HOUSE COMMITTEE ON

AUDIT & HUMAN SERVICES BUDGET REFORM

 

 

February 17, 2003   Hearing Room 50

3:00PM Tapes 28 - 29

 

MEMBERS PRESENT:            Rep. Ben Westlund, Chair

Rep. Steve March, Vice-Chair

Rep. Jeff Kruse

Rep. Jeff Merkley

Rep. Alan Bates

 

MEMBER EXCUSED:             Rep. Randy Miller

                                                Rep. Susan Morgan, Vice Chair

 

GUEST MEMBERS:               Rep. Laurie Monnes Anderson

                                                Rep. Gordon Anderson       

                                                Rep. Mitch Greenlick

                                                Rep. Carolyn Tomei

 

STAFF PRESENT:                  Rick Berkobien, Administrator

Kelly Fuller, Committee Assistant

 

ISSUES HEARD:                     Informational Meeting

                                                Dr. Joel Daven, Medical Director

                                                Douglas County and Physicians with Douglas County IPA

 

These minutes are in compliance with Senate and House Rules.  Only text enclosed in quotation marks reports a speaker’s exact words.  For complete contents, please refer to the tapes.

 

TAPE/#

Speaker

Comments

TAPE  28, A

005

Chair Westlund

Calls meeting to order and introduces Dr. Joel Daven and opens informational meeting.

INFORMATIONAL MEETING

010

Dr. Joel Daven

Douglas County IPA (Independent Physicians Association), Roseburg.  Offers written materials and overview of his presentation describing services provided. (Exhibit A)

143

Rep. Bates

Asks where the date for his presentation came from.

148

Daven

Responds the information came from Darin Coffman, Director of Health Services, Oregon Health and Policy Research.

158

Rep. Merkley

Asks if the legislative changes in drug policy for the Oregon Health Plan from the last session impacts the way he does business.

195

Daven

Answers they now have evidence of drug methodology to backup what is being done and makes the plan work much easier.

108

Rep. Merkley

Asks where this process has ended up in comparing drugs.

203

Chair Westlund

Comments that all fourteen fully capitated plans has some form of drug list.

213

Rep. Kruse

States not all of the plans have a list.

223

Rep. Bates

Offers explanation that the preferred drug list moving forward in the fee for service area.

245

Daven

States the drug methodology works better for the manage care side than the fee for service side.

260

Berkobien

Comments about which drugs are exempt from this list.

261

Chair Westlund

Asks if there is an exception process.

262

Daven

Responds  there are exceptions every day.

284

Chair Westlund

Asks how someone avails themselves to the exception process.

TAPE 29, A

001

Daven

Responds that physicians prescribing  medication that is not on their formulary should have it listed in their office notes.

010

Rep. Merkley

Comments about managing drugs effectively.

013

Rep. Kruse

Asks if this is a disease management concept.

015

Daven

Answers it is case management.

022

Rep. Kruse

Asks if this is restricted to only certain categories.

034

Daven

Responds that they constantly review medical management.

060

Chair Westlund

Asks if his market area is just Douglas County.

063

Daven

Answers most of Douglas County.

070

Chair Westland

Asks if all the physicians in his market area participate

071

Daven

Answers not all are members but all are providers.

072

Rep. March

Asks what percentage of population in his area does he manage and why would some not be in the program.

079

Daven

Articulates the fee for service issue.

087

Rep. Bates

Asks for response to the way to the plan is presented to clients and asks how he handles the payment of durable goods.

095

Daven

Responds to paying Office of Medical Assistance Program (OMAP) rates on durable medical equipment.

125

Rep. Bates

Asks how the pharmacists are paid.

 

Daven

Explains payment is made to a pharmacy benefit manager who pays the pharmacy.

140

Rep. Bates

Asks if his Pharmacy Benefits Manager (PBM’s) has ever been audited.

142

Daven

Responds that they have done some auditing in the past.

155

Rep. Bates

Asks if they have ever thought of asking for user fees in his area.

156

Daven

Asks for clarification of the question.

157

Rep. Bates

Explains reimbursement matched monies.

169

Daven

States if reimbursement drops to fee for service level it would be difficult to continue seeing OHP patients.

171

Chair Westlund

Asks what is the gap between managed care participants and fee for services reimbursements.

200

Daven

Answers fee for service reimbursement is 28% less than Medicare.

203

Chair Westlund

Asks if it was mandated that Medicare patients had to be in managed care would it be helpful.

210

Rep. Deven

Indicates they could do a much better job if the patients were in managed care.

239

Berkobien

Asks if there is any type of cost shift between the two groups.

245

Daven

Responds that the standard patients were costing them more money.

266

Rep. Bates

Asks if the plan stayed the same and didn’t go forward with the waivers,  and standard patients were seen but expansion did not occur is this something he could live with.

280

Daven

Answers they are not even looking at expansion.

283

Rep. Bates

Reiterates not picking up any new patients.

284

Daven

Comments they could live with that.

305

Rep. Kruse

Points out under the old waiver standard patients would make them money.

307

Daven

Answers it depends on what category the patient is in.

320

Rep. Kruse

Asks how many categories are there.

325

Daven

Indicates there are fifteen different payment rates and the capitation rates are based on the category the patient is in.

328

Chair Westlund

Notes lesser capitation defines lesser reimbursement.

330

Deven


Responds that is right.

333

Berkobien

Asks how many fall under this categorical eligible standard.

334

Daven

Describes the fifteen different categories and different rates for each.

360

Berkobien

Asks if the formula has been a complication or a major concern of theirs.

