Patti Davis:

Oklahoma Hospital Association (OHA) Opposes SoonerSelect

While OHA supports measures to improve access to high quality and affordable health care and supports paying for outcomes through value-based payment, such as enhancing the state’s existing patient centered medical home model, we do not support SoonerSelect. This RFP has been fast tracked without input from essential stakeholders including patients, health care providers, and the Legislature.

Access to Care

The Oklahoma Health Care Authority’s (OHCA) actuary partner, Mercer, uses assumptions that hospital care will be reduced by 40% while behavioral health is reduced by 20%, all in year one. This, during an ongoing pandemic when Oklahomans are struggling with isolation, depression, and joblessness.

The OHCA mentions that these actuarial savings will be achieved by preventive services. However, we do not see a corresponding increase for preventive service cost in the actuarial tables provided by Mercer. It is impossible for us to understand how health outcomes will be improved by reducing utilization by 40% on pregnant women and children and the newly added expansion population, which will no doubt have pent up demand for services.

In addition, the proposed changes to move SHOPP to directed payments will create cash flow uncertainty for hospitals as well as changes to the existing federal 340B drug program. The 340B program expands access to lower cost outpatient drugs at more than 50 hospitals statewide for patients with high-cost conditions such as cancer.

State Budget

Managed care organizations (MCOs) are great at making promises, but OHCA already delivers cost-effective, quality care for Oklahomans. Unfounded claims of budget certainty will come at a cost for the state. There are no scholarly articles that prove moving to an MCO model either provides budget stability or improved outcomes. For example, OHCA’s current administrative costs are much lower than MCOs at 3.7%, and the rush to implement this program puts the state at risk for overpaying for health care.

Closing

It has been stated that this proposal will shift the financial risk of the SoonerCare program from the state to MCOs. However, we ask you to consider:

• Patient care services will be reduced by 40% for hospitals and 20% for behavioral health providers.
• The evidence is inconclusive at best that an MCO model improves health outcomes as claimed by these insurance companies.
• Changes to the SHOPP and 340B programs will create financial uncertainty. These programs are lifelines for Oklahoma hospitals.

This proposal does not shift the risk to these insurance companies, but rather shifts the risk to Oklahoma patients and health care providers.

Jayne Van Bramer:

The State did not engage the Hospital Association or hospital providers in the planning of SoonerSelect. A collaborative process could have identified the means to improve care and save on costs.  As a hospital CEO, I oppose Oklahoma's  movement towards Medicaid managed care as  assumptions built in this plan call for a 40% reduction in hospital care and 20% in behavioral health in the first year.  That is reduced services for pregnant women, children, and the population covered under Medicaid expansion which traditionally is a population with the more severe forms of mental illness.  

Robert L. Carter, CEO EOMC :

As the administrator of a rural CAH in southeast Oklahoma, I adamantly oppose transitioning our Medicaid program to managed care.  I oppose sending Oklahoma dollars out of state to private insurance companies for management fees.  This is money that, for the most part, will never return to Oklahoma.  For your own actuarial study to show that you will decrease utilization of care by 40% and then try to sell this as increasing access to care is laughable.  Finally, turning a blind eye to the unified opinion of the vast majority of medical associations and providers in state and marching forward with this plan is both irresponsible and reprehensible. 

Citizen Potawatomi Nation Health Services :

Please note - your description on this page says AI/AN member may choose to opt out, when it should say "opt in".   Please make this correction.

The Citizen Potawatomi Nation (CPN) appreciates the opportunity to offer the following comments on OK SPA 21-0015 Adult Expansion ABP Service Delivery System Update.  The proposed Title XIX State Plan Amendment (SPA) adds two additional types of delivery systems to the Adult Expansion Alternative Benefit Plan (ABP) while utilizing the Adult Expansion ABP as the benefit array for adults, including the new adult group.  Qualified managed care organizations (MCOs) are added to facilitate medical services and Prepaid Ambulatory Health Plans (PAHPs) are added to provide dental services via a dental benefit manager for adults.  Additionally, the primary care case management (PCCM) delivery system is added to the ABP as American Indian/Alaskan native (AI/AN) members are exempt from mandatory enrollment in MCO/APHP.  The AI/AN member must “Opt-In” if they choose to enroll in MCO/PAHP.  The AI/AN members will continue to receive services through the existing PCCM if they remain is the traditional Fee for Service category and continue to seek their services through an Indian Health Service/Tribal/Urban (ITU) provider and facility.   

