The Oregon Health Authority is imposing curbs on Trillium Community Health Plan that will prevent the coordinated care organization from enrolling new members in the tri-county Portland area market starting in December.
The authority said in a notice Monday it is penalizing the CCO because Trillium has failed to comply with and make adequate progress on its corrective action plan. The authority’s notice warned Trillium that further non-compliance could lead to termination of its state contract to serve the Portland market.
The state’s move caps several years of dispute between the OHA and for-profit Trillium over Trillium’s desire to insure Medicaid members in the Portland market.
The corrective plan, issued in September 2020, sought to correct deficiencies in Trillium’s services to members in Clackamas, Multnomah and Washington counties.
The authority on Monday said Trillium has failed to sufficiently improve network development, health equity and language access, community engagement, and intensive care coordination. The state contracts with and pays coordinated care organizations that provide Medicaid coverage to Oregonians.
Due to Trillium’s failure, the state is suspending all new enrollment in the CCOs health plan for Medicaid members in the tri-county area. Trillium will continue to insure the roughly 18,000 members it already has in the tri-county area. The sanction will remain in place until Trillium fixes its network adequacy and health equity shortcomings, state officials said.
Current Trillium members will see no change in service levels due to the action. The sanction does not impact Trillium’s ability to gain new members in Lane County, another market it serves.
In August, Trillium had 18,059 Oregonians enrolled in the Portland area market. The CCO has slowly signed on members in that market. It had 1,014 members in September 2020, its first month in the tri-county market. The CCO has struggled to be competitive with Health Share of Oregon, the major CCO in the Portland market which has 387,068 members as of latest count.
In Lane County, Trillium has 34,924 members, while rival CCO PacificSource has 76,857 members.
In a statement, a Trillium spokesperson said the CCO will continue to work with officials to address outstanding issues.
“Trillium Community Health Plan has been operating in Oregon for more than 20 years and we take our responsibility to provide high quality healthcare to our 57,000 members very seriously," a Trillium spokesperson said in a statement. "Our corrective action plan for services provided in Clackamas, Multnomah and Washington counties was approved by the state in March 2021 and as of August, the state recognized we have partially met more than 85% of the action areas. We will continue to partner with the Oregon Health Authority to address any outstanding corrective actions.”
In the state notice, officials note some improvement in the various targeted areas, but not enough.
Network adequacy: The authority’s notice said Trillium has shown “some improvement” in network adequacy reporting and monitoring, including provider-to-member capacity ratios for home health, rural health centers, hospital and behavioral health crisis services. However, the authority notice said, “it was not clear” how Trillium is using that information as part of their strategy to contract with providers.
“Documentation submitted in this area continues to lack overall context and the depth of information necessary to communicate a cohesive approach to ensuring an adequate provider & service network in the Tri-County service area,” the state notice said.
Health equity and language access: Trillium’s improvement in this regard, which includes language interpreter services, is insufficient, the notice said. Trillium’s corrective action plan requires it to engage with the community to determine health equity issues and have a solid roster of language interpretation services.
At this point, Trillium has not demonstrated it has systems to monitor and anticipate member needs with language access services, the notice said.
Community engagement: Trillium is required to have a community advisory council for the Tri-County region and engage in the community in other ways, such as development of a plan and engaging with stakeholders and community groups. The notice said Trillium has made some improvement, such as hiring an external consultant to work on its community advisory council’s process and strategies for recruiting members. Other documentation shows evidence to engage community-based organizations, but that information lacks the depth and context necessary to show a “cohesive approach” to community engagement, the notice said.
Intensive care coordination: Trillium also needs to improve on its contractual requirements to screen prioritized populations for intensive care coordination. At this point, Trillium still needs to provide documentation that demonstrates improvements, such as how it tracks different populations during health risk screenings and referrals
OHA’s quality assurance and CCO contract oversight team has reviewed documentation and reports to gauge if substantial progress has been made and has met regularly with Trillium about the corrective action plan. The state’s finding of non-compliance comes on the heels of a series of meetings authority quality assurance officials had with Trillium staff from May to July. Based on its review, the health authority found that Trillium is still non-compliant with “minimal progress” towards correcting most violations in the September 2020 notice, state officials said Monday in a press release.
The state action extends the corrective action plan another six months to resolve all the issues. Trillium had to start filing monthly corrective action plan reports in March 2021. Trillium also is required to resolve the network adequacy and health equity findings within three months.
If Trillium doesn’t resolve those two issues in three months, the health authority has warned the CCO it could take other sanctions, including termination of the contract.
Trillium is owned by Centene Corp., a Missouri-based Fortune 500 company that is the largest Medicaid insurer in the country.
You can reach Ben Botkin at [email protected] or via Twitter @BenBotkin1.