CareOregon, the largest Medicaid provider in the state, will soon stop covering mental health and substance use treatment from out-of-network providers. Coverage will will end on Oct. 1 for Medicaid members and on Jan. 1 for members of Medicare Advantage. The decision will disrupt care for an estimated 15,000 patients, or about 15% of the organization’s members who use behavioral health services. The organization says the changes will bring it back into alignment with industry best practices after making provisions to expand access to mental health care during the COVID-19 pandemic.
Amit Shah is the chief medical officer at CareOregon. He joins us with more details about the decision.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. CareOregon, the largest Medicaid provider in the state, will soon stop covering mental health and substance use treatment from out-of-network providers. Coverage will end on October 1 for Medicaid members and on January 1 for members of Medicare Advantage. The decision will disrupt care for an estimated 15,000 Oregonians.
Amit Shah is the chief medical officer at CareOregon. He joins us now. Welcome to Think Out Loud.
Amit Shah: Thank you.
Miller: My understanding is that this change is the end of a pandemic era policy. What is that policy?
Shah: That’s correct. During the pandemic, Oregon faced quite a shortage of behavioral health providers. That was combined with a rising demand for those services. So CareOregon responded to that moment by opening its network to work with contracted and non-contract providers, while spending millions of dollars trying to support the system during a really difficult time in our state. That allowed us to serve members during these difficult times. We did what we did during the COVID because it was needed. But it was unusual and done to meet an unprecedented demand.
Miller: Unusual, meaning other people or groups who managed patient care for members of the Oregon Health plan, they didn’t make the same decision?
Shah: Yeah, I can’t necessarily speak to what others did, but many people did different strategies. What we did was we wanted to focus on what we always focus on, which is the member, and ensuring that they’re able to have the highest level of quality of care and access during that really difficult time – which we did. During this time, [it] was really, as I mentioned, not the standard practice that was done.
Miller: How successful was it?
Shah: Very successful, in the sense that we were able to provide that needed access for membership during a very difficult time, as we all remember in COVID. Access was difficult in a variety of means, both physical and virtual access that was needed. So it was as successful as it could be, given it was a unique time and a unique scenario with the pandemic that everyone was experiencing.
Miller: How many of your members have been getting their behavioral health care from these non-contracted, these out-of-network providers?
Shah: It’s about 15,000 members, or about 3% of our total membership, and 15% of our members who use behavioral health services.
Miller: How did you decide it was time to end this policy?
Shah: As I mentioned, during the pandemic, we decided that we needed to be able to focus on the challenges of the access that was there. What we decided was [to] open that network to the non-contracted providers. And the services from those non-contracted providers, as times have changed, have resulted in costs that are 40% to 95% more than from other contracted providers. And what we really needed was to understand what our network looked like and determine that we had the adequate adequacy and ability to provide access to these members after the pandemic – which we determined we did.
Miller: Why is it that out-of-network providers are more expensive for you as an organization?
Shah: As usual, in health plans when you have contracted providers, you have the ability to manage the continuity of care and control the costs because you’re able to do things like have appropriate data exchange. [You] have an ability to monitor the quality of care really, to do the things that a contract enables you to do, when you partner with that provider. A non-contracted provider does not have those specific methods or ways to be able to have us monitor that quality and/or cost.
Miller: Those seem like important but different things. So let’s actually go with the quality first. Are you saying that you were less able to ensure that your members who are getting behavioral health care, say, for a mental health issue or, say, for substance use disorder … you were less able to assure the quality of that care from non-contracted providers, from out-of-network providers?
Shah: Often, when you have non-contracted providers, as I mentioned, you have an inability to be able to use some of the standard methods that you’re able to do to monitor and to be able to manage them as an agreement of a contract provides. And without that agreement or a contract, you do often not have the best opportunity to be able to monitor and share the information and data that’s needed to be able to monitor the quality of care.
Miller: OK, so that’s the quality piece. In terms of cost, if the whole point of this was to boost the availability of providers for your members without having costs spiral out of control, why not just say, “If you want to do this, then we will reimburse you, we’ll pay you at the exact same rate as our in-network providers?”
Shah: That’s a good question. And the hard part is that when you do not have a contract with a non-contracted provider, you don’t have the ability to be able to go and do that. So the hope is that if you do have a contract, then you could begin that discussion to determine the rate that you’re given. If not, you have to be able to provide the rate that is already set and given, including the inability to monitor the respective utilization.
Miller: Maybe what’s catching me up is what you mean by “contract.” But you do have some kind of agreement with these providers, even if they, at one point, were out of network or are technically out of network. There still has to be some kind of agreement before they could be providing services for you, right? I still guess I’m just still wondering why, at that point, you can’t just say, “If you want to be an out-of-network provider, this is how much we’ll pay you for this service?”
Shah: Yeah, there is not a specific agreement, because the specific agreement would be, as I described, the contract. In reality, for us, it’s really about the member’s care and our determination of the adequacy of the provider network, meaning we have adequate access and availability in our contracted members network. So it doesn’t really make sense to continue to allow non-contracted providers who we can’t monitor, as I described.
Miller: OK, so back when this policy did start, you didn’t feel like you had network adequacy, enough in-network providers to provide behavioral health care. But now you do. How many more providers do you have in the network than before?
Shah: I think it was less about straight numbers as you’re describing, as much as the COVID pandemic was an unknown. Oregon, as well as us and many other states, did what they could to be able to anticipate what they thought would be the demand that was needed. From that point until now, we had several providers, behavioral health providers, physical health providers who naturally, as part of any health plan, contract with a health plan.
So as time has moved on from the COVID pandemic, and we’ve done a thorough analysis of our network, we have had the appropriate amount of expansion in our contracted provider network to easily meet the demands of the members that need to be seen.
