to replace its Medicaid contracts. Each time, losing bidders have sued, alleging improprieties.

 
 

Medicaid is a need-based state-and-federal benefit program that provides health care services to certain low-income individuals. Pennsylvania, like most other states, uses private health insurers to manage the benefits for participants.Read moreDreamstime / MCT

Medicaid payments are like starvation wages for doctors and hospitals.

But to insurers, the government-paid health insurance for low-income families is a feast worth fighting over.

Pennsylvania is trying for the third time since 2015 to replace its Medicaid contracts — worth a total of $65 billion over the last five years — with companies that manage physical health benefits for 2.6 million Pennsylvanians.

Each time, losing bidders have protested, alleging improprieties in the way the state picked winners. Twice, in 2016 and 2018, Commonwealth Court judges agreed. The current protests against the winners announced last summer are pending in the same court.

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“The plans see this as really big business,” said Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation, the nation’s largest health philanthropy, in Princeton. That’s why they protest every loss nationwide, though the length of the protests in Pennsylvania may be extreme, she said. “By stalling it, they get a stay of execution.”

The losers’ protests underscore the importance of government backed insurance programs — Medicaid, Medicare, and individual Affordable Care Act plans often bought with the help of tax subsidies — as a source of growth for insurers, Hempstead and other experts said.

Medicaid rolls in particular have surged during the pandemic, driven by millions of people losing their jobs and their health insurance.

» READ MORE: Medicaid enrollment soars as Americans lose jobs to pandemic: ‘I never thought I’d experience this’

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But dragging out the appeals for years has a potential downside for consumers because they need both stability and competition to benefit, said Patrick Keenan, director of consumer protections and policy at the Pennsylvania Health Access Network, a nonprofit advocacy group.

“Stability helps plans develop relationships with patients and implement long-term strategies to improve outcomes while at the same time competition is necessary to ensure plans remain responsive to patients’ needs and their strategies don’t stagnate,” he said.

The Pennsylvania Department of Human Services, which oversees the state’s Medicaid program, called HealthChoices, runs the bidding process, and said its hands are tied until the court rules.

Historically, states have chosen private insurers to manage Medicaid benefits to save money. “They were just getting killed in terms of their state budgets. Twenty-five or 30% of their state budgets were going for Medicaid,” recalled Michael McCue, a professor emeritus at Virginia Commonwealth University who has studied Medicaid managed care.

Despite a history of Medicaid managed care dating to the 1990s, Pennsylvania’s spending on Medicaid, accounted for 28% of general funds in 2019, according to the Kaiser Family Foundation. That’s among the highest ratios in the nation.

Medicaid profits as a percentage of revenue are not huge, experts said, but can still be substantial given the amount of money in the program. The average operating profit before taxes and investment income for Pennsylvania’s Medicaid managed care companies was 2.4% in 2017, said Allan Baumgarten, an independent analyst in Minneapolis.

“When you compare it to pharmaceutical companies, it doesn’t sound like much of anything, but for insurance companies an operating gain of 2.4% is very good,” said Baumgarten, who last year authored a study of Medicaid managed care for the Robert Wood Johnson Foundation.

Over the last five years, AmeriHealth Caritas, a sister company to Independence Blue Cross, has averaged a smaller net profit of 0.55%, but that added up to a five-year total of $300 million. Medicaid has accounted for a significant portion of Independence’s growth over the last three years.

That trend will continue, with AmeriHealth Caritas about to start providing services in North Carolina and being selected a winner in Ohio last month.

With so much money at stake, Aetna Better Health of Pennsylvania, UnitedHealthcare of Pennsylvania, and others have refused to walk away without a fight.

Aetna, which now operates statewide, has been shut out twice in a row, winning none of the state’s five geographic zones. Thanks to protests, which prevent the state from completing the process, Aetna has collected a total of $3.9 billion in Pennsylvania Medicaid revenue since 2017 when new contracts were originally supposed to go into effect.

Asked for comment on its current protest, an Aetna spokesperson sent a link to the Commonwealth Court website. Aetna is fighting in that appeals court to obtain records of last year’s selection process using the state’s Right-to-Know Law.

UnitedHealthcare initially did better, getting picked in 2016 for Medicaid contracts in all five zones. But since then its fortunes have dwindled, getting the nod for just one zone, the Southeast, last summer. In the last four years, UnitedHealth has collected $4.7 billion in Medicaid revenue in Pennsylvania by providing services in three zones.

“While we are pleased to continue 30 years of service to our HealthChoices members in Southeastern Pennsylvania, we are disappointed about the overall decisions,” a UnitedHealthcare spokesperson said. “We are actively pursuing all available remedies.”