The Citizen Potawatomi Nation has gone on record more than once that it does not support the approval of Managed Care Organizations (MCOs) and Prepaid Ambulatory Health Plans (PAHPs) as effective delivery systems for Oklahoma’s Adult Medicaid Expansion.  Although the agency did conduct formal tribal consultation during some bi-monthly meetings, the annual tribal consultation meeting, and tribal MCO workgroup meetings at which time transition to a managed care organization was discussed, CPN does not and has never supported the provision of Managed Care for Medicaid Expansion.  Of importance to note, OHCA’s previous attempt to implement MCOs in the past failed, and the agency moved back to a fee for service model.  This has been very effective for current members, including AI/AN members, as well as for Indian Healthcare providers.

Managed care can be detrimental to Indian Health patients and providers.  While the Nation appreciates the opt-in MCO enrollment provision for AI/ANs, the process for those who do elect to opt-in can be confusing and overly burdensome for both the patient and the Indian Healthcare provider, while delaying much needed care in some instances.  Patients are required to navigate outside the Indian Health system where private sector providers have little understanding of the referral process and Indian Health system overall. 

The current fee for service model has been effective for SoonerCare members and providers, including AI/AN members and Indian Healthcare providers.  As noted, the Managed Care model failed previously and the current fee for service model has proven effective.                         

In closing, we submit these comments for record of our opposition to a Managed Care model for Oklahoma Medicaid Expansion.

Emma Morris:


Oklahoma Policy Institute appreciates the opportunity to submit a comment on the SPA 21-0015 Adult Expansion ABP Service Delivery System Update. A nonprofit, non-partisan think tank, Oklahoma Policy Institute provides research and analysis in support of equitable and fiscally responsible public policies that will ensure prosperity for all Oklahomans through good schools, good jobs, good health, and strong communities. As this delivery system update includes the addition of managed care organizations (MCOs) and Prepaid Ambulatory Health Plans (PAHPs), we would like to raise significant concerns about the state’s proposed transition to a privatized managed care model. Privatizing the state’s Medicaid program likely won’t save the state money and could even end up costing taxpayers more: - OHCA’s administration cost of 4.05 percent in 2017 (https://okpolicy.org/wp-content/uploads/2017-OHCA-Annual-Report-WEB.pdf?x38273#page=3) was lower than that of most states using managed care at that time (https://www.healthaffairs.org/do/10.1377/hblog20180430.510086/full/). - Proponents of privatization often point to the elimination of fee-for-service as an avenue for state savings. However, only 1 in 4 SoonerCare members (https://oklahoma.gov/content/dam/ok/en/omes/documents/bud22.pdf#page=274) are enrolled in SoonerCare Traditional, the traditional fee-for-service system. OHCA manages the remaining 75 percent of SoonerCare enrollees through its efficient partially capitated managed care (PCCM) model. With so few enrollees currently in fee-for-service — and with most of those enrollees unlikely to transition to managed care — it would be difficult for OHCA to somehow find sweeping cost savings by moving away from fee-for-service. - Peer-reviewed evidence on whether or not privatized managed care saves states money is mixed at best (https://okpolicy.org/wp-content/uploads/Medicaid-managed-care-Costs-access-and-quality-of-care-via-Robert-Wood-Johnson-Foundation.pdf?x31514#page=13), and since SoonerCare is already so efficiently managed, it remains unlikely that privatization will generate savings for the state. Privatization is unlikely to improve health outcomes for Oklahomans who use Medicaid to see a doctor and fill a prescription: - Again, peer-reviewed evidence as to managed care’s impacts on health outcomes is mixed at best (https://okpolicy.org/wp-content/uploads/Medicaid-managed-care-Costs-access-and-quality-of-care-via-Robert-Wood-Johnson-Foundation.pdf?x31514#page=17). While the OHCA should take steps to improve Oklahomans’ health and racial disparities in health outcomes, managed care is not the silver bullet. - In fact, privatized managed care could have negative impacts (https://okpolicy.org/wp-content/uploads/Managed-Care-Fact-Sheet-2021-Medicaid-Research-via-Oklahoma-Policy-Insitute.pdf?x31514) on many Oklahomans, including those residing in rural areas, American Indians, Oklahomans of color, and those with behavioral health needs. - The projected 40% decrease in inpatient hospital utilization and 20% decrease in behavioral health utilization as a result of the transition will likely result in increased patient denials for necessary care. Providers will lose critical revenue, which will exacerbate the state’s provider shortage and limit access to care, particularly in rural areas. - The projected 40% decrease in inpatient hospital utilization and 20% decrease in behavioral health utilization (https://oklahoma.gov/content/dam/ok/en/okhca/docs/about/procurement/soonerselect/documents/SoonerSelect%20Medical%2020201208.pdf#page=30) will ensure lower pay for providers. Even if rates remain the same, hospitals and behavioral health providers will see fewer patients, and therefore receive lower payments. - The RFP states that OHCA can develop requirements in the future to further the goal of “cost savings” (https://oklahoma.gov/content/dam/ok/en/okhca/docs/about/procurement/soonerselect/documents/Solicitation%208070001240%20-%20SoonerSelect%20RFP.pdf#page=248). Many advocates and experts predict MCOs will be unable to reduce costs, which would require the companies to lower provider payment rates. - The last time Oklahoma privatized the Medicaid program, 90% of dentists were forced to stop accepting Medicaid patients. With less than 100 dentists left in the state accepting Medicaid, countless Oklahomans were forced to go without necessary dental care. - This change will particularly harm rural providers and patients. Because so many rural providers rely on the consistency of Medicaid payments to keep the lights on, change in payment rates or patient utilization, an increase in red tape, or delayed payments could easily put rural providers out of business. This could force rural patients to drive for hours to see their doctors. Lastly, we have significant concerns about the timeline of this transition. During meetings with MCOs this fall, multiple MCO representatives expressed concern and dismay with the state’s unnecessarily compressed timeline. Hasty approaches in other states, like North Carolina, Iowa, and Kentucky, have resulted in long-lasting problems for both patients and providers. Additionally, as the state moves to implement Medicaid expansion, OHCA should be focusing on ensuring the implementation of expansion is accessible and robust. A privatized managed care model with the needs of patients and providers in mind must be measured and intentional to be successful. We don't believe the current path to be either of those things.

