Critics Accuse Trillium Of ‘Bait And Switch’ Approach In Medicaid Negotiations
The Oregon Health Authority may have recently approved a new player in the Portland-area Medicaid market, but many providers still object to the for-profit company as an outsider with questionable tactics and an allegiance to nationwide shareholders rather than the low-income Oregonians they’re supposed to serve.
The Lund Report has learned that Trillium Community Health Plan, a for-profit company owned by Fortune 500 company insurer Centene, has used what one provider called “bait and switch” tactics to get providers to sign up. Others say the company is unfamiliar with the main players and appears to be more focused on its bottom line than the community.
The health authority approved Trillium’s application to accept Medicaid patients in the tri-county Portland-area market in August, months later than for all of the other 14 coordinated care insurers in Oregon. And when it gave the go ahead, it put Trillium on a short leash by ordering the company to beef up its provider network, particularly in behavioral health care, and take steps to provide equitable health care, such as language interpreters.
The company declined a request for an interview and did not answer detailed questions from The Lund Report. It released a statement saying it is committed to providing top notch care for Medicaid members.
Trillium has until Oct. 15 to show that it meets all requirements.
Even if it does, resistance against the company is likely to linger for some time, with providers and coordinated care experts continuing to question whether Trillium’s status as a for-profit corporation beholden to shareholders conflicts with the broader goal of having coordinated care organizations investing in communities and the people they serve. Trillium was an Oregon company before Missouri-based Centene, the nation’s largest Medicaid insurer, purchased it in 2015.
Much of the criticism has been behind-the-scenes or off-the-record. But not all. Though coordinated care organizations executives tend to avoid saying anything they fear might upset the health authority, the head of Health Share of Oregon, which serves Oregon Health Plan members in the Portland area, has openly questioned Trillium’s fitness to enter the market. Others have grumbled about the inefficiency of having two coordinated care organizations in the Portland area, which includes about 350,000 members. Nearly a third of the overall Medicaid population in the state. The market is lucrative. Health Share, formerly the sole insurer in the Portland area, reaped about $2 billion a year from the state to pay for coverage.
In all, there are 15 coordinated care organizations in Oregon that operate as regionally based Medicaid insurers. To do business, they have to demonstrate to the health authority that they have a network of providers large enough to care for patients.
Trillium has struggled to sign up providers, and even now does not have an extensive network like Health Share.
Nevertheless, the health authority does not appear to be willing to reconsider Trillium’s entry into the Portland area. Director Patrick Allen told one coordinated care executive recently that backtracking on that decision was out of the question.
‘Bait And Switch’ Tactics
Those who don’t sign up with Trillium have faced some high pressure sales pitches from the company’s representatives. In one account, a behavioral health provider in the Portland area said Trillium attempted to aggressively recruit him with a “bait and switch” approach. The provider asked to remain anonymous for fear of retribution but provided email records and proposed contract documents to The Lund Report that back up the account.
Before the authority approved Trillium, the source said, company representatives called repeatedly telling the company it should sign up with Trillium to ensure it didn’t cut itself out of future business. Trillium’s representative attempted to lure the company with a promise to negotiate pricing after the contract was signed, the records show. At the time, Trillium still was attempting to persuade the health authority that it had capacity to serve the region.
Medicaid insurers have to sign up enough providers to ensure that their members can obtain needed medical, dental, behavioral health and vision services.
But later the company retracted that promise, according to emails reviewed by The Lund Report.
Instead, a representative said Trillium would only pay the same rate as what the state pays for those on the open card plan. Open care members are typically not in a coordinated care organization and the services they use are reimbursed on a fee-for-service model. Those rates are lower than those offered by Health Share, the provider said.
In the end, the provider opted not to sign up with Trillium.
“They essentially wanted providers to take a pay cut just for the privilege of being in their network,” the provider said. “As it stands right now, we would not contract with them even if they are approved by the state because they have proven untrustworthy and as far as I know they have not given any indication they will negotiate for a reasonable contract.”
Another large provider in the Portland area who spoke with The Lund Report on the condition of anonymity echoed that sentiment. The provider said that in a meeting with Trillium it was clear that Trillium’s negotiators had not done their homework. They were not familiar with the provider and appeared to have no clue about the role of the provider in the community.
That provider also refused to sign a contract with Trillium.
Trillium declined to respond to questions about provider concerns. Instead, it released a statement: “As we continue our growth into the tri-county area, bringing over 20 years of experience in serving Oregon Health Plan members, Trillium Community Health Plan remains committed to improving access to high-quality care for OHP members. We continuously work with health care providers to improve and enhance our network, and are actively negotiating with providers in the tri-county area.”