Two other bidders also protested the latest picks.

Gateway Health Plan Inc., a joint venture of Pittsburgh-based Blue Cross Blue Shield insurer Highmark Inc. and Trinity Health, a national Catholic hospital system, was dropped to one zone last summer — after being picked for five zones in 2017. The company did not respond to a request for information about its protest.

Centene Corp., which operates here as Pennsylvania Health & Wellness, is the fourth protester. The St. Louis company, by far the largest Medicaid insurer in the country, is a relative newcomer to Pennsylvania, having won a contract in 2016 to manage long-term services, such as home care and nursing homes. It has the smallest market share in the business, behind Independence unit AmeriHealth Caritas and UPMC.

Some in the industry expected Centene to win a large chunk of the Pennsylvania business. It did at first, winning three zones with the largest number of Medicaid beneficiaries, the Southeast, the Southwest, and one that stretched from the Lehigh Valley to Fulton County.

But in the most recent bidding round, it was shut out. The company declined comment.

The big winners last year, selected to offer services statewide but held up by their competitors’ protests, were AmeriHealth Caritas, Health Partners Plans, Geisinger, and UPMC for You.

What went wrong with the state’s process? The Human Services Department was tripped up during the protests in 2016 and 2017 by its use of a secret criteria in the selection process, favoring legacy operators to avoid disruption in the marketplace, and making improper communications with Centene executives.

The current protests include allegations that state officials took an idea from UnitedHealth’s application and shared it with other bidders. Aetna alleged that UPMC should not have been eligible because it had a work stoppage within the last five years at one of its hospitals.

The biggest winner last summer was Health Partners Plans Inc., a nonprofit in Philadelphia that was selected for all five zones, up from one zone now, the Southeast, which covers Bucks, Chester, Delaware, Montgomery, and Philadelphia Counties.

Health Partners, which is expected to be acquired by Thomas Jefferson University in December, had little to say about the protests that could upend its chance to expand statewide. The company had a profit of $23.5 million on revenue of $1.78 billion in 2019, according to its audited financial statement.

It’s unclear how long Commonwealth Court will take to work though the appeals.

The new contracts have a long term — five years — with the possibility of three one-year extensions.

“That raises the stakes, too,” said Hempstead, the Robert Wood Johnson expert. “If you lose, you might not get another bite at the apple for a while.”

Clipped from: https://www.inquirer.com/business/health/medicaid-managed-care-pa-southeast-philly-unitedhealthcare-aetna-ibc-20210620.html

 
 

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OHIO- Proposed budget changes said to threaten Medicaid reforms

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New information suggests that the former Medicaid director helped the losing plan lobby lawmakers to require the bids be thrown out.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

Disappointed bidder seeking a do-over

The Republican leadership of the Ohio Senate is attempting to give an Ohio-based Medicaid managed-care company a do-over after it failed badly in a competitive process to keep its business with the state.

Critics say the do-over — which was apparently lobbied for by the previous Medicaid director — would at least delay a series of reforms to a Medicaid system that has been vulnerable to huge rip-offs related to prescription drug purchases. It also threatens a new program that would coordinate care for up to 60,000 kids with complex behavioral needs, critics add.

Perhaps worst of all, said one opponent, using legislation to possibly restore a contract to a business that lost it through competitive bidding sets a terrible example for all future failed bidders.

“Regardless of the rationale, I have tremendous concern that unravelling the Medicaid managed-care procurement after-the-fact undermines the whole intent of the competitive bidding process, which is a necessary accountability mechanism in the system,” said Antonio Ciaccia, who helped lead the drive to reform the way Ohio spends billions annually on prescription drugs. “It would send a signal to the entire insurer marketplace that if you underperform and lose out, all you have to do is lobby and litigate your way back into the winner’s circle.”

Whether the do-over will happen will partly be decided in the coming days as conferees from the Ohio House and Senate hash out a compromise budget that would go to Gov. Mike DeWine for his signature, or veto. If DeWine is forced to make such a decision, it promises to be politically dicey for him.

Claims of bias

The care company that would benefit from the do-over, Paramount Advantage, says it’s the victim of a flawed process that stands to cost Northwest Ohio 600 jobs.

“Paramount maintains that the Ohio Department of Medicaid’s managed care organization… procurement process was systemically flawed and unfair,” Tausha Moore, its director of public relations, said in an email Wednesday. “Out-of-state, for-profit, multi-billion-dollar Fortune 500 companies appear to have been favored over mission-driven, not-for-profit managed care organizations headquartered in Ohio, including those that have received some of the highest quality scores as Medicaid managed care providers.”

