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DC Council expected to extend Medicaid benefits via emergency contract

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D.C. will re-bid all contracts again in order to appease losing bidder MedStar.

 
 

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 long and winding path D.C. lawmakers have taken to ensure more than 250,000 residents don’t lose Medicaid benefits is nearing the finish line.

The council is expected to vote on extending contracts for three companies for nine months, giving the District just enough time to complete the process all over again.

“Needless to say there’s been a lot of controversy about this,” D.C. Council Chair Phil Mendelson said.

Mayor Muriel Bowser’s administration has essentially dealt with legal concerns over the contracts with three companies to provide Medicaid benefits by re-evaluating each of them, Mendelson said.

“The mayor has rescored the contracts and two of them, Amerihealth and Carefirst, came out on top in the rescoring,” he said.

The council will approve a separate emergency contract for MedStar Health, which indicated that it did not score third in the administration’s reevaluation. Bowser’s office did not comment on when the reevaluation was completed or where Medstar Health scored.

WTOP reached out to Medstar Health for comment on the anticipated emergency contract extension.

“I think the guiding principles of this solution are avoiding the destabilizing of reassigning folks. Moving forward with a new procurement, it allows any bidder to bid going forward,” Mendelson said of lawmakers’ desire to ensure Medicaid patients were not reassigned to new doctors and risk a lapse in reliable medical care.

The vote before the council extends all three contracts for just nine months, which Mendelson said will give the District time to put out bids and select the health care companies that will provide Medicaid benefits in the future.

And she has said that can be done in nine months. We are saying it has to be done in nine months. And so I believe the votes are there for this solution to the controversy, which will enable contracts to continue largely uninterrupted or with less risk of disruption,” he said.

Meanwhile, Ward 5 Council member Kenyan McDuffie has introduced a bill expected to be discussed by the council on Tuesday that would attempt to avoid any one company providing Medicaid benefits from raising the costs of other companies by refusing to participate in universal contract pricing.

In August, Deputy Mayor for Health and Human Services Wayne Turnage told WTOP that Medstar Health had informed the two smaller contractors providing Medicaid benefits that if it did not have a contract with the city, it would not provide Medicaid coverage at all. Days later, the mayor declared a state of emergency to allow her administration to enter into a contract with Medstar Health to continue benefits. However, the council issued a resolution of disapproval out of concern that the move would not hold up if challenged in court.

“I just don’t think it’s right that MedStar can say, ‘You know what, unless we have our way, we refuse to serve these people,'” At-Large Council member Elissa Silverman told WTOP at the time.

Mendelson sees the contract extension as a necessary, albeit imperfect solution.

“You know, sometimes in government, it’s incumbent that we find a solution, rather than just stick to a position that doesn’t get anything done,” Mendelson said.

 
 

Clipped from: https://wtop.com/dc/2021/10/dc-council-expected-to-extend-medicaid-benefits-via-emergency-contract/

 
 

 
 

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Centene reaches $72M settlement with Illinois, Arkansas for alleged Medicaid overcharges

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2 more states have been paid out from the $1.1B settlement fund Centene set aside to deal with PBM scandal issues.

 
 

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.

 
 

Samantha Liss for Healthcare Dive

UPDATE: Oct. 1, 2021: Centene said in a statement: “We respect the deep and critically important relationships we have with our state partners. These no-fault agreements reflect the significance we place on addressing their concerns and our ongoing commitment to making the delivery of healthcare local, simple and transparent.”

Dive Brief:

  • Attorneys general for Arkansas and Illinois announced Thursday they both reached multi-million dollar settlements with Centene after the insurer allegedly overcharged their respective state Medicaid programs for prescriptions.
  • The alleged overages occurred after Centene subsidiary Envolve Pharmacy Solutions failed to disclose relevant discounts, Arkansas Attorney General Leslie Rutledge claims. Centene also improperly inflated dispensing fees, Illinois Attorney General Kwame Raoul alleged.
  • Centene will pay Illinois a total of $56.7 million in two installments over the next 12 months and $15.2 million to Arkansas in a similar arrangement.

Dive Insight:

The latest settlements come just months after Centene reached similar agreements in Ohio and Mississippi, in which the St. Louis-based insurer agreed to pay a total of $143 million to resolve allegations of overcharging the two states for medications.