362

Daven

States it has not been a major concern.

364

Rep. Greenlick

Asks if the predicted rates under the various categories of services are good.

392

Daven

States no problem with the rates just that the patients are placed in the right category.

400

Chair Westlund

Asks where do these patients go to begin with.

420

Berkobien

Asks if patients will be re-classified for eligibility.

422

Daven

Notes he is unable to give a figure.

TAPE 28, B

423

Chair Westlund

Notes as time goes on the number will exacerbate due to AIDS and diabetic drugs.

012

Daven

Responds these people will move over to a category.

016

Berkobien

Asks if it will affect hospital costs and contract costs.

022

Chair Westlund

Asks why pharmaceutical benefits that go away from the standard population make their relationship with the hospitals unattainable

030

Daven

Explains when benefits are lost patients end up in the emergency room which results in increased costs.

050

Rep. Merkley

Asks if they have wrestled with the trade offs of fewer people covered under the standard option but include drug benefits.

058

Daven

Responds these are public health and public policy issues.

065

Rep. Merkley

Asks if cuts from the standard population under the current waiver would be feasible.

088

Rep. Kruse

Notes under the current waiver the drugs have been stopped altogether.

092

Chair Westlund

Comments these patients cannot find a provider.

095

Rep. Kruse

Asks if the standard population will have trouble finding a doctor to go to.

098

Daven

Responds it will be troublesome.

099

Chair Westlund

Informs it is an immediate cost savings and huge cost shift.

109

Rep. March

Asks if the other plans are in the ballpark.

112

Daven

Offers other plans that are.

121

Berkobien

Asks if he has seen any changes in the groups that are using the OHP, and changes that may be effecting the OHP.

148

Daven

Responds about the changes in those using the OHP.

157

Rep. Monnes Anderson

Asks if this organization would work in a very populated area.

159

Daven

Responds that the programs are more alike than we think and give some examples.

174

Chair Westlund

Asks is the success of the plan is determined by the relationship with the hospitals.

195

Daven

Answers it is but hospitals are different in different areas.

200

Rep. Kruse

Asks if there is a reduction in people being served won’t the ones being served be only the sick people and what kind of impact will this have on the ability to operate.

213

Daven

Indicates there would be a change in the capitation rate.

215

Rep. Anderson

Asks if the fourteen plans around the state are breaking even.

217

Daven

Notes he does not have the 2002 figures but three or four lost money.

230

Rep. Anderson

Asks if these plans are staying in.

231

Daven

Answers yes they are in for the long haul.

233

Rep. Anderson

Asks if there is in fact some making money with the managed care plans.

240

Daven

Responds yes but that it is tough for everyone.

245

Chair Westlund

Points out it goes back to what kind of relationship the hospital provides.

260

Rep. Greenlick

Asks if you were dealing with physicians services alone and losing money would it still be feasible.

289

Daven

Responds it is feasible and there is a model that does just that.

307

Rep. Anderson

Asks if IPA’s have the physician put in a sum of money to join and this money acts as a reserve.

309

Daven

Responds affirmatively and states that the physicians have access to their contracts and receive a higher reimbursement level than if they were not a member.

332

Rep. Anderson

Asks if this reserve stays fairly stable.

334

Daven

Explains the state mandates this reserve it does not fluxuate.

335

Rep. Anderson

Asks if it affects the cost of medical care.

342

Daven

Responds this is an emergency reserve.

354

Rep. Anderson

Asks what would happen if there were benefits from the federal government to increase these reserves rather than changing the capitation rate.

356

Daven

Responds the need for clarification.

380

Rep. Anderson

Asks if the capitation was lowered and the grant was increased would it make his plan more stable.

383

Daven

Responds if they are paying physicians less than Medicare there would be difficulty in getting patients to see these doctors.

394

Chair Westlund

Asks when the state makes an appropriation do the plans take a percentage of Medicaid before the physicians are reimbursed.

TAPE 29, B

003

Daven

Answers the state pays them reimbursement but any extra money that the plan makes goes back to the physicians.

013

Chair Westlund

Asks what percent goes back to the doctors.

020

Daven

States the doctors that see more OHP patients get greater reimbursement.

029

Chair Westlund

Indicates the doctors have lost the most money on OHP patients.

030

Daven

Counters for fees for service rates but not from what OHP pays the doctors.

031

Rep. March

Responds that OHP is then subsidizing the Medicare rates.

035

Daven

Notes they are providing more access for these patients.

045

Rep. Merkley

Asks how much is received for each patient for the standard plan.

067

Daven

Responds he does not know the figure.

070

Rep. Merkley

Asks if OHP has talked about providing options of multiple plans for standard patients.

071

Daven

Responds theoretically that would  feasible but there would be some practical issues.

080

Berkobien

Points out if other packages were offered it would be an alternative instead of the state making these precise decisions for what works for the whole state.

098

Daven

Offers it would be possible but hard to administer.  Defers to Jeff Heatherington

104

Heatherington

President, Family Care Inc.  Explains the categories of patients that are in the group of fee for service.

124

Chair Westlund

Asks what is the best thing that the legislature can do for the medical directors.

125

Daven

Responds to allow the plans to do the work and the directors to manage the care.

136

Chair Westlund

Asks specifically what can be done.

137

Daven

Describes ideas and elaborates.

169

Chair Westland

Closes informational meeting and adjourns committee meeting at 4:35 p.m.

 

 

EXHIBIT SUMMARY

 

A – Informational, prepared testimony, Dr. Joel Daven,  2 pp