Coalition Loses Members on Louisiana Medical News

Coalition Loses Members

By: TED GRIGGS

Dr. Dean Griffen

Medicaid Revamp Still Opposed

The state’s effort to revamp the healthcare delivery system for the poor has gained the support of two major players in the industry, but groups representing family practice physicians say they still have many questions about the proposal.

“We do know that we’re very uncomfortable with the insurance model side of it,” said Berkley Durbin, director of MedicineLouisiana, a physicians’ trade group. “We feel that way because of the track record in other states, what we’ve seen and the documentation that we have reviewed.”

Durbin said the remaining members of the Coalition to Protect Louisiana’s Healthcare – MedicineLouisiana, the Louisiana Chapter of the American Academy of Pediatrics, and Louisiana Academy of Family Physicians – represent the majority of doctors who treat the Medicaid population.

The coalition members are not as uncomfortable with the state Department of Health and Hospitals’ shared-savings approach, but there are still concerns over a lack of details, Durbin said.

The policy-and-procedures guides are not available and won’t be until DHH issues its request-for-proposal documents later this month. DHH has not issued its final rule so physicians don’t know what the health plans are going to do for contracting purposes.

DHH has said the rate structure will be based around the current Medicaid fee schedule, Durbin said, and “that’s good to hear. But no one can tell us whether we’ll get paid at all or what services will be covered.”

No one knows what the health plans will put into its contracts with providers, according to Durbin who also says that’s very disconcerting for the people who review these contracts.

“While we may have problems with current claims management system, it’s one claims management system, and it’s one payer,” Durbin said. “And we have direct relationships with the state in order to resolve those issues when they come up.”

That’s a much different situation than what could take place under the Coordinated Care Networks proposed by DHH, Durbin said. Providers could end up dealing with six to eight different health plans, which means a much heavier administrative burden for practices.

“So that’s a huge issue for us. Even if we get paid the Medicaid fee schedule, it’s still not the same amount of money when you have to add staffing and resources to deal with all that additional administrative burden,” Durbin said.

The Jindal Administration has proposed moving about two-thirds of the state’s 1.2 million Medicaid enrollees into plans overseen by private insurance companies or through third-party administrators. DHH plans to begin phasing in the Coordinated Care Networks Jan. 1. The networks are designed to improve health outcomes and reduce costs by focusing more on managing chronic conditions.

Almost immediately the proposal met with opposition from providers, who formed a coalition that included the Louisiana State Medical Society, the Louisiana Hospital Association and the Louisiana Ambulance Alliance. The latter three have since dropped their opposition and their membership in the coalition.

Dr. Dean Griffen, LSMS president, said the society threw its support behind DHH after the agency altered the proposal, making the bid process competitive and limiting insurers’ profit, and held a series of informational presentations about the CCNs throughout the state.

Among other things, DHH is requiring insurers to pay doctors promptly, Griffen said. Insurers are also being asked to design prompt and user-friendly appeals processes when claims are denied; reimbursement denials have been a problem in previous managed care systems.

However, Ragan LeBlanc, executive vice president of the Louisiana Academy of Family Physicians, said the current process remains flawed.

Health plans are asking physicians to sign a letter of intent now, LeBlanc said. Then if the plan wins a bid, it will ask the physicians to sign a contract.

Under the usual process, doctors have to deal with the insurer only once, she said.

Ashley Politz, executive director, Louisiana Chapter of the American Academy of Pediatrics, said the process takes up time the physicians could be spending with patients.

And Durbin said there are too many unknowns, such as what the medical loss ratio will be.

The federal healthcare legislation sets the medical loss ratio, the percentage of premium dollars that insurers spend on medical costs, at 80 percent to 85 percent, Durbin said. But Massachusetts recently got a waiver to lower that to 65 percent.

Durbin also said it will be difficult for insurers to develop a sustainable healthcare delivery model based on the Medicaid population DHH is targeting, mainly women and children.

That population, although large, makes up a small portion of Medicaid’s total costs, she said.

Molena HealthCare Inc., which oversees Medicaid claims in Louisiana, has said 27 percent of Medicaid recipients, the elderly and developmentally disabled, account for 68 percent of the costs.

Those people are the ones that need additional care management, Durbin said.

Molena, in conjunction with the coalition, had proposed an alternative to DHH’s plan. Molena officials said they could almost immediately reduce costs by $60 million among the 800,000 people DHH’s plan targeted. The company has dropped that that proposal.

Durbin said the company, which has bid for a state contract, was uncomfortable about continuing to work with the coalition.