The state of Ohio dropped its lawsuit against Centene as a result of the settlement. The payer did not admit fault in the settlements, but at the time the company set aside $1.1 billion to resolve future disputes in other states, according to a previous filing with the U.S. Securities and Exchange Commission.

In a series of tweets on Thursday, Rutledge explained that Centene’s Envolve was tasked with managing the state’s prescription drug program and was contracted to reimburse pharmacies, create preferred drugs lists and negotiate rebates with other pharmaceutical companies.

“When Envolve charged Arkansas Medicaid for the drugs, contracts required the costs to be capped by certain industry-standard prices, however Envolve charged Arkansas Medicaid more than the allowed price cap,” Rutledge tweeted.

Centene did not immediately respond to a request for comment.

Pharmacy benefit managers have come under fire in recent years for the opaque ways in which they operate and their role in rising drug costs. PBMs’ less-than-transparent business model has previously garnered scrutiny from lawmakers interested in tackling drug pricing reform.

 
 

 
 

Clipped from: https://www.healthcaredive.com/news/centene-72m-settlement-illinois-arkansas-overcharge-Medicaid-medicines/607535/

 
 

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Civil rights groups file complaint over DC Medicaid dispute

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Advocates are framing MedStar’s tactics as a health equity issue.

 
 

 
 

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.

 
 

Advocates for D.C.’s Medicaid recipients have filed a complaint with the U.S. Department of Health and Human Services over threatened changes to the D.C. Medicaid program.

The groups, including the D.C. branch of the NAACP and the Health Alliance Network, a community organization devoted to health equity, have written to the HHS Office for Civil Rights, complaining that the health of the city’s Medicaid recipients is imperiled by MedStar Health’s dispute with the District government over its Medicaid contract.

The groups pointed to an Aug. 20 letter penned by the D.C. Department of Health Care Finance to the D.C. Council Committee on Health, which said that MedStar Health intends to terminate its contracts with AmeriHealth Caritas DC and CareFirst Blue Cross Blue Shield, two Medicaid managed health care programs operating in the District.

MedStar, which operates two of the city’s largest hospitals, MedStar Washington Hospital Center and MedStar Georgetown University Hospital, has been in a long-standing dispute with the D.C. government over the Medicaid managed care contract of its subsidiary, MedStar Family Choice.

The D.C. Contract Appeals Board ruled last December against MedStar Family Choice’s Medicaid contract with the city. Mayor Muriel Bowser issued an emergency order this month extending that contract and the other two, despite the CAB ruling. But with contracts set to expire at the end of the month, the D.C. Council passed a resolution disapproving of the mayor’s emergency order extending the contracts.

The civil rights and advocacy groups speaking out against MedStar’s threat to end Medicaid contracts with the two insurance companies that provide Medicaid health coverage to the city’s poor.

“MedStar’s actions jeopardize the lives, the health and the safety of over 200 thousand vulnerable DC residents on Medicaid, A majority of whom are “Black and Brown people,” said NAACP D.C. branch president Ali Akosua.

The D.C. Department of Health Care Finance said the action would threaten access to care for as many as 230,000 District residents.

“MedStar Health is using its market share leverage to bully the District into contract renegotiations and threatened to raise the discount pricing they have made to other managed care organizations, jeopardizing the health, well-being and health services access for hundreds of thousands of Black and Brown residents,” said Ambrose Lane, chairman of the Health Alliance Network.

In a statement to WTOP, spokeswoman Marianne Worley said MedStar Health has an unwavering history of caring for all patients in D.C. and its intent has never been to cancel contracts and leave the District’s most vulnerable residents without care.

“MedStar Health’s notifications to the other two Managed Care Organizations (MCOs) in the Medicaid Managed Care program were intended to prompt renegotiation of the existing provider agreements,” Worley said. “Such notices are a routine way to initiate negotiations and occur across our industry as a normal part of how healthcare is delivered and financed.”

With the mayor and the D.C. Council at odds over the Medicaid contracts, the D.C. Department of Health Care Finance warned that if the current contracts between the health plans and MedStar expire Sept. 30, D.C. Medicaid patients will be left without access to MedStar hospitals, clinics, rehabilitation facilities and a network of physicians.