Paramount Advantage is a subsidiary of Toledo-based ProMedica, a health care system operating in Northwest Ohio and Southeast Michigan. And while it and many other health care systems are 501(c)(3) nonprofit organizations, they’re quite profitable for their top employees.

ProMedica’s 2018 tax filings show that it had six employees making more than $1 million that year and 18 others earning more than $500,000.

Paramount is a longtime Ohio Medicaid managed-care organization, meaning that it creates networks of providers such as doctors for its Medicaid clients, handles reimbursements and works to create savings because it receives a fixed amount each year for each client it serves. But during its tenure, the Medicaid managed-care system has faced problems.

In 2016, Paramount and the other four managed-care companies serving Ohio Medicaid came under scrutiny over the conduct of companies they hired to handle pharmacy benefits. Pharmacists around the state complained that those companies, known as pharmacy benefit managers, used a non-transparent system to often reimburse them below their cost, billed companies such as Paramount top dollar and then pocketed the difference.

An analysis of 2017 transactions showed that for the cheapest class of drugs alone, pharmacy benefit managers CVS Caremark and OptumRx billed the state almost a quarter billion dollars more than they reimbursed pharmacists.

More recently, Centene, owner of another managed-care plan, this month agreed to pay $88 million after Ohio Attorney General Dave Yost accused it of a number of bad acts, including using a chain of pharmacy benefit managers in a scheme that amounted to double billing. The company has set aside more than $1 billion to settle claims of wrongdoing with other states’ departments of Medicaid.

Attempted reforms

DeWine’s Medicaid Director, Maureen Corcoran, and the legislature are implementing sweeping changes intended to address those and other problems.

One is intended to shed more light on drug transactions by hiring a single pharmacy benefit manager to work directly for the state, instead of behind the curtain of managed-care providers such as Paramount and Centene’s Buckeye Health.

The change seems to promise savings for taxpayers. Centene CFO Drew Asher last week described such carveouts as a “headwind” as he explained to analysts the company’s plans to grow profits.

Another reform is a broader redesign of the Medicaid managed-care system, with would-be contractors required to submit bids explaining how they would implement the new vision. And a big part of that vision is the implementation of the OhioRISE program.

A major DeWine initiative, the program is intended to coordinate services for kids with “significant mental/behavioral health and substance use disorders, in addition to medically complex illnesses,” the program’s description says. 

Currently, up to 60,000 such children are receiving care from various agencies. Advocates say a lack of coordination creates some excruciating gaps. 

“OhioRISE is the state’s answer to the ongoing, multi-decade issue of custody relinquishment,” said Loren Anthes, Treuhaft chair in health planning at the Cleveland-based Center for Community Solutions. “The idea is that adolescents that are involved in multiple systems — often who have developmental delays, and who are engaged with the foster-care system or Medicaid or the corrections system or all of the above — couldn’t get access to basic services and kept getting hospitalized over and over again. 

“In order for them to receive some essential services, many times parents would have to hand their children over to the county government in order to get those benefits and those parents were no longer the guardians,” he said.

Anthes explained that not nearly all of the children who would be helped by OhioRISE face being handed over by desperate parents to county health authorities. But the program is aimed at keeping all from that dire situation, he said.

“You don’t want to wait for them all to be hospitalized; you don’t want to wait until the moment of crisis,” he said. “But things aren’t very coordinated right now.”

Sen. Theresa Gavarone, R-Bowling Green. Official photo.

However, measures inserted into the budget at the behest of Senate President Matt Huffman, R-Lima, and Sen. Theresa Gavarone, R-Bowling Green, could keep OhioRISE from getting off the ground next year as planned. 

Anthes said the Medicaid redesign depends on multiple things occurring simultaneously. They include hiring managed-care providers — including the single pharmacy benefit manager, which would itself function as a managed-care provider. Those entities would then work together to help launch OhioRISE, he said.

“All of these things are premised on moving forward at the same time,” Anthes said, adding that if they don’t, everything will fall apart.

Paramount spokeswoman Moore said those concerns are unfounded.

“Whether stemming from misdirected concern or political motivation, that assumption is just not true,” she said. “An amendment (to the budget) specifically clarified that the changes in the MCO procurement process would not apply to OhioRISE.

Paramount lost by a lot in its unsuccessful bid to manage Medicaid care for two regions of Ohio. It received roughly half the score of the lowest of six companies that were selected to provide managed care starting next year.

The Toledo Blade last week reported that one knock against the Paramount proposal was that it didn’t adequately explain what Paramount would do to facilitate the launch of OhioRISE. For example, the Paramount bid only mentioned the program 17 times, while the highest-scored bid mentioned it 94 times.

