Seeking to overturn a rejection by the state late last year, Trillium Community Health Plans has filed a new application to enter in the Portland area that lists an expansive health care provider network and says the for-profit company is primed to insure Medicaid patients who live in the three counties.
The Oregon Health Authority said it will decide by the middle of this month whether it will allow the for-profit company to enter the 350,000-member market, which is now served by just one coordinated care organization: Health Share of Oregon.
In its filing, Trillium said it has signed contracts with multiple hospital and major clinic systems and hundreds of providers in the Portland area. Oregon Health & Science University said it has agreed to provide “specialty services” such as sports medicine and pregnancy care for Trillium, but the contract excludes primary care. Trillium has also signed up two OHSU-affiliated hospitals, Tuality Community Hospital in Hillsboro and Adventist Health Portland, for some services, as well as with the Portland-based Legacy Health network of hospitals for services such as pediatrics and rehabilitation medicine.
The county-run community health centers in Multnomah, Clackamas and Washington also have signed contracts with Trillium, according to Trillium’s submittal.
Trillium has not signed up Portland’s largest provider, Providence Health & Services, which has four hospitals and an extensive network of primary care and specialty clinics in the metro area, nor has it contracted with Kaiser Permanente, which has clinics and two hospitals in the Portland area.
Late last year, the state refused to let Trillium handle Medicaid members in the tri-county area, saying the company had failed to line up a sufficient list of providers. Not a single hospital had signed on with Trillium, and the three county community health center systems also had balked. Some officials and others said Trillium wasn’t needed in the tri-county area, where Medicaid has long been managed by Health Share. With a monopoly in the lucrative area, Health Share has a provider network that includes all the metro area hospitals. The majority of its clients are in Multnomah County -- 187,000 people -- followed by 92,000 clients in Washington County and 68,000 in Clackamas County.
The state pays Health Share about $2 billion a year for the coverage, making it the biggest of the 15 coordinated care organizations in the state. When the health authority approved the contracts last year, there were nearly 1 million Medicaid patients. Now there are nearly 1.2 million.
State Will Scrutinize Trillium’s Lineup
David Baden, chief financial officer at the OHA, said his agency and a consulting group are evaluating Trillium’s tri-county application and provider lists.
“We are looking at everything from their primary care providers to behavioral health to dental care to pharmacies to hospitals and assessing that what they are presenting meets” federal and state requirements for a complete provider network, Baden told The Lund Report.
Owned by Missouri-based insurance giant Centene Corp., Trillium has been itching for many months to enter the Portland market. It now serves the Lane County market.
The state pays Medicaid insurers roughly $6,000 per year per member, which insurers use to cover member medical expenses and turn a profit.
Trillium said having fresh competition in the Portland area will be a boon for patients, and it said it has a solid track record in Lane County.
“We are confident that our expansion into the tri-county (area) will create value in the form of member choice and capacity, which is more important than ever given the unfortunate consequences of COVID-19, including, but certainly not limited to, unemployment,” wrote Trillium President Chris Hummer to the OHA in June. Hummer said Trillium’s work over the past eight years in Lane County shows it is “ready to expand.”
In 2015, Centene bought Trillium from its Lane County-based owners. Trillium was the sole CCO for the roughly 90,000 Medicaid members in Lane County until this year, when the state let PacificSource Community Health Plans enter the market. Many providers and members shifted to PacificSouce, turning a cold shoulder on Trillium.
As of the latest tally, PacificSource has nearly 63,000 members in Lane County, and Trillium has about 34,000.
Even if the state approves Trillium’s request to enter the Portland market, it may be tough for the company to gain members there.
State Will Alert Oregon Health Plan Members
If approved, the state would alert all Oregon Health Plan members in the tri-county area that Trillium had been approved as a Medicaid insurer, Baden said. Clients then would be able to switch if they wanted to do so.
And any new tri-county residents who were approved for the Oregon Health Plan would be allowed to pick between the two, he said. If new members didn’t choose an insurer, the state would assign them to an insurer, giving each about half, Baden said.
But members who now are with Health Share would stay with that organization unless they opted to move away, he said.
If the state approves Trillium’s application, “Health Share will collaborate with Trillium as it begins service in our area,” Health Share CEO James Schroeder told The Lund Report.
"It is a critical time in our community, as we respond to the COVID-19 pandemic and its economic impacts, work towards racial and health equity and address social determinants of health,” Schroeder added.
When the state rejected Trillium’s first application late last year, it gave the company until June 30 to propose a more robust lineup of health care providers. Baden said he wasn’t surprised that Trillium persisted, given the work that it initially put into applying for the Portland-area market.
Trillium did not respond to emails from The Lund Report seeking comment.
Trillium’s Parent Company Thrives
Last year, Trillium was deeply frustrated as Portland-area hospitals and the three counties resisted Trillium’s requests that they sign provider contracts. Contracts set out rates that providers charge the insurer for services to patients, allowing the insurer to calculate whether it can make a profit in a market. Late last year, Trillium went so far as to sue Legacy, OHSU and Providence in federal court, accusing them of violating federal antitrust laws by colluding to keep Trillium out of the Portland-area Medicaid market. Legacy, OHSU and Providence in 2012 jointly set up the nonprofit Health Share of Oregon and still oversee it with CareOregon and other partners. Last December, Trillium dropped the lawsuit.
When it failed to get into the Portland market and had to share Lane County with PacificSource, Trillium was forced to cut back operations, eliminating an estimated 70 of its roughly 400 jobs. The reduced workforce moved from Trillium’s longtime headquarters in Eugene to offices in Springfield.
In the meantime, Trillium’s massive parent company is thriving.
Centene is one of the largest health care insurance companies in the nation, handling Medicaid, Medicare and commercial members. In January it bought rival health insurer Wellcare Health Plans. For the first six months of this year, Centene reported a profit of $1.25 billion on revenues of $53 billion.
The newly combined company serves 22 million members.
In its report for the quarter ended June 30, the company said member usage of medical services showed a “significant decrease” as people stayed home during the COVID-19 crisis. Now, usage is rising as elective procedures and other non-emergency care resume, it said. Overall, the situation should “slightly benefit” the company’s financial results for all of 2020, the company said.
You can reach Christian Wihtol at [email protected].