 
 

Clipped from: https://wtop.com/dc/2021/09/civil-rights-groups-file-complaint-over-dc-medicaid-dispute/

 
 

 
 

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Aetna misrepresented network to secure Pennsylvania Medicaid contract, lawsuit claims

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A whistleblower alleges that Aetna management was aware that the network was inadequate but did not disclose it to the state.

 
 

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 whistleblower lawsuit alleges Aetna misrepresented its network to land lucrative Medicaid contracts in Pennsylvania. (Mark Van Scyoc/Shutterstock.com)

A newly unsealed whistleblower lawsuit claims that Aetna misrepresented its provider network to secure lucrative Medicaid contracts in Pennsylvania.

The suit was originally filed in 2017 and saw an amended complaint in January, which was unsealed earlier this month. In the suit, former care management nurse Carol Wessner said she reported multiple times to superiors at Aetna Better Health of Pennsylvania that patients were being assigned to primary care doctors who were falsely represented as in-network.

Aetna Better Health of Pennsylvania CEO Jason Rottman and Alice Rottman, director of its quality management division, told Wessner to “refrain from recording her findings in writing and, ultimately, to stop reporting her findings altogether,” according to the lawsuit.

Wessner also says she was fired in retaliation for repeatedly attempting to report her findings.

RELATED: PhRMA files federal lawsuit to get rid of controversial Medicaid drug rebate rule

Aetna, which is now a subsidiary of CVS Health, said in a statement to Fierce Healthcare that it intends to “vigorously defend itself” if the case moves forward.

“Aetna is pleased that after reviewing all of the evidence, the government chose not to participate in the lawsuit. Aetna denies the allegations in the complaint, and intends to vigorously defend itself should the relator choose to move forward with her non-intervened complaint,” the insurer said. “Aetna places the highest priority on the health and wellbeing of its members, and we provide access to quality care through a comprehensive provider network, including in Pennsylvania.”

“Plaintiff’s allegation that Aetna has network adequacy deficiencies across the country is irresponsible and unrelated to the DOJ’s investigation,” Aetna said.

Medicaid managed care organizations are contractually held to network adequacy standards. In Pennsylvania, MCOs are paid in a capitated per member, per month model, with the insurer covering their medical costs.

As such, if a member is seeing a PCP that is unavailable, they’re less likely to seek out care, reducing what the MCO is paying out without cutting their intake from the state’s Medicaid program. This was the financial incentive behind the scheme, according to the lawsuit.

The false networks were crucial to Pennsylvania’s decision to award contracts to Aetna in 2010 and 2014, according to the lawsuit.

“ABHP is aware that its provider network does not meet its contractual adequacy standards,” the lawsuit says. “However, in both the contract procurement and in periodic reporting, ABHP represented to the government that ABHP’s network did meet its contractual adequacy standards.”

Clipped from: https://www.fiercehealthcare.com/payer/aetna-misrepresented-network-to-secure-pennsylvania-medicaid-contract-lawsuit-claims

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Aetna Barred From Suing Over North Carolina Medicaid Bid Denial

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The MCO seems to have reached the end of the appeals process.

 
 

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.

 
 

Aetna Better Health of North Carolina’s lawsuit protesting its loss of a bid to operate a Medicaid managed care prepaid service is barred because the company didn’t comply with rules for judicially appealing the decision, a state court said Tuesday.

Noncompliance with a state law that sets out mandatory provisions for appealing administrative agency decisions requires the appeal’s dismissal, the North Carolina Court of Appeals said.

North Carolina is in the process of transitioning its Medicaid plan from a fee-for-service model to a managed care model. Aetna unsuccessfully bid for a prepaid health contract and protested its loss through …

 
 

Clipped from: https://news.bloomberglaw.com/health-law-and-business/aetna-barred-from-suing-over-north-carolina-medicaid-bid-denial

 
 

 
 

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DC Council hits pause button on Medicaid contract

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DC’s MedStar contract is now off again.

 
 

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.

 
 

Health care for Medicaid recipients in D.C. is in limbo yet again: The D.C. Council has effectively hit the pause button on a contract with the health care provider that was set to extend benefits to a quarter-million residents.