Paramount President Lori Johnston seemed dismissive when asked about that critique.

“I guess in hindsight we should have thrown that buzzword out a few times,” she told The Blade. “I don’t think the number of times we used OhioRISE should be indicative of our approach and understanding of that plan. We support the program and are very committed to seeing the program is successful with that population.”

Political implications

A spokesman for Senate Republicans didn’t respond to questions for this story. But they apparently inserted language mandating a new bid process partially at the urging of Barbara Sears, who was Medicaid director under DeWine’s predecessor, John Kasich. Corcoran, the current Medicaid director, early last year said she inherited a mess from Sears when she took the helm in early 2019.

Now a principal with the lobbying firm Strategic Health Care, Sears registered this year to lobby on behalf of Paramount owner ProMedica on the budget and on the Medicaid managed care procurement. 

Her participation is notable for a few reasons.

First, she’s in the pay a client that had a mammoth contract with Ohio Medicaid while she was running the agency. And if, as critics say, the Senate budget measure delays reforms it could mean Sears worked to delay fixes to problems that developed on her watch as Medicaid director.

She didn’t respond to questions sent to an email address listed on her lobbying-disclosure forms.

If House and Senate conferees keep the requirement to rebid Medicaid managed-care business in the budget, they’ll be placing DeWine in a politically painful position.

He’s already under attack from his right for taking measures against the coronavirus pandemic that some claim were dictatorial.

Now he might have to decide between two of his most important initiatives or issuing a veto that Paramount says would cost Northwest Ohio 600 jobs. And DeWine might have to make that decision with a contested primary less than a year away.

A DeWine spokesman didn’t respond to questions about the matter on Tuesday.

 
 

Clipped from: https://ohiocapitaljournal.com/2021/06/24/proposed-budget-changes-said-to-threaten-medicaid-reforms/

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Health insurers capitalize on pandemic-fueled Medicaid growth

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36M of the now 80M Medicaid enrollees are in one of 6 national plans. Centene alone has 14M of them.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

Data: Company filings, CMS, Kaiser Family Foundation; Chart: Michelle McGhee/Axios

National Medicaid enrollment hit a record 80.5 million this past January, as Congress provided extra funding for states to retain and sign up more low-income adults and children during the coronavirus pandemic.

Between the lines: Because more states have outsourced their Medicaid programs to private health insurers, this pandemic-fueled growth also has been a boon for some of the largest insurance companies.

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State of play: Health insurers have been pursuing more revenue from government health programs, including Medicaid.

  • Seven out of 10 Medicaid enrollees are in a plan run by an insurance company, according to the Kaiser Family Foundation.
  • That would mean roughly 55.5 million of the 80.5 million people now on Medicaid are in a privately run plan.
  • And of those 55.5 million, roughly two-thirds are in a plan owned by six dominant insurance companies.
  • Centene covers 13.6 million Medicaid enrollees, the most of any company. Centene acquired WellCare last year and is now so large, it essentially functions as a branch of state and federal governments.

Worth noting: “The evidence is thin that these contractors improve patient care or save government money,” Chad Terhune reported for Kaiser Health News in 2018.

Go deeper:
Medicaid will be a coronavirus lifeline

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Clipped from: https://news.yahoo.com/health-insurers-capitalize-pandemic-fueled-090044633.html

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Mississippi is probing another Medicaid contractor over pharmacy benefits

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After getting a $55M payout from Centene, MS is thinking UHC/Optum may also be willing to make financial atonement for PBM gaffes.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

A member of the Senate Medicaid Committee reviews a Mississippi Division of Medicaid handout that reviews the managed care rule in this 2018 file photo. Mississippi officials recent reached a settlement with managed care provider Centene following an investigation into its billing practices.

Rogelio V. Solis | AP

JACKSON • Mississippi announced a $55 million settlement with its largest Medicaid contractor, Centene, last week related to allegations it was overcharging taxpayers for prescription drugs, but state authorities say they are not finished scrutinizing pharmacy benefit management practices at other companies that are paid with public money.

State Auditor Shad White told the Daily Journal last week that his office has been probing another Medicaid contractor, UnitedHealthcare, and its subsidiary, OptumRx, over pharmacy benefits. He declined to provide more details.

From 2016 to 2020, Mississippi’s Medicaid program paid $916 million for pharmacy benefit management services provided by OptumRx, according to agency data. OptumRx, a subsidiary of UnitedHealth Group, the fifth-largest company in the U.S., did not respond to a Daily Journal request for comment.