Steven Goldman:

This SPA 21-0015 seems incomplete and needs further clarifications about member/beneficiary processes and rights.

All quotes are from page 3 of SPA 21-0015:

"...enrollment processes seek to preserve provider-beneficiary relationships...."

Does this mean that when OHCA assigns a member to an MCO it will check that this MCO includes the member's current provider? OHCA has this information about current provider choice....will OHCA use it in assigning an MCO when the member does not make a choice during the short window available in late 2021? Or will arbitrary "auto-assignment" be used?

There are "quality-weighted assignment factors" for member assignment to MCOs.

When are the first quality measures results available?

When do "quality factors" begin to be utilized in the OHCA auto-assignment process?

Will the quality measure results be listed for each MCO in the OHCA "selection module"  used by members, so members can see the quality ratings on the same screen where they make their choice of MCO??

Members must wait until "the next open enrollment" period to request a transfer to another MCO (after the initial 90 days).

When is the "open enrollment" period scheduled?

How does this affect member ability to change MCO when the "contractor does not cover" a procedure "for moral or religious reasons"? (RFP Sec 1.5.7.2) The example given in RFP is cesarean section and tubal ligation. For a pregnant woman, how far in advance of day of birth must an MCO change request be made for this situation?

Thank you for your consideration.

---------

These comments are the personal views of the author. They do not represent any group or employer.

Matt Robison:

On behalf of the nearly 4,000 physician and medical student members of the Oklahoma State Medical Association (OSMA), the state’s largest physician led organization strongly opposes the Oklahoma Health Care Authority (OHCA) utilizing private Managed Care Organizations (MCOs) for Medicaid claims administration (a/k/a SoonerSelect). Although some share high expectations for utilizing this form of “capitated” managed care, the experiences in Oklahoma as well as other states prove that such high expectations are unwarranted and unattainable.

Oklahoma previously implemented a managed care model which resulted in hundreds of Oklahoma health care providers opting out of the failed system, creating an access to care crisis for Oklahomans most vulnerable population. A capitated managed care approach institutes an access to care crisis for an Oklahoma population that already faces a serious shortage of health care providers while combating a world-wide pandemic.