The complicated twists and turns of the contract process is entirely bureaucratic, and could result in the District’s most-vulnerable residents losing access to their doctors during a pandemic.

As the District’s Medicaid contract was less than a month from expiring, Mayor Muriel Bowser declared a state of emergency, allowing her administration to enter into a contract extension with MedStar Health.

The nine-month extension allowed for D.C. to restart the process of finding its next Medicaid provider. A previous selection process had awarded the contract to MedStar, but a judge last year nullified the award, citing a failure of the health care company to meet the requirements to win the $3 billion bid.

The contract extension would have passively passed the council had it not taken action in 10 days. But four council members co-signed a resolution of disapproval Friday, allowing it to “extend our review period from 10 to 45 days,” the resolution reads.

Four members of the council, Chair Phil Mendelson, Kenyan McDuffie, Elissa Silverman, and Robert White, co-signed the resolution, which questions the legality of the contracts.

“Extending our review period also gives time to the Mayor to re-evaluate the bid
proposals as ordered by the Contract Appeals Board last December 1st (the CAB expressly ordered the District to “re-evaluate the competitive range offerors’ proposals in accordance with District procurement law and regulation, the terms of the solicitation, and the instant decision,” Mendelson wrote in the resolution.

The council wants more time to review but has three options. First, to do nothing, which Mendelson contends given the controversy and legal advice, is “not a positive image for the Council.” The second option would be to disapprove the contracts, and the final option would be to act by emergency legislation and overrule the CAB’s decision and approve the contracts.

Deputy Mayor Wayne Turnage believes the mayor’s move to enter into extended contracts via emergency order was the only way forward.

“The mayor has responsibly submitted these contracts under emergency to avoid any disruption in the health care for over 250,000 people. That is the extent of what she can do at this point. So really, it’s up to the council,” said Turnage.

In response to the council’s resolution, the mayor outlined the potential outcomes of letting the contract expire. Among them, she said, the Department of Health Care Finance will have no legal authority to pay for health care services; District residents will have to navigate the health care system; and health care costs will likely increase.

“To avoid these substantial, unnecessary, and harmful disruptions, I urge Chairman Phil Mendelson to withdraw the disapproval resolution immediately as the Department of Health Care Finance resolicits the procurement over the next few months in order to add additional services for beneficiaries and to address the Council’s concerns,” Bowser said. 

The council is out on recess until Oct. 1, and sources within the council said its rules prohibit council members from voting until it reconvenes. Its next legislative meeting is set for Oct. 5.

“I think you could have made the argument early in his process that this was such a challenging issue, that people of goodwill were legitimately confused as to what should be done. I don’t think you can make that argument anymore. Everybody understands precisely what has happened. And precisely what will happen if the council disapprove these contracts. Or if they just take the entire 45 day review period,” Turnage told WTOP.

Clipped from: https://wtop.com/dc/2021/09/dc-council-hits-pause-button-on-city-contract-to-extend-medicaid-benefits/

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Georgia Eyes New Medicaid Contract. But How Is the State Managing Managed Care?

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GA MCO contracts are expected to be rebid soon and journalists are reporting that current contracts lack financial controls that are standard in other states.

 
 

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.

 
 

 
 

(Hannah Norman / KHN photo illustration / Getty Images)

Just before Frank Berry left his job as head of Georgia’s Medicaid agency this summer, he said the state “will be looking for the best bang for the buck” in its upcoming contract with private insurers to cover the state’s most vulnerable.

But whether the state — and Medicaid patients — are getting an optimal deal on Medicaid is up for debate.

Georgia pays three insurance companies — CareSource, Peach State Health Plan and Amerigroup — over $4 billion in total each year to run the federal-state health insurance program for low-income residents and people with disabilities. As a group, the state’s insurers averaged $189 million per year in combined profits in 2019 and 2020, according to insurer filings recorded by the National Association of Insurance Commissioners. Yet Georgia lacks some of the financial guardrails used by other states.

“Relative to other states, Georgia’s Medicaid market is an attractive business proposition for managed-care companies,” said Andy Schneider, a professor at Georgetown University’s Center for Children and Families.