UnitedHealth and its PBM subsidiary are also facing investigations in other states, according to a recent report by The Wall Street Journal. And Ohio sued OptumRx in 2019, alleging the company bilked that state’s workers’ compensation program out of millions of dollars worth of generic drug discounts.

Meanwhile, the investigation into Centene and its subsidiary Envolve Pharmacy Solutions may be over after the recent settlement, but the mega corporation is apparently not finished doing business with the state. A Division of Medicaid spokesman said earlier this month the agency will exercise an optional one-year contract extension with Centene’s subsidiary Magnolia Health, as well as the state’s other two managed care providers, including UnitedHealthcare. New five-year managed contracts will be bid out by the state and begin next summer.

The three companies provide health insurance benefits for about 485,000 poor adults and children, disabled people, pregnant women, and others. They employ the pharmacy benefit managers as subcontractors to manage drug benefits, negotiate drug prices and reimburse pharmacists.

In the $55.5 million settlement agreement drawn up between Centene and Mississippi — in which Centene did not admit fault — the state had to acknowledge “Centene’s good faith and responsible corporate citizenship” by agreeing to settle. And it agreed that the company and its subsidiaries “have provided high quality pharmacy benefit services to the State and are qualified to continue to provide such services.”

Centene acknowledged it has an “obligation to comply with the requirements of Mississippi’s laws” as it delivers benefits for Medicaid patients going forward, and that the company will “provide full transparency” around its pharmacy benefit claims. Centene is set to pay the state in two installments, with some of the money going to attorney’s fees and the rest to compensate the Division of Medicaid.

Centene also will pay Ohio $88 million to settle a lawsuit alleging the company had inflated its pharmacy costs to the state in order to pad its profits. On top of the settlements with Mississippi and Ohio, the company has set aside another $1.1 billion for payments to 20 additional “affected states,” according to a U.S. Securities and Exchange Commission filing. It is negotiating with a pair of law firms that includes Ridgeland-based Liston & Deas to settle those states’ claims.

But neither Centene nor Mississippi officials have yet gone into detail about specific findings from the investigations into the company, including how much Centene may have cost taxpayers overall. White said the key finding from Mississippi — which was different than Ohio — was that Centene’s PBM had been billing the state for drugs at a higher price than its contract with the Division of Medicaid allowed.

Centene’s top executive only described the allegations in vague terms during a Wednesday call with shareholders, according to an Ohio Capital Journal report.

“The agreement addresses a situation from 2017 to 2018,” Michael Neidorff, the chairman, president and CEO of Centene, said of the settlement deals. “The policies and practices that created the situation were changed in 2019, making the matter very much a thing of the past. With this agreement, Centene will be able to put the situation behind us in a timely manner.”

Centene is the largest Medicaid managed care firm in the country, and the 24th-largest company overall. It brought in $111 billion in revenue last year. And this year, according to its Wednesday investor presentation, it expects to bring in more than $120 billion.

Rep. Becky Currie, R-Brookhaven, a nurse who serves on the House Medicaid Committee, said the state’s $55 million settlement with Centene is “ridiculous” and a “slap on the wrist, with nothing else happening to them, and a possible new contract.”

Currie, who has long raised concerns about the state’s Medicaid managed care system, said she was also disappointed that Centene did not admit fault in the deal.

“If I stole $55 million, how am I not at fault?” Currie asked. “If Becky Currie stole $55 million, I would be in jail. Somebody would (be).”

Currie said she doesn’t believe it’s smart for the state to extend Centene for another year, despite the company’s assurances of reform since 2017 and 2018.

She said she recently sent a letter to Gov. Tate Reeves and other state leaders urging them to take a careful approach as they bid out the next five-year managed care contracts. State officials, she said, need to provide more active oversight of the managed care firms.

Clipped from: https://www.djournal.com/news/state-news/mississippi-is-probing-another-medicaid-contractor-over-pharmacy-benefits/article_676e499e-3c9a-51b4-85c6-236e19ce2e7f.html

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Ohio overhauling $20B Medicaid program, but budget could pump the brakes

MM Curator summary

The Senate insistence on reinstating Paramount as an MCO no jeopardizes various improvements to the program.

 
 

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

The DeWine administration’s overhaul of the more than $20 billion Ohio Medicaid program could halt under a budget amendment that would essentially restart the process.

Ohio Medicaid is already over two years into transforming its clunky bureaucracy and re-awarding billions of contracts with a new set of spending conditions, which should translate to better care for the 3 million Ohioans covered by the health insurance program for the poor and disabled.

 
 

The sweeping reforms range from stopping parents from having to give up custody when they can’t afford their child’s mental health care, slashing provider paperwork hassle and implementing long-demanded pharmacy reforms.