OSMA supports avenues to improve access to high quality and affordable health care and supports positive health outcomes through value-based payment; however, the bureaucratic red tape and delayed payments that are a reality of managed care forced many state physicians to stop taking Medicaid patients. Regardless of the intent to curb costs while expanding services, the fact remains that the number of physicians willing to serve the Medicaid population will decline if MCOs are implemented, especially in rural areas. Rural citizens will be forced to drive hours into Oklahoma City or Tulsa just to see a doctor, even if they are lucky enough to find one who was accepting new patients.

Other states that have privatized their Medicaid systems have not seen the savings they were promised. Any cost reductions that have been made have come at the expense of health care providers and patients through denied care, reduced reimbursement, and delayed payments. Implementing a capitated managed care system could again result in a catastrophic loss of providers for Oklahoma’s most vulnerable citizens and the newly enrolled Medicaid participants.

Many of Oklahoma’s rural physicians are small employers working as sole practitioners or in a small office. Like any small business, they rely on steady cashflow to keep their doors open. At present, OHCA does an excellent job at processing and paying claims quickly—far more quickly than most private insurers. Many of these small practice physicians depend on the steady and reliable payment stream from OHCA to pay staff and keep the lights on while waiting for reimbursement from other insurers. This reliable structure allows physicians and other health care partners to maintain their practice and continue to provide quality health care to those who are in most need.

OSMA absolutely agrees that items like improved coordination of care is a laudable goal, but that can be accomplished under the current system without requiring wholesale and disruptive changes to Medicaid delivery.  Any public or private sector entity administering hundreds of millions or billions of dollars will always be able to find more efficiencies. That will be the case regardless of structure. However, rationing care to Oklahoma’s most needy citizens and forcing existing providers to accommodate profit-minded MCOs is not the way to improve health outcomes.

Physicians appreciate OHCA looking for more efficient methods for providing health care services to the Medicaid population. However, capitated managed care will not improve healthcare outcomes for Oklahoma’s most vulnerable.

The Oklahoma State Medical Association urges the Oklahoma Health Care Authority to reject this MCO “SoonerSelect” SPA proposal.

Gregory A Reid:

Oklahoma Ambulance Association (OKAMA) Opposes Ok SPA 21-0015, SoonerSelect The Oklahoma Ambulance Association supports sustainable efforts to improve the health of Oklahomans.  Based on the limited information provided to us, the Oklahoma Health Care Authority’s plan, SoonerSelect (OK SPA 21-0015), will not improve health. 

Access to Care

History in Oklahoma and other states’ experiences show that SPA 21-0015 will drive current facility-based providers to cease participation or limit the number of Medicaid beneficiaries they treat. Patients will be forced to travel from rural areas to receive care.  If traveling for care becomes too much for these patients, they will not keep appointments and experience a decline in health status. As a result, our Oklahoma emergency medical services (EMS) and ground emergency medical transport (GEMT) providers will realize increased demand from Medicaid beneficiaries.

Additionally, rural hospitals will begin transferring – usually by EMS/GEMT – more patients out of their facilities, as they will not have physicians available to treat Medicaid beneficiaries.

Given the relatively low Medicaid reimbursement rates, a higher Medicaid payer mix and increased transfers could force some EMS/GEMT providers – particularly those in underserved rural communities – to close. Further, EMT/GEMT providers will spend more time outside of their usual service areas handling hospital transfers and will be decreasingly available to respond to requests for emergency service within their local communities.   

OK SPA 21-0015 will decrease both facility-based and pre-hospital access to care for many Oklahomans.

Mental Health Patients

If Oklahoma continues to decrease mental health services (plan projects a decrease of 20%), EMS will be relied upon to offer crisis intervention, treatment, and transport to the limited mental health facilities to patients that could have been managed affirmatively.  Simply spending less on patients and more on administrative costs to deliver care is illogical.

Loss of Fiscal Support

Oklahoma EMS/GEMT expects that MCOs will affect ambulance services’ ability to cover their expenses to provide care.  Reports from the GAO and CBO demonstrate that the Medicaid Fee Schedule for GEMT is less than the actual cost to provide service. This is supported by data from the Certified Public Expenditure program for publicly operated EMS agencies.

There are questions about the effort to replace supplemental payments to hospitals, but the Oklahoma supplemental payments for EMS have not been addressed.  This is critical funding that governmental EMS agencies need to continue the level of services they provide.

Closing

Oklahoma Ambulance Association respectfully requests that you deny approval of the Oklahoma SPA 21-0015.  Oklahoma needs to improve the health of Oklahomans, but this strategy will deliver the exact opposite result.