Georgia is among more than 40 states that have turned to managed-care companies to control Medicaid costs. These contracts are typically among the biggest in these states, with billions of government dollars going to insurance companies. Insurers assume the financial risk and administrative burden of providing services to members in exchange for a set monthly fee paid for each member.

The health plans, though, have at times drawn questions both on spending and quality of care delivered to Medicaid members.

“The transition to managed care was supposed to save states money, but it’s not clear that it did,” said Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation. (KHN receives funding support from the foundation.)

States can require Medicaid insurers to pay back money if they don’t hit a specified patient-spending threshold. That threshold is typically 85% of the amount paid to the insurance companies, with the rest going to administration and profit.

But Georgia does not require its Medicaid insurers to hit a specific target for spending on patient care, a federal inspector general report noted. Though Georgia is trying to “claw back” $500 million paid to its Medicaid insurers, it could have lost out on recoupment dollars, the report indicated.

And state documents show that the Peach State company, which now has the largest Medicaid enrollment of the three insurers, failed to reach the 85% mark from 2018 to 2020.

Overall, Georgia’s Medicaid “medical loss ratio,” which assesses how much was spent on patients’ claims and expenses, was fifth from the bottom nationwide last year, behind only Mississippi; Washington, D.C.; Wisconsin; and Arkansas, according to data from the insurance commissioners association. Spending rates on patient care in the state fell from 82.9% to 80.8% in 2020. (The NAIC uses a different method for calculating the ratio than the state and federal governments do.)

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“Profits for Georgia Medicaid HMOs are very healthy,” said Allan Baumgarten, an independent analyst and consultant.

When asked whether Georgia planned a spending requirement in the new contract, Fiona Roberts, spokesperson for the Department of Community Health, which runs Medicaid, said “a number of considerations are being discussed.” She noted that the state having a low medical loss ratio does not necessarily translate to “unreasonable profit” for the insurers.

The insurers also make money off their management services firms. In 2020, the insurer Peach State paid a subsidiary of its parent company, Centene Management Company, $114.7 million for administrative services. The nonprofit CareSource paid its management services firm $86.5 million in 2020.

“Fees paid to subsidiary companies represent another source of revenues for the parent companies,” said Baumgarten. “And it’s done in a way that does not allow the state to hold the HMOs accountable.”

The state’s latest performance data, which covers 2019, shows the plans did as well or better than the national median on many measures, including on access to a primary care provider.

But low birthweight rates appear to be on the rise despite the state’s goal of bringing them down to 8.6% or less. The companies hovered at an average of about 9.8% in 2019, the latest available data.

“We continue to hear stories from families and health care providers about children in Medicaid managed care who have considerable trouble getting the services they need — whether it’s medication to control their asthma, getting connected to behavioral health care after a mental health crisis lands them in the emergency room, or any number of health challenges,” said Melissa Haberlen DeWolf, who directs research and policy at the Voices for Georgia’s Children advocacy group.

Compared with other states, Georgia has a stunningly low rate of referring poor children to specialty services under Medicaid, according to a recently released National Health Law Program report. DCH said recently it’s investigating why the rate is so low.

And, currently, the state is reporting low covid vaccination rates for those 12 and older covered by the Medicaid managed-care companies. A state posting shows the rates for the three companies are each below 10%, far lower than Georgia’s overall rate.

The companies, when asked about profitability, quality of care and administrative costs, directed a reporter to Jesse Weathington, executive director of the Georgia Quality Healthcare Association trade group. He said he could not comment on individual companies’ financial performance.

“Our goal is to continue to drive quality improvement, and successful patient outcomes, in the most cost-efficient manner for taxpayers who fund Georgia Medicaid,” Weathington said.

Georgia is expected to open the high-stakes bidding process on a new Medicaid contract next year. The bid process typically is fierce and the results often contested.

It’s not clear, though, when Georgia’s new contract process will be completed as the timelines have hit snags in several other states. North Carolina rolled out its managed-care system July 1 after two years of delays. It will spend $6 billion annually, the largest contract in the state health agency’s history.

Last year, Louisiana’s contract process fell apart after insurers that lost out disputed the results. And Centene and other companies are protesting Pennsylvania’s decision not to award them contracts, delaying implementation.