The new system is supposed to be in place early 2022.

But that could change because of the proposed state operations budget that just cleared the Ohio Senate. The budget now has an amendment that would prompt the state to give out Medicaid contracts under new rules — most notably requiring that the contracts awarded lean toward companies based in Ohio with Ohio-headquartered parent companies.

 
 

“A couple of the Ohio companies, who for many years have been providing this service, and of course their employees and everyone else are here in Ohio, those folks were concerned what the process was and how it went forward,” Senate President Matt Huffman, R-Lima, said when discussing the Senate’s budget version, according to the Columbus Dispatch.

 
 

This would impact Paramount Advantage, which was one of the bidders based and headquartered in Ohio that just lost out on its bid to keep doing business with Ohio Medicaid. Paramount is operated by Toledo-based ProMedica and is appealing the decision.

Dayton-headquartered CareSource is another bidder also based in Ohio, but it won its contract.

It’s not clear what the proposed Ohio budget would mean for the locally based company, whose primary business line is its Ohio Medicaid contract. A message was left with a company spokesman.

The amendment drew criticism and concern from some of the people banking on an urgent overhaul.

One of the hallmarks of the new system will be a specialty program called OhioRISE to coordinate care for children with complex needs. Those includes kids with significant mental health needs, who have sometimes spent time in foster care, in juvenile detention, or multiple other state systems.

Every year some Ohio parents choose to give up their child’s custody, sometimes returning an adopted child back to state care, because kids in state custody get all their expensive residential treatment covered. OhioRISE would help parents and children navigate these systems with experienced care coordinators and would cover residential treatment.

The Ohio Senate budget amendment does not call for a redo of the OhioRISE contract. But critics of the amendment noted the new overhauled system is full of interlinked programs that only work with the other parts in place, like how OhioRISE would be paid for with with savings from the other parts of the overhaul.

Lisa Norris, who has also been following the OhioRISE proposal, surrendered custody of her 12-year-old daughter on Tuesday in Franklin County because she had been unable to get the nearly $80,000 cash she would need up front to secure her daughter an open residential treatment spot. Norris said as an experienced special educator she knows the resources and there wasn’t another way to get her daughter care.

“I want no other family to ever have to sit in the court and make that decision yesterday because it’s devastating,” Norris said.

The DeWine administration’s overhaul is already underway. All the contracts awards have been announced and the administration did 18 months of pre-work before the bid, got feedback from 1,100 different people and organizations in the lead up to opening up bidding.

 
 

“The Department of Medicaid, from our perspective, spent a really incredible amount of time listening. They listened to providers they listened to consumers, they listened to families, they listened to stakeholders and advocates,” said Teresa Lampl, CEO with The Ohio Council of Behavioral Health & Family Services Providers, who is concerned the proposal could undo the work.

Pausing the overhaul would also pause the overhaul of Ohio Medicaid’s $3 billion pharmacy benefit system. The old system had been roiled in controversy over spending and transparency for years, and pharmacists had celebrated the incoming changes.

“The problem started in 2016, it didn’t see the light of day until the beginning of 2018. And here we are in 2021 with the ball on the tee to fix the problem, and this could throw a wrench into all of it,” said Antonio Ciaccia, pharmacy consultant with 3 Axis Advisors, who had lobbied for years for the changes with Ohio Pharmacists Association.

The new system is five contracts, which have already been awarded: one transparent pharmacy benefit manager instead of a handful of contractors; a central stop to get credentialed; a single clearinghouse for all provider claims and prior authorization requests; a new system to coordinate benefits for kids with complicated needs; and several large contracts for insurance companies to manage benefits and care.

The large contracts went to UnitedHealthcare, Human, Molina, AmeriHealth, Anthem and CareSource.

 
 

Clipped from: https://www.daytondailynews.com/blog/ohio-politics/ohios-overhauling-20b-medicaid-program-but-budget-could-pump-the-breaks/EBES6EYMDBBE5KHTKUQZNGMAX4/

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Senate Budget Derails Ohio’s Medicaid Managed Care Process

MM Curator summary

 
 

The Senate insistence on reinstating Paramount as an MCO no jeopardizes various improvements to the program.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

COLUMBUS, Ohio — A plan to revamp Ohio’s Medicaid managed care system could be thrown off course.

After two years of input from key stakeholders, the state announced six managed care plans in April, but the Senate-passed budget calls for a re-do of the managed care procurement process, and stipulates managed care organizations based in Ohio be significantly considered.

