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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 

 
 

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Centene creates stability for shareholders by rolling out a settlement plan and related damages budget.

 
 

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 pharmacy manager retrieves a medication. (Photo by Joe Raedle/Getty Images)

In what could be a harbinger of more settlements, Medicaid managed-care contractor Centene on Monday settled potential fraud claims by Ohio and Mississippi for $88.3 million and $55 million, respectively.

Ohio is the only state to file suit so far alleging improper double billing through Centene’s pharmacy middlemen. But Mississippi, Kansas, Arkansas, Georgia, Oklahoma and New Mexico are also reported to be considering such litigation. Centene operates in Iowa under the name Iowa Total Care as one of the managed care organizations under the state’s Medicaid program.

In a filing Monday with the U.S. Securities and Exchange Commission, St. Louis-based Centene announced the settlements with Mississippi and Ohio. And it said it had money set aside to settle with other states.

“Additionally, the company announced it is in discussions with a plaintiff’s group led by the law firms of Liston & Deas and Cohen & Milstein in an effort to bring final resolution to these concerns in other affected states,” the filing said. “Consistent with those discussions, Centene has recorded a reserve estimate of $1.1 billion related to this issue, exclusive of the above settlements.”

In announcing the Ohio settlement, Attorney General Dave Yost said that Centene, the largest Medicaid managed-care contractor in the United States, didn’t admit wrongdoing. But he said the amount of the settlement speaks for itself.

“I will accept an apology note that has this many zeros behind it,” he said.

Ohio has been a leader in trying to police middlemen known as pharmacy benefit managers. And Yost said one of the terms of the settlement is that if any other state gets more than $88 million, Ohio will as well.

In a press release, Centene said “the practices described in the settlement focus on the structure and processes of Envolve (a subsidiary), primarily during 2017 and 2018.”

As a managed-care provider, Centene uses state Medicaid money to sign up clients and to manage and pay networks of providers such as doctors to care for them.

To handle the complexity and volume of drug transactions, manage-care providers hire pharmacy benefit managers. They negotiate discounts from manufacturers, create lists of preferred drugs and determine reimbursements to pharmacies.

The PBM industry is highly concentrated and critics say the biggest players use a lack of transparency to gouge payers. Prompted by an investigation by The Columbus Dispatch, the Ohio Department of Medicaid in 2018 analyzed all reimbursement data from the prior year. It found that in 2017 alone, CVS Caremark and OptumRx billed the state almost a quarter billion dollars more for generic drugs than it reimbursed the pharmacies that had bought and dispensed them.

Reporting by The Dispatch also showed that a Centene-owned PBM was paid $20 million that year for work that its subcontractor, CVS Caremark, said it did. Both companies later denied that it was a case of double-dipping.

The lawsuit Yost filed against Centene in March accused the company of several kinds of double billing.

It said Centene hired its own PBM, Envolve, which hired another Centene-owned PBM, Health Net Pharmacy Solutions, which hired CVS Caremark, the biggest PBM in the country. Working through that chain of middlemen, the lawsuit said, Centene pocketed $6.7 million a year that was intended to cover pharmacists’ dispensing costs.

The suit also accused Centene’s PBMs of wildly marking up drug prices. During a single week in 2018, that amounted to $400,000, the suit said.

Centene said that starting in 2019, it introduced new rules. 

“Going forward, Envolve will operate as an administrative service provider, not a PBM, on behalf of Centene’s local health plans to further simplify our pharmacy operations,” the statement it released on Monday said.

The company also seemed anxious to reassure states it depends on for billions of dollars worth of business every year.

“We respect the deep and critically important relationships we have with our state partners,” Brent Layton, the company’s president of health plans, markets and products, said in a statement. “These agreements reflect the significance we place on addressing their concerns and our ongoing commitment to making the delivery of healthcare local, simple and transparent. Importantly, putting these issues behind us allows us to continue our relentless focus on delivering high-quality outcomes to our members.”

Because of the suit, Centene’s managed care organization, Buckeye Health Plan, was suspended from its business with the Ohio Medicaid department, which has an annual budget of $29 billion. Yost said it’s up to the Medicaid department to decide whether Centene will be reinstated.

Pharmacists across the country have for years complained of predatory reimbursement practices by huge pharmacy middlemen. They greeted the news of Monday’s settlement.

“This is just the latest evidence that PBMs have been using their self-infused complexity in prescription-drug pricing to fleece providers and payers for billions,” Scott Knoer, executive vice president and CEO of the American Pharmacists Association, said in a text message. Ohio “Gov. Mike DeWine and Attorney General Dave Yost have been national leaders in bringing needed accountability to the shady PBM industry. I’m glad the taxpayers in my home state are finally getting some of their money back.”

Since Medicaid is funded both by state and federal governments the settlement money will be split among those entities, Yost said. Similar arrangements are likely to be made in other states Centene settles with. 

It typically does business as a Medicaid managed-care provider with a local-sounding name. In addition to Ohio’s Buckeye Health Plan, in Mississippi it owns Magnolia Health Plan, in Georgia it has Peach State Health Plan, in Kansas it’s Sunflower Health Plan, in Arkansas, Arkansas Total Care, while in Oklahoma the company owns Oklahoma Complete Health, and in New Mexico it owns Western Sky Community Care.

Yost said hoped that Monday’s settlement catches the attention of all big Medicaid contractors.

“I hope that the message is going out to the entire industry across the country that the days of operating behind the curtain as the great Oz are over and that you’re working for the people of these states that hire you to bring value and quality and to do it with integrity.” he said.

Ohio Capital Journal is part of States Newsroom, a network of news outlets supported by grants and a coalition of donors as a 501c(3) public charity. Ohio Capital Journal maintains editorial independence. Contact Editor David DeWitt for questions: info@ohiocapitaljournal.com. Follow Ohio Capital Journal on Facebook and Twitter.

Clipped from: https://iowacapitaldispatch.com/2021/06/14/centene-agrees-to-settle-medicaid-claims-with-ohio-mississippi-for-143-million/