St. Louis-based Centene has more Medicaid managed-care business nationally than any other company. Centene last year acquired WellCare, a Medicaid insurer in Georgia, then closed down that operation in May.

Centene has also faced questions about overbilling. Ohio settled an $88 million pharmacy fraud lawsuit it filed against Centene months before awarding it a contract, while Mississippi settled with it for nearly $56 million. Now Georgia is expected to get money back under the $1 billion that Centene set aside to settle with other states affected by the pharmacy overbilling.

Consumer groups want the state to take stronger steps to advance the health of those who rely on Medicaid and to make the deals with the insurers more transparent.

“Medicaid members are best served when they have ready access to providers, insurers are eager to resolve their health care needs, and policymakers exercise strong oversight to ensure members’ health and well-being are prioritized over profits,” said Laura Colbert, executive director of Georgians for a Healthy Future, a consumer advocacy group.

A bill that aimed to bring more transparency and accountability to the state’s health care plans was vetoed last year by Republican Gov. Brian Kemp. The legislation would have allowed a committee to examine records of health care contractors and compel the state to respond to questions about them. Kemp said the bill would have violated the separation of powers doctrine between the executive and legislative branches of government.

 
 

Clipped from: https://khn.org/news/article/georgia-medicaid-contract-managed-care/

 
 

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Physicians booted from board after blocking Stitt Medicaid plan

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Doctors appointed by the Governor who thwarted his major health initiative have been removed from their appointments.

 
 

 
 

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.

 
 

 
 

OKLAHOMA CITY — Gov. Kevin Stitt fired the only two physicians who serve on the state’s Health Care Authority governing board after they opposed his plan to outsource Medicaid.

Dr. Jean Hausheer said when a Stitt staffer called Saturday to give her and Dr. Laura Shamblin the news, he was unable to provide a reason why the governor was kicking two of his own appointees off the nine-member board. The governor appoints five of the board members, to the panel, who serve as volunteers and which oversees more than $2 billion in taxpayer funds for state healthcare programs, including Medicaid.

The Legislature appoints the remaining four members.

Hausheer said the axe fell after the two doctors stymied Stitt’s latest effort to outsource the state’s Medicaid program using a backdoor administrative rules process instead of working with the Legislature and health care community.

Stitt has argued that outsourcing Medicaid could save money and improve health outcomes.

“He didn’t get his way, so he’s just getting rid of those of us that don’t see eye-to-eye with him,” Hausheer said.

She said as of Tuesday, Stitt had filled the posts with non-physicians.

Hausheer, an ophthalmologist with the Dean McGee Eye Institute, which is based in Lawton, said Stitt had previously tried a similar unsuccessful strategy to outsource the program to managed care providers. Earlier this year, the state’s highest court rejected that plan, ruling that it was pushed forward without proper legislative approval.

Hausheer said Stitt’s administration now is attempting to create administrative rules under Senate Bill 131, which put guardrails on the governor’s plan. She said lawmakers, though, told her the Senate bill never took effect because of the Oklahoma Supreme Court ruling.

Hausheer, a practicing physician for more than 40 years, said Stitt appointed her to the board in 2019 with the understanding that she’d serve for four years. She and Shamblin were two of three women who served on the board and the only two licensed physicians. She said the timing was odd because the dismissal came during the month that honors women in medicine.

Hausheer said instead of attempting to outsource Medicaid through administrative rules, Stitt should put together a team that includes legislative leadership, Health Care Authority staffers and members of the state’s health care community.

“We would meet with him gladly and find a pathway forward,” Hausheer said. “(Managed care organizations) by themselves are not necessarily evil for all things. They’re not. It’s just that they would work better for some things and would work terrible for other things.”

She said that strategy would result in a more meaningful partnership as opposed to Stitt’s methods right now of getting rid of people who don’t agree with him.

In an email Tuesday, Carly Atchison, a Stitt spokeswoman, did not comment on why Stitt decided to boot Hausheer and Shamblin from the board.

“The governor is grateful for Dr. Hausheer and Dr. Shamblin’s service to the state of Oklahoma,” Atchison said.

She also said Stitt welcomes Susan Dell’Osso and Gino DeMarco to the board “to help make Oklahoma a Top 10 state for health outcomes.”