LeeAnn Brooks, chemical dependency counselor for Health Recovery Services in Athens, is concerned about the impact on her patients.

“It’s going to make this whole managed care plan start all over,” Brooks contended. “And then that in turn is going to affect Southeast Ohio and Appalachia, and it’s going to take services away from people in the region as well as others in the state. That’s going to be a bigger setback, and it’s going to cost the state more money.”

It’s estimated more than $400 million in administrative costs would be wasted by stopping the procurement process.

Backers of the amendment claim there was not enough transparency in the bidding process for the $20 billion in contracts, and they argued Ohio companies should get special consideration.

This week, a budget conference committee will assemble. The final biennium budget is due June 30.

Brooks pointed out the Medicaid program is a crucial tool in helping those impacted by the opioid epidemic, many of whom don’t have any other type of insurance. She explained because addiction is a brain disease, it is important treatment not be interrupted.

“That’s planting a seed with people and getting them to understand that what they’re doing is really making their life unmanageable,” Brooks asserted. “With Medicaid, we can continue those treatment services in hopes of changing behaviors, in hopes of getting people into recovery.”

One of the current providers that did not make the list, Toledo-based Paramount Advantage, complained out-of-state companies were favored over those with headquarters in Ohio. The state countered the procurement process is competitive and included extensive public outreach.
 

Clipped from: https://www.clevescene.com/scene-and-heard/archives/2021/06/14/senate-budget-derails-ohios-medicaid-managed-care-process

 
 

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Oregon Health Authority, Medicaid Insurers Haggle Over Vaccination Incentive Money

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Oregon is moving a significant amount of its MCO P4P payments into vaccination measures.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

The Oregon Health Authority is paring down its COVID-19 vaccination proposal that would give the state’s Medicaid insurers incentive money for 2021 based on boosting the vaccination rates of their members.

The reworked proposal, not yet approved, is less ambitious than two earlier drafts by the state, but officials hope it is the final one. Medicaid insurers — known as coordinated care organizations — would have an easier time hitting the goals. However, the reward money at stake in the vaccination incentive would be much less: under $25 million, compared to the nearly $100 million the state initially wanted to offer as vaccination-rate improvement rewards.

The money would go toward the work of vaccinating Oregon’s Medicaid members — 1.3 million people, or about one-quarter of the state’s population. It’s a segment of the population with some of the lowest vaccination rates in the state, and the health authority is prodding insurers, health care providers and others to focus on increasing the rates.

The haggling over the incentive payments reflects the sentiment among many CCOs that getting Medicaid members vaccinated is extremely hard.

For various reasons, from vaccine hesitancy to lack of transportation and lack of computer access to schedule appointments, Medicaid members around the state have been much slower than the population at large to get vaccinated. While the state is closing in on a 70% vaccination rate for adult Oregonians, the vaccination rates for Medicaid members 16 and older in many rural parts of the state languishes at 25% to 30%.

The state’s new proposal would designate slightly less than one-eighth of the annual incentive funding for CCOs for the COVID-19 vaccination metric. To qualify, CCOs would have to achieve either a 70% vaccination rate for their members or hit a CCO-specific target that would be based on progress from the baseline vaccination rate of its members.

The state is watering down the vaccination-driven incentive cash after CCOs complained the state’s initial plan was unrealistic. The state initially proposed that Medicaid insurers must vaccinate at least 80% of their population age 16 and older by Dec. 31 in order to qualify for all the incentive funding. Also, the state initially suggested that nearly $100 million — or nearly half of the annual incentive funding that coordinated care organizations would be slated to receive for 2021 — go for the COVID-19 vaccination metric.

Coordinated care organizations responded that the 80% vaccination rate was unrealistic, especially in rural areas with high vaccine hesitancy. Health care executives also opposed putting such a large share of the incentive funding toward the vaccine metric.

The state awards incentive funding to CCOs each year based on how they perform in designated targets, from diabetes monitoring to behavioral health screenings. In October, CCOs received about $160 million in incentive money for their work to hit targets in 2019.

Sixteen CCOs serve different regions of Oregon. Medicaid insurers pushed for a vaccination metric that would take into account each CCO’s challenges, including its starting point in the push to vaccinate more people.

Preliminary estimates put the total incentive money for 2021 at $200 million. The state’s initial proposal would have put nearly $100 million on the line for the vaccine metric. 

The estimated $200 million incentive money anticipated for 2021 is just a small portion of the roughly $5 billion the insurers will receive for the year. But the incentive money is valued highly by the insurers because it is extra cash that they can scramble for, on top of the standard per-member monthly payment they receive from the state. The insurers typically share the incentive money with health care providers that work to meet the incentives.

