FamilyCare, CareOregon in Medicaid Conflict

May 26, 2010 -- The largest group of pediatricians in the Portland metropolitan area got caught off guard when they dropped their affiliation with CareOregon and signed a contract with FamilyCare in mid-March.

 

The 110-member pediatric group, known as the Children’s Health Alliance, assumed they’d still be able to take care of the 15,000 children enrolled in the Oregon Health Plan. Instead they’re embroiled in a face-off with the state Medicaid agency and CareOregon.  

 

A deadline is looming. Parents have until June 15 to notify Medicaid about their desire to keep their current pediatrician and, if so, choose FamilyCare as their managed care plan. Otherwise, they’ll remain with CareOregon and be given a new pediatrician on July 1.

 

“There’s so much confusion out there; patients are calling in, not understanding what’s been going on; it’s not the kind of collaboration we’d hope for with Medicaid,” said Sharon Fox, the alliance’s executive director.

 

The alliance is urging Medicaid to rescind its earlier decision and transfer these children and their parents to FamilyCare, giving them the choice to return to CareOregon. “This is the method that was used in 2008 and allows for the least disruption in ongoing care and is less stressful for families,” Dr. Resa Bradeen, president of the alliance, told the Senate Health Care Committee on Monday.

 

Insisting he didn’t have “a dog in the fight,” Senator Alan Bates (D-Ashland) called the situation “a mess.” He encouraged CareOregon to take the lead and transfer those children to FamilyCare to quell the situation. People have a much deeper relationship with their physician than their health plan, he contended.

 

But CareOregon seemed unwilling to budge. “If we moved the children wholesale, what would happen to their family members; I’m not willing to endorse that gamble,” said Pam Mariea-Nason, director of health policy and community engagement. “The alliance terminated its contract without thinking through what would happen to their families.”

 

FamilyCare doesn’t have the same large network of providers as CareOregon, she insisted. “Children don’t live in a vacuum; we need to treat them in the context of a family unit. Our concern is that provider panels won’t match up. When you split up the family, there are lots of ramifications. It makes good sense particularly in families that have complex medical issues and require a higher degree of involvement by the health plan.”

 

But FamilyCare is quite capable of handling the situation, countered Jeff Heatherington, its president. “They’re saying all of these people need to change providers, but we don’t know if that’s true. For example, there’s never been analysis by Medicaid to determine the real number of family members impacted by this change. There needs to be a fair and transparent process, which hasn’t happened. Now some patients are going to be forced to change doctors because of the restricted timeline.”

 

Criticizing the Medicaid agency in front of legislators, he said “there’s been virtually no communication. I’ve had to chase down rumors and this is the most bizarre nontransparent situation I’ve seen in 25 years. We don’t know who’s in charge. The agency lacks leadership.”

 

Medicaid should follow the example of a similar situation that occurred 18 months ago when the Yakima Valley Farmworkers Clinic switched from CareOregon to FamilyCare without incurring any wrath. 

 

“It was a clean and easy process,’ said Heatherington, who urged Medicaid to transfer these children and their parents to his health plan, giving them the option to switch back to CareOregon within 30 days. “At least transfer all of those for whom we have the same provider.”

 

CareOregon wasn’t caught off guard. Long before the alliance officially terminated its contract, it swung into action. The alliance had shared its discontent; the pediatricians wanted more money and had closed their doors to new Oregon Health Plan members after the governor signed the Healthy Kids Act last summer.  

 

Concerned that children would end up in a fee-for-service environment with limited access, CareOregon started rebuilding its network and intends to open new clinics this summer in Multnomah and Washington counties as well as Beaverton.