Atchison said Dell’Osso served as former chief innovation officer for Integris Health, has experience across the state’s different health systems, and a passion for serving Oklahoma communities.

“Gino DeMarco has voluntarily left retirement to once again serve the state, bringing a unique entrepreneurial talent for innovation, growth and development” including years as a senior executive at a Medicaid consulting and software company, she said. DeMarco previously served as the state’s “PPE czar” during the COVID-19 pandemic where he was tasked with obtaining personal protective equipment during a nationwide shortage. He also served as deputy director of the state’s Tourism and Recreation Department.

State Rep. Marcus McEntire, R-Duncan, said it’s disappointing that Stitt chose to dismiss the only two physicians who served on the board.

“Those people care deeply about our state and the direction it’s going with health care,” McEntire said. “I have an idea why he did it. But, I don’t think it bodes well for people who are willing to serve the state on these boards that if they make a decision that somebody higher above them doesn’t like, then they get axed. We’re all trying to pull the state in the right direction.”

McEntire, House author of Senate Bill 131, said the measure was intended to put limitations on the same policy that the Oklahoma Supreme Court voided. He said the measure didn’t take effect given the ruling.

He also said he’s disappointed Stitt is attempting to press forward with outsourcing managed care through administrative rules.

McEntire said the Health Care Authority governing board is comprised of medical experts, yet the majority continues to be against managed care.

Now the board is void of the expertise of practicing physicians, he said.

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Clipped from: https://www.enidnews.com/news/state/physicians-booted-from-board-after-blocking-stitt-medicaid-plan/article_f4a411ca-1028-11ec-9e1b-6f751872d9b5.html

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After Weeks Of Uncertainty, D.C. Medicaid Recipients Avoid Losing Access To MedStar Doctors

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After threatening to stop seeing Medicaid patients unless its competitor health plans paid them more, a hospital health plan got its contract extended for at least 9 months by the mayor of the U.S. capital.

 
 

 
 

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.

 
 

 
 

Thousands of Medicaid recipients were recently at risk of loosing access to their doctors.

Tyrone Turner / WAMU

Over the past several weeks, a chaotic situation unfolded in D.C.’s Medicaid system, potentially disrupting the care of thousands of the city’s poorest residents. 

MedStar, a health system in the city that also manages a health insurance company, announced that it was ending its contracts with two other companies that cover the city’s Medicaid recipients. Thousands of residents were at risk of losing access to a range of MedStar’s services – including primary care doctors, specialists, and pharmacies. 

According to the city, 80% of D.C.’s Medicaid recipients are people of color; 75% are Black residents living in wards 7 and 8. 

“You have to have a working Medicaid system in order to care for low income and poor communities,” says Ambrose Lane Jr., the founder of Health Alliance Network, a group that advocates for health equity in the city. “That’s what it was built for. Now, one could argue whether or not it was the best system that was built. Now, that’s an argument for a later date right now, we need health care coverage for poor and low income communities.” 

Mayor Muriel Bowser used an emergency order to extend the city’s contract with MedStar for at least nine months, but the debacle marked the latest development in a complicated relationship between MedStar and the D.C. government. 

 
 

Clipped from: https://wamu.org/story/21/09/07/after-weeks-of-uncertainty-d-c-medicaid-recipients-avoid-losing-access-to-medstar-doctors/

 
 

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Akron Children’s creates new company to care for 100,000 Medicaid patients

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A children’s hospital is starting a Medicaid ACO for children.

 
 

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.

 
 

Akron Children’s Hospital is creating a new subsidiary to help coordinate and improve overall care of 100,000 Medicaid patients in a 13-county region. 

The new company called the Akron Children’s Health Collaborative will be what’s called an accountable care organization or ACO.

An ACO is a “partnership between doctors, hospital and other health care providers that work together to offer high quality care at a lower cost and directly with insurers,” said Kris Grayem, Akron Children’s vice president of population health. 

 
 

The first contract for the new company is with CareSource, the largest insurer of Medicaid-covered children in the state. The collaboration will begin Oct. 1. 

Akron Children’s is in negotiations with the other Medicaid managed-care insurers for children in its 35-county coverage area to create similar collaborations, hopefully within the next six months to a year, said Shawn Lyden, Akron Children’s chief strategy officer. 