Trillium has a track record serving Medicaid members in Lane, Douglas and Linn counties. But during its initial foray into the Portland area, Trillium failed to lure any hospital system or other large providers, such as Multnomah County, which offers mental health services.
It’s since signed contracts with several large providers but in some cases they limited services.
Oregon Health & Science University agreed to provide speciality services like sports medicine and pregnancy care, but not primary care. Two OHSU-affiliated hospitals, Tuality Community Hospital in Hillsboro and Adventist Health Portland, agreed to provide some services. The Portland-based Legacy Health network of hospitals agreed to contract with Trillium for pediatric services and rehabilitation medicine.
County-run community health centers in Multnomah, Clackamas and Washington also signed contracts with Trillium.
But Portland’s largest provider, Providence Health & Services, didn’t sign on, denying Trillium access to its four metro-area hospitals and a network of primary and specialty-care clinics. And Trillium failed to attract Kaiser Permanente, which has clinics and two hospitals in the Portland area.
The Oregon Health Authority also has concerns about Trillium’s connections in the community. Coordinated care organizations are required to have a community advisory council with local representatives, but the health authority has told Trillium it has “has not demonstrated these requirements are being met.” The health authority told Trillium it has to develop a community engagement plan.
Experts Question Health Authority’s Position
Critics contend that Trillium is out of touch with the Portland area and shouldn’t be open for business. They say the market already has a well-established Medicaid insurer - Health Share -- that has a track record of meeting members’ needs.
Many question why the health authority approved the company in the first place.
The health authority has indicated that it wants patients to have more options. But critics say bringing on another Medicaid insurer does not necessarily serve them better. A new insurer doesn’t add to the number of providers available to patients, increase services or resources.
At the end of the day, the amount of Medicaid money available from federal and state coffers will stay the same, regardless of how many coordinated care organizations are in the mix, said Derald Walker, CEO of Cascadia Behavioral Healthcare, a large Medicaid provider based in the Portland area.
“The question for an overburdened nonprofit provider system in the tri-county area is in what way does a second CCO improve the quality of care, access to care and in any way benefit the provider system?” Walker said.
Walker said that adding competition to the market does not improve the quality of care for patients or help therapists, doctors, nurses or other providers.
In fact, having to deal with a second coordinated care organization only increases the burden on providers because they will have to spend more time on paperwork and other administrative tasks, Walker said.
Another critic of Trillium is former Democratic Gov. John Kitzhaber, who shepherded Oregon’s novel approach to Medicaid. He said the health authority needs to be on the guard against companies beholden to interests outside the state. Having an out-of-state owner makes it more difficult for a company to establish community relations than one based locally, he said. He also doesn’t think that for-profit companies with shareholders should be involved in the social safety net.
“I’m not shy about the fact that I do have problems with for-profit companies that are funded primarily with public dollars, and the concern I had with Centene is they have a larger business model,” Kitzhaber said in an interview with The Lund Report.
Kitzhaber said he would have supported requiring that the majority of a coordinated care organization’s directors live in Oregon. But when the state passed his landmark legislation on the system in 2012, Kitzhaber said, getting that approved was a “bridge too far.”
As for the Oregon Health Authority, health care observers wonder why the agency approved Trillium’s application and allows it to enroll people, albeit on a conditional basis, when the company still has not met all requirements. Specifically, the health authority told Trillium to add providers specialized in behavioral health, work more closely with the community through an advisory body and improve its work on health equity, including adding language translators.
A need to ensure that the state is serving minority populations has become a major focus for the state.
“If that’s such a strong policy, why are we auto-enrolling people in a CCO that we acknowledge might not meet equity standards?” Kitzhaber said.
When people apply for Medicaid, they can pick a coordinated care organization or have the authority “auto enroll” them in one. If the new members have family members in a CCO, they’ll be assigned to the same coordinated care organization as their spouse or parent, for example. But if they are completely new to the system without those connections, the health authority will assign them to a CCO on an even basis. In the Portland area, that means that half of new members without any affiliation would go to Trillium.
The authority continues to defend its decision to back the company. In a statement, chief financial officer David Baden said Trillium met the necessary requirements and that the authority will continue to monitor areas of concern through the corrective action plan that’s due by Oct. 15. Trillium will have to meet expectations by the end of the year, Baden said.
If Trillium doesn’t, additional sanctions are possible.
Oct 3 2020