Trillium Faces Wall Of Opposition In Portland Area Medicaid Market

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Powerful players in the Portland area’s health care marketplace are trying to slam the door on Missouri-based Centene Corp., days after the Oregon Health Authority put out the welcome mat.

The tussle pits the for-profit company, the nation’s largest Medicaid insurer, against an Oregon nonprofit that currently enjoys a monopoly in the tri-county area.

Health Share of Oregon has been the sole Medicaid insurer, or coordinated care organization, in the metro area’s tri-county area since last year. But a week ago, the health authority also tentatively approved the application of Centene’s Oregon-based subsidiary, Trillium Community Health Plan, for the next round that starts in 2020. The Portland-area contract, worth more than $1.5 billion a year, would be good for the next five-year cycle, dubbed CCO 2.0. 

Health Share has influential partners who don’t want to see competition in the Portland area -- and they’re fighting back.

Deborah Kafoury, chairwoman of the Multnomah County Commission, is on the forefront of that opposition. In a statement Tuesday, she hammered Trillium. 

“We’re concerned that Trillium lacks the network (of health care providers) to provide primary care, behavioral health and hospital care” in the Portland market, Kafoury said.

At the same time, Kafoury and other political and medical leaders lauded Health Share of Oregon, asserting that the market needs only a single Medicaid insurer to serve the more than 300,000 low-income residents in the tri-county area.

In its analysis of Trillium’s application for the Portland market, the Oregon Health Authority said it had “letters of support” for Trillium’s bid from Multnomah, Washington and Clackamas county governments. But Kafoury said Tuesday that no Multnomah, Washington or Clackamas county agencies have endorsed Trillium.

The Oregon Health Authority has not publicly disclosed the actual letters that it said came from Clackamas County Behavioral Health, Clackamas County Public Health Division, Multnomah County Health Department, Multnomah County Mental Health and Addiction Services Division, Washington County Mental Health Authority and Washington County Public Health. 

On Tuesday, the Oregon Health Authority told The Lund Report that lawyers are reviewing all the coordinated care organization applications before deciding what the state can release to the public.

“Multnomah, Clackamas and Washington Counties did not submit letters of support,” Kafoury asserted in her statement. “What we did send was a statement that (Multnomah County is) not interested in entering into a Memorandum of Understanding with Trillium. We don’t have one currently, and neither does Clackamas or Washington Counties.”

Mary Rumbaugh, director of the Clackamas County Behavioral Health Division, said the county never sent any letters of support either. 

“Clackamas County did not provide letters of support from any county department to Trillium Community Health Plan. The county did send Trillium a letter indicating that we would not enter into a memorandum of agreement or a provider agreement with them until we were informed that Oregon Health Authority was planning to award them a contract. We are consulting our county counsel to see what we can do to have the referenced letters removed from Trillium’s application.”

Washington County said it knew of no letters of support sent by its agencies, and that staff had sent letters declining to enter into agreements with Trillium.

Just days before the Oregon Health Authority announced it would allow both Health Share and Trillium to serve as Medicaid insurers in the Portland metro area, leaders of the Multnomah, Washington and Clackamas boards of commissioners wrote to the health agency, effusively lauding Health Share.

“Health Share’s application reflects our collective goals and strategies as we work together to address the social determinants of health within our communities and deliver on the coordinated-care promise: better care, smarter spending and healthier people,” their letter stated.

On Tuesday, Kafoury added, “We believe a single CCO in our region will better support our collective goals of providing better care, improving our community’s health and holding down costs.”

The furor that’s erupted over Trillium touches on at least two hot issues: Whether it’s good to have two competing Medicaid insurers in a single market, and whether it’s preferable to have non-profit or for-profit Medicaid insurers.

As Oregon’s system for providing health care to the state’s roughly 1 million Medicaid recipients has evolved, the questions of competition and for-profit status have repeatedly surfaced. Moves in the Oregon Legislature to phase out for-profit coordinated care organizations fizzled. Critics said for-profits may be more interested in the bottom line than in serving patients, while defenders said it’s best for the state to focus on health care results rather than on whether an insurer is for-profit or not-for-profit.

Meanwhile, in recent months, many counties have vehemently opposed having competing coordinated care organizations in a single service area, saying that fosters inefficiency by splitting up members among rival insurers. Leaders of at least 15 counties wrote to urge the Oregon Health Authority to designate just a single coordinated care organization in each county or health region. 

But last week, the health agency designated two for the Portland area and two for Lane County – Trillium and PacificSource, a nonprofit based in Springfield. The state also nixed some potential competition, for example awarding the Marion/Polk market to PacificSource and rejecting a new non-profit’s bid for that market.

Responding to Kafoury, the Oregon Health Authority issued the following statement on Tuesday about last week’s CCO 2.0 announcement:

“The Oregon Health Authority issued intent-to-award letters to applicants who showed they could meet the higher expectations set for CCO 2.0 and can accelerate health transformation by improving behavioral health, addressing health risks outside the doctor’s office and holding down costs. All applicants who demonstrated they could meet the higher bar for the CCO 2.0 contracts received awards. Community support is a foundation of Oregon’s innovative approach to coordinating care for Oregon Health Plan members. We expect successful applicants to have strong local partnerships in place before we award final contracts, just as we expect local partners to collaborate with CCOs to improve the health and well-being for OHP members in their communities.”

Trillium did not respond to requests for comment Tuesday.

Kafoury was hardly the only Portland-area official who reacted unfavorably to the state green-lighting Trillium for the Portland Medicaid market.

Two major Portland-area health care systems, Oregon Health & Science University and the Providence Health and Services hospital and clinic network, stressed they have not signed contracts with Trillium.

Last week, OHSU’s CEO John Hunter wrote to Trillium pointing out that OHSU is a founding partner of Health Share of Oregon, a collaboration of numerous non-profits, hospital systems and government agencies. The collaboration includes the Kaiser, Legacy and Adventist systems.

“The OHSU health system has decided at this time not to enter into a contract with Trillium Health Plan as part of Trillium’s CCO contract in the Portland metropolitan area,” Hunter wrote.

Meanwhile, the Providence system, with five hospitals in the greater Portland metro area, said it, too, will not sign a contract with Trillium. Providence did not elaborate or explain the reason.

For coordinated care organizations, it’s typically crucial to secure contracts with all major health care providers in their area. Those contracts typically promise that hospitals, clinics, health departments and other providers will render their services at guaranteed below-market rates to Medicare members. Without such contracts, Medicaid insurers can still send their members to those facilities for care, but the cost may be exorbitant, in essence making it impossible for the insurer to function. The state provides only limited money to Medicaid insurers per member.

That’s why it’s so important for Medicaid insurers to line up support from local hospital and clinic systems as well as from local government agencies such as county health departments.

Kafoury stressed that Multnomah, Clackamas and Washington counties have not signed contracts with Trillium, and that no metro-area hospitals have either.

The Oregon Health Authority is still in the midst of evaluating all the insurers it tentatively designated for Medicaid territories for 2020 onward. The evaluation includes determining whether each insurer has substantial community support and a strong lineup of health care providers. Once insurers are approved for final contracts, the state will disclose the rates it intends to pay the insurers, and insurers will decide if they want to sign on.

You can reach Christian Wihtol at [email protected].




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