Managed Care Round Table Beth Spoto, Spoto & Associate Mike Scribner, SHP Savannah shpllc.com &...
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Transcript of Managed Care Round Table Beth Spoto, Spoto & Associate Mike Scribner, SHP Savannah shpllc.com &...
Managed Care Round TableManaged Care Round Table
Beth Spoto, Spoto & AssociateMike Scribner, SHP Savannah
shpllc.com& Associates, LLCSpoto
Georgia’s Payer MixGeorgia’s Payer Mix• Medicare 13%• Medicaid 16%• State Health Benefit 7%• Commercial 46%
• (52% 4 years ago)
• Uninsured 18%
Georgia’s Current Population is 9.6 million
shpllc.com& Associates, LLCSpoto
State Retirees Retirees moving to be under either Cigna (2) or UHC
(2) Medicare Advantage PFFS Plans effective 1/1/10
Plans must move from PFFS to MA PPO/HMO for 2011
Active State Employees
All new employees must be enrolled in HRA or HSA
high deductible plan
United PPO no longer offered to state employees
State Health Benefit PlanState Health Benefit Plan
shpllc.com& Associates, LLCSpoto
WellCare◦ Small impact of HB 1234◦ Aggressive stance to avoid cost increases
Peach State◦ Outsourcing therapy network to TRS with caps on
daily rates◦ Requesting take-backs based on adjusted CCR or
pricing increases (assumed or actual). Need to check your letter/computed amounts.
◦ Increasing triage rate
CMO UpdateCMO Update
shpllc.com& Associates, LLCSpoto
• PFFS plans must be contracted by 2011 to continue
• Coventry and Wellcare discontinuing PFFS plans effective 12/31/2009
(they will still have MA PPO/HMO plans
• Clients received solicitations from many plans recently:Humana Aetna United (Secure Horizons)
Cigna Sterling AmerigroupWellcare
• Many solicitations will attempt to add PPO/HMO as well.• SHBP moving retirees to Cigna/UHC MA Plans
• Cigna – No action required, providers will be “deemed” into PFFS• UHC – Opt In for PFFS and Opt Out for PPO/HMO
shpllc.com& Associates, LLCSpoto
Medicare AdvantageMedicare Advantage
Blue Cross Blue Shield of GABlue Cross Blue Shield of GA
Losing market share in rural areas
Overtaken by UHC in several markets
Still retained Board of Regents / University SystemBig push to complete Open Access products
statewide and MA in targeted areas
Moving business to POS product
shpllc.com& Associates, LLCSpoto
% of Patient Liability (Sample Hospital)
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
BCBS UHC Cigna Aetna Other Commercial
2006
2009
• 3 Major Initiatives Ongoing• Move to OOPS
• Moving to Medicare rates/methodology for PPS hospital
• CAH move to Medicare rates/methodology• 12/01/09
• Selected as program administrator • United awarded contract from Humana – effective 4/1/09• Humana appealed award –final decision 12/31/2009• Humana will now administer at least through 9/30/2009
shpllc.com& Associates, LLCSpoto
TRICARETRICARE