Oregon Health Authority officials are close to the finish line with the proposal.

“We do not anticipate seeking further feedback on the measure,” OHA spokesman Jonathan Modie said Monday in an email. “We expect to have the measure finalized at the end of this week after walking through changes with CCOs.”

Third Proposal May Be Final One

The latest proposal is the third draft that the Oregon Health Authority sent to CCOs for input. The authority sent it to CCOs on Friday and officials are “hoping this is the final version,” Modie, the spokesman, said.

Here’s how it would work: 

Due to the urgency of the vaccination work, the COVID-19 vaccination metric is bypassing the authority’s usual process that creates new metrics in the incentive program, which can take a couple of years going through committees. Instead, the authority is setting up the metric administratively and calling it “emergency outcome tracking for CCO panel vaccination” instead of an official CCO metric. 

The money will come from the existing pool of incentive dollars. So, any dollar put toward the vaccine metric is a dollar taken away from the pool that rewards CCOs when they hit other health incentive targets. 

CCOs can qualify for the funding — or a portion of the funding — in several ways. They qualify for 90% of their portion of the vaccine metric dollars if they achieve a 70% vaccination rate of members age 16 and older. 

Alternatively, an insurer can qualify for 90% of their vaccine metric dollars if they make progress in their vaccination rate using a formula set by the state that takes the CCOs April 1 vaccination baseline. To qualify for the 90% funding level, a CCO also would need to reach that vaccination rate among each race and ethnicity group. A race or ethnicity needs to have at least 50 members in order to be a separate group within the metric. 

CCOs can get partial funding if they achieve the overall vaccination goal and have a lesser rate among each race and ethnic group.

To qualify for the remaining 10% of the vaccine metric funding, CCOs will need a vaccination rate of at least 42% among 12-15-year-old children. The vaccine became eligible for this group on May 13. Due to the small number of members in that group, the state does not break out race and ethnicity separately, the proposal says.

Health authority records show the latest proposal dropped the vaccination rate bar even lower than the agency’s second draft of the proposal, which went to CCOs for feedback in late May and early June. 

Specifically, the third proposal made it easier for each CCO to meet targets based on their improvements from the April 1 baseline.

Records show that CCOs pushed back against the tougher standards set out in the second proposal, and asked to qualify for funding for smaller, incremental improvements in vaccination rates.

The vaccination improvement formula set out in the second proposal  “negatively impacts the CCOs that operate in counties that have struggled with vaccination rates thus far,” wrote Sean Jessup, president of Eastern Oregon CCO, in a June 3 email to Oregon Medicaid Director Lori Coyner. “Unfortunately, we do not believe we will be able to even come close to meeting the targets in the revised proposal.”

As an alternative, Jessup suggested that the health authority reward CCOs when they make small, incremental improvements in vaccination rates. 

“These improvements would be a significant success and something we believe may be achievable,” Jessup emailed.

EOCCO has nearly 61,000 members in a vast swath of 12 counties in rural Oregon — the most geographic territory of all the CCOs.

Jessup also candidly assessed Umatilla County’s prospects of boosting its vaccination rate, based on conversations with local health departments. The county has one of the lowest general-population and Medicaid vaccination rates in Oregon. 

“The lowest performing counties, including Umatilla County, believe achieving a 45% vaccination rate for the entire eligible county population 16+ would be an unbelievable achievement,” Jessup wrote. The current vaccination rate for that population in Umatilla is 39%.

Jessup’s suggestion of rewarding small, incremental increases didn’t make it into the state’s third draft proposal. 

Other CCO feedback did, though. 

For example, AllCare Health CCO chief compliance officer Cynthia Ackerman wrote the health authority that its suggested 50% vaccination rate for children 12-15 is “unattainable in our region,” given historically low vaccination rates. The health authority dropped that to 42%. 

AllCare Health CCO has about 54,000 members in Curry, Douglas, Jacson and Josephine counties.

Ackerman also raised concerns about the proposal setting individual targets for race and ethnicity groups with only 30 members or more in a CCO. With that low a figure, the focus would shift to specific individuals, Ackerman wrote, “which could be viewed negatively” in those communities.

The health authority bumped that up to 50 people instead.

However, the second proposal mirrors the final one in significant ways, such as setting a 70% vaccination rate as the overall goal, and putting less money towards the metric. CCO officials unanimously praised the change to put less money towards the vaccination metric.

You can reach Ben Botkin at ben@thelundreport.org or via Twitter @BenBotkin1.

Clipped from: https://www.thelundreport.org/content/oregon-health-authority-medicaid-insurers-haggle-over-vaccination-incentive-money