This will be Children’s first foray into an ACO.

Instead of getting paid every time a child covered by CareSource is seen at the hospital or at Children’s physician offices,  Children’s will receive a set amount of money per CareSource enrollee per month, according to Grace Wakulchik, Children’s Hospital president and CEO. 

With those funds, the company is “entrusted to use to care for these group of Medicaid children,” Wakulchik said. “The thought being with our excellent clinical coordination systems, we can coordinate that care better so that those kids get better front-end care. So we manage their health better so there aren’t those adverse expensive hospitalizations. 

“We want to intervene early. We want to coordinate your care. We want to have the best possible outcome and so that’s the risk we are taking by accepting this per member per month amount that we will be able to manage that care better for those families,” she said. 

Akron Children’s officials declined to share financial details of the contract. 

How does the Akron Children’s Health Collaborative work?

Currently, the hospital loses money on each Medicaid patient, Wakulchik said.  

“We’re hoping by managing kids getting preventive care, dental care and other care, we’ll be able to manage their care when it costs less not only to us but to keep the kids healthier,” she said. “In the long run, I don’t know this will be as profitable per se, but hopefully we won’t lose as much money.” 

About 42% of the 100,000 children who will be part of this new care model are currently Akron Children’s patients and already get some of the holistic care through the hospital’s population health efforts, which started in 2017, Lyden said.  

For instance, Children’s already has been helping with other social barriers to health care —such as transportation needs, food insecurity and housing needs — for its existing Medicaid patients, said Grayem. 

But 58% of children covered in the new collaborative have primary care physicians who are independent practitioners or aren’t affiliated with Children’s. The monthly money Children’s collaborative will get can be used for some of those same social barriers for all covered children in the plan, according to Lyden and Wakulchik. 

Part of the model will be partnering with those providers to engage them in the proactive care of the children. Those independent practitioners still have their contract with CareSource and also will receive an incentive from Children’s ACO company to work together. 

An example, Wakulchik said, is “say we have a pathway that helps asthmatics stay out of the hospital. We’re not just going to use that for patients we serve in Akron Children’s. We want to work with our community partners and they will use them in their practice to help keep them healthier.” 

Medicaid is Akron Children’s single largest payor, accounting for 53% of total charge, Lyden said. 

“This is a ripe area for us to get involved in this accountable care population health,” he said. 

Akron Children’s has been working with a network of independent physicians and federally qualified health centers to set up the collaborative and also will have five members on the collaborative board, Wakulchik said. 

In a statement, CareSource Ohio Market President Steve Ringel said “CareSource’s history is built on breaking down the barriers of health care to increase access to seamless high-quality cost-effective care. 

“Our partnership with Akron Children’s Hospital will continue to support our youngest members and their families in northeast Ohio.” 

13 counties covered

The collaborative’s CareSource contract will cover 13 counties: Summit, Stark, Portage, Wayne, Medina, Ashland, Carroll, Holmes, Tuscarawas, Trumbull, Mahoning, Columbiana and Huron. 

There are still another 120,000 Medicaid-covered children in the 13 counties with other insurers that are not yet covered under this new model, Lyden said.  

Akron Children’s currently has a 35-county service area and will consider opportunities to expand the collaborative in future years, he aid. 

The new model is not a “patient-steering mechanism” to try to get more patients to Akron Children’s facilities, Wakulchik said. While she would like it if working with more community partners would involve better access to Akron Children’s facilities, the collaborative would be responsible for children’s care in the program anywhere they go. 

“They can go anywhere they want,” Lyden added. “They could go to Columbus and it’s still on our nickel. It still comes out on our fixed payment.” 

Said Grayem: “The main thing is we want to improve the health of kids by focusing on quality and improving health equity for better outcomes.” 

 Beacon Journal staff reporter Betty Lin-Fisher can be reached at 330-996-3724 or blinfisher@thebeaconjournal.com. Follow her @blinfisherABJ on Twitter or www.facebook.com/BettyLinFisherABJ To see her most recent stories and columns, go to www.tinyurl.com/bettylinfisher

 
 

Clipped from: https://www.indeonline.com/story/news/2021/08/31/akron-childrens-creates-new-company-care-100-000-medicaid-patients/5622988001/