Miller: How much has it expanded?
Shah: I would say that it expanded … I don’t have the specific numbers of the level of the expansion.
Miller: But you’re saying there is more in-network capacity now for behavioral health therapists than there was before the pandemic?
Shah: Yeah, I think in general there has been more access created throughout the pandemic, regardless of behavioral health or not.
Miller: In a press release about this change, your organization talked about the “incredibly challenging financial environment.” And obviously, none of this is happening in a vacuum. The backdrop is the fact that because of the huge policy and tax bill that Republicans in Congress passed and that the president signed on July 4, we are looking at extraordinarily large cuts to Medicaid funding nationwide and billions of dollars less in the coming, say, six years, in Oregon alone. Can you give us a sense for what this is going to mean for CareOregon?
Shah: I think there are some big themes in Medicaid that are having very significant financial challenges. And I think that whatever winds up happening with our federal level, there’s going to be some difficult fundamental questions that will arise and take effect and impact Oregon.
How that affects us is that we’re going to continue to ensure our members have a sustainable health system amid quite challenging anticipated financial circumstances. But we will always be here for those members and ready to support them for this transition, which really means, we’re going to continue to focus on how we create a sustainable system while being real honest about the financial challenges, and ensuring that the quality of care and the system of care that they need happens.
Miller: Are you doing your own modeling internally right now to estimate how many of your current enrollees will be dropped in the coming years?
Shah: Yeah, there is modeling that’s done in participation with the state. And a lot of it has to do with that sort of modeling that will occur when the bill is actually passed and taken into effect in 2027.
Miller: But what does that look like? I mean, one of the things that we’ve already heard about, for example, is that with much more frequent eligibility checks, some not insignificant number of current enrollees nationwide will lose their coverage through their state Medicaid plans – here, the Oregon Health Plan. What could that mean for your members?
Shah: Health care in Oregon has been under tremendous strain for quite a while since COVID. We know that the costs keep rising and our state continues to struggle to support our Medicaid system. We’re concerned that the federal changes, like you’re describing, impact our ability to cover those costs. We’ve had this time period where we’ve been super fortunate to provide as much as possible for our members. But as the budgets and resources contract, we must make decisions that allow us to provide the best level of care for our members.
Those questions include how many members will eventually be on the rolls and not be able to get service or drop off of service and come back on. They are really what the state and other partners like ourselves are gonna have to manage. But a lot of that will be part of the regulatory design that the state legislators, governor, in partnership with CMS, will eventually decide when the bill takes effect.
Miller: Are you expecting both a drop in the overall number of people who get their health care covered through the Oregon Health Plan … that seems to be a given, at this point. But are you also expecting that people who are able to retain their insurance through OHP [will] see fewer benefits, even as they are still getting their health care covered through the Oregon Health Plan?
Shah: Yeah. And I think that, once again, those are questions that are pretty tough to answer right now. Really, the state is who we’re gonna have to rely and partner with to answer and determine when the bill and and these effects wind up happening. But I do agree that these are things that we’re gonna have to consider as a state and we’re gonna have to consider both CareOregon and our communities around what that effect will be.
Miller: I want to go back to the change that has already been announced, maybe you can tell us more about this – no longer covering out-of-network, non-contracted providers, for behavioral health care. What are you doing right now to help the 1 in 7 of your members who, as you said, get behavioral health care, to get that care currently through these out-of-network providers? What are you doing to help them transition?
Shah: We’ve done several things. First, we’ve informed all affected providers. Then second, we have internal care coordination teams that have been proactively looking at providers that we know are seeing our members, [who] we believe need to have continuity of care. We’re providing that proactive care coordination to those impacted members. And we’ve identified those with certain risk factors who we believe may need more care coordination than some of the regular care coordination that happens. And of course, anyone who identifies the need for that care coordination can get it.
We are mailing all the PCPs and members who have prescribers that are impacted, including the total number of people that are there. But really, what it comes down to is our focus about the members and the transitions of care. And I think that needs to be emphasized because that’s the most important thing we’re trying to do. Members always come first. But once again, as a health plan, this is part of our standard work that we do. We do transitions of care on a normal basis, about 3,000 people per month. So this is work that we’re used to doing and we know we want to do to be able to ensure that the members get to the right care in our contracted provider network.
Miller: If you were talking directly to somebody who said, “OK, I hear all of that, but finally, I was able to get a therapist who is really helping me and I’ve opened up with them. And after years of either bouncing around or just not getting adequate care, I have it now and I like my provider. Now, you’re telling me they’re out-of-network and I’ve got to find someone else.” What would you tell that member right now?
Shah: I would tell that member that we know that the challenges around changing providers and/or transitions could be challenging. But we have many ways where we’ll be able to engage with the provider as well as the member themselves, with the priority of the member and helping them find an in-network provider that could meet their needs.
We spent a lot of time proactively looking through the members and the list of them, and ensuring that we have ways to contact them and be able to make sure that we can get them to an in-network contracted provider who will be able to provide them with the same level of quality of care that we know is needed.
Miller: Amit Shah, thanks very much.
Shah: Thank you.
Miller: Amit Shah is the chief medical officer at CareOregon. It is the state’s largest Medicaid provider. CareOregon announced recently that it is soon gonna be no longer covering mental health and substance use treatment from out-of-network providers.
“Think Out Loud®” broadcasts live at noon every day and rebroadcasts at 8 p.m.
If you’d like to comment on any of the topics in this show or suggest a topic of your own, please get in touch with us on Facebook, send an email to thinkoutloud@opb.org, or you can leave a voicemail for us at 503-293-1983.
