Sunday, April 3, 2016

Framework for governor's Medicaid "bill of rights" originated from managed care company Centene, concerning some lawmakers

Posted By on Sun, Apr 3, 2016 at 5:17 PM

Information circulating among legislators purports to show that Centene has had a hand in crafting legislation and talking points for Gov. Asa Hutchinson's proposal to use managed care for certain populations in the traditional Medicaid program. 

Centene, a St. Louis-based insurance company that offers plans on the state's Health Insurance Marketplace (including the private option), is a likely bidder for managed care contracts if the state moves forward with the governor's plan.

A document created by Centene, outlining bullet points for "bill of rights" protections for both patients and providers, was sent to the governor's office and appears to serve as a framework for the governor's own "bill of rights" in his proposed managed care bill. Former state representative John Burris, who is now a lobbyist for Centene, was involved in looking over the document and providing minor edits (Burris, if you're wondering, registered as a lobbyist this January; he was subject to a one-year cooling off period rather than two years because of when he left the legislature). 

Screenshots of the document's properties, establishing that it originated with Centene and that Burris had been involved in its modification, have been circulating among legislators by text and e-mail yesterday and today (see an example below). 

Both the governor's office and officials from Centene said that from the beginning, Hutchinson had solicited input from a variety of relevant stakeholders regarding his managed care plan — including providers, advocates for patients, and others — and there was nothing unusual about receiving input from Centene. They both also pointed out that the document in question offers "bill of rights" additions to the governor's bill that place limitations on the managed care companies and are the sorts of protections that provider groups generally like. 

The bill of rights framework offered by Centene was a "model of transition" summarizing legislation that had been successful in other states, said John Ryan, CEO of Arkansas Health and Wellness (that's the Arkansas branch of Centene, which sells insurance plans in the state under the name Ambetter).

"As a stakeholder, we were asked to provide some input and some feedback into things that have been successful in other states," Ryan said. "We oftentimes are asked by either legislators or the executive branch to provide those types of examples to show, when you transition from a fee for service environment to a managed care environment — what are the protections for consumers, providers, and states. These are the types of protections that, quite frankly, all those constituencies are somewhat fearful of because they’ve not done this. Change is not necessarily easy. What we did is provide that documentation to the governor’s office as an example of what other states have done." 

Legislators who oppose Hutchinson's managed care plan, however, argue that managed care companies like Centene will look after their own bottom line rather than protecting providers and patients. The fact that the "bill of rights" framework meant to offer those sorts of protections originated from a managed care company makes them even more concerned, said Rep. Deborah Ferguson, one of the coalition of providers' allies in the legislature backing DiamondCare, an alternative to the governor's managed care plan. 

"The managed care plan is a plan that makes money for big insurance companies," Ferguson said. "It's concerned me from the beginning the amount that Centene has interjected themselves into this discussion." 

The legislature will take up Hutchinson's proposal, which would enact managed care for two of the most high-cost Medicaid populations — the developmentally disabled and those with severe and persistent mental health issues — at a special session this week. The governor has refused to put DiamondCare — an alternative which would pursue the same slate of reforms for the same populations but continue to pay providers directly on a fee for service basis rather than using managed care companies — on the call for the special session.

The document that Centene provided to the governor's office, a bullet-point list of protections for patients, providers, and the state, appears to largely be a summation of "bill of rights" legislation that exists for managed care in North Carolina. Centene, along with other issuers, were among the stakeholders involved in negotiating that legislation. 

The governor's office thought that initial framework would represent a good model for Arkansas, and then worked with health care stakeholders in the state, including provider groups, to revise it and eventually craft it into legislation.

How did the origin of this document come to light? An email sent on March 25 from the governor's Senior Advisor, Betty Guhman, to all members of the Arkansas legislature included an attached document, titled "Proposed Medicaid Bill of Rights," with the bullet-point list of "bill of rights" protections. ("Note that the Bill of Rights has been incorporated into the [governor's managed care legislation]," Guhman wrote in the email.)

Opponents of the governor's managed care plan did some sleuthing and found that the properties for the document show that it originated from Centene and that the original author was an employee of Centene's corporate office in St. Louis, Richard Johnston. Recipients of the email forwarded it to the Times. Here is a screenshot of the document properties:

guhman_document.png

An earlier draft of the same document was sent by Guhman to certain stakeholders and lawmakers. That earlier version likewise had properties showing that it originated from Centene and that the original author was Centene employee Richard Johnston, but this earlier version was "Last Modified" by Burris. 

Burris acknowledged that he had helped work on small tweaks to make the bill of rights applicable to Arkansas as opposed to other states (for example, adding a bullet point mentioning that a portion of savings would be used to help eliminate Arkansas's DD wait list). Burris said that he met with Rep. Michelle Gray and other DiamondCare backers to go over the bill of rights, and that together they made minor suggested changes to the governor's office. 

It's worth noting that the original document that Centene developed was essentially a summary of existing legislation in North Carolina. And the truth is that any "bill of rights" language in the legislation itself can only go so far; real protections for beneficiaries and providers have to come via the actual terms of the managed care contracts that the state will negotiate. That said, the optics here are potentially ugly for the governor. He's trumpeting his "bill of rights" as strong protections, but the original framework for the bill of rights came from a managed care company. And it came from a managed care company likely to be bidding on contracts during the procurement process to come if this legislation passes. 

The governor's office rejected the notion that Centene was improperly or too heavily involved in developing the legislation. Spokesperson J.R. Davis provided the following statement: 

The savings plan presented in the legislation originated with the Governor's presentation to the Task Force. The actual drafting of the legislation was coordinated by Bureau of Legislative Research. We asked numerous stake holders for comments on the legislation, and we received numerous suggestions from both providers and legislators. Some of these were incorporated, and some were rejected. The Governor made the initial call and then the legislative sponsors have to agree also since it is their bill. One of the suggestions was the Patients' Bill of Rights — a good list of principles that protects providers and taxpayers, and the Governor recommended its inclusion in the latest draft.

The governor's plan isn't the only bill that has gotten input from stakeholders. The DiamondCare alternative developed by managed care opponents like Ferguson and Gray was heavily influenced by provider groups, who no doubt provided their own frameworks incorporated into the legislation (a draft of the bill will be released tomorrow). For Ferguson, that's the point: 

Would you, as a patient, rather have lawyers and insurance companies write a bill on how to best deliver healthcare to the elderly, developmentally disabled, or children with autism — or have it written by people who actually treat these individuals and help them navigate a complex system?
Ryan said that the focus should be on the bill of rights itself. "These aren’t Centene ideas, these are good policy ideas that other states have implemented," he said.

The bill of rights (both Centene's bullet points and the final legislation) includes community advisory committees to protect beneficiaries, a prohibition on reducing currently available Medicaid benefits, a prohibition on increasing co-payment amounts, no limits on primary care visits, and the right to choose a primary care provider. For providers, the bill of rights includes guarantees of timely payment, guarantees of contracts for safety net providers, provider advisory committees to protect their interests, requirements for the managed care companies to enter contract negotiations with any willing provider, and a guarantee to pay the prevailing Medicaid fee unless mutually agreed upon by the provider and the managed care company (this last point is a source of dispute; Ferguson says that because of their limited bargaining power in Arkansas, providers will have no choice but to take the rate they're offered). Finally, the bill of rights places certain requirements on how the managed care companies interact with the state and state agencies, including transparent reporting, use of local staff for care coordination, and actuarially sound rate settings. 

“We’ve got a degree of experience in other states and we wanted to lend that experience to the state of Arkansas," Ryan said (Centene offers Medicaid managed care in 23 other states). "We want to make sure that if the state chooses to go down this path of managed care for Medicaid recipients, that it does so with protections for everybody involved. That's the feedback we provided. We want those common concerns addressed up front so that the conversation can be, what’s the best way to address health care concerns in the state of Arkansas?"

Ryan said that there was nothing in the bill of rights designed to benefit Centene. 

"These are not written toward a certain issuer or insurance company," he said. "These are good things to do, these are good things to have as protections for providers and members in the state. How the state translates that into a [request for proposal], that’s for the state to decide."   

Ryan's pitch is unlikely to convince managed care skeptics in the legislature, who remain convinced that — with or without a bill of rights — the managed care companies will squeeze providers (and ultimately, beneficiaries). The kerfuffle over the origin of the "bill of rights" framework signals how bitterly divided the legislature is over the managed care question. Will that fight complicate the governor's unrelated effort to continue the private option Medicaid expansion? The legislature will convene on Wednesday. Expect fireworks. 

Support for special health care reporting made possible by the Arkansas Public Policy Panel.

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