Thursday, March 19, 2015

Mississippi managed care or Mississippi managed crony capitalism?

Senate Bill #2441. One of the biggest stories taking place in the current session of the Mississippi Legislature. A true case of insider baseball.  It's discussed by the legislators, lobbyists, consultants, and even the bureaucrats, but completely unnoticed by the media. The older reporters probably think it's a song by Chicago.  The story of SB #2441 is The Mississippi Hospital Association and other groups are making a determined push to get this bill passed, as they seek to enter the HMO business and grab more Medicaid business, as well with some friendly re-writing of Mississippi health insurance laws.   The bill passed both the House and Senate but with some differences. 

SB #2441 states:

SECTION 1. (1) In order to encourage and facilitate collaboration between Mississippi Medicaid providers and managed care entities contracting on a capitated* basis with the Division of Medicaid pursuant to Section 43-13-117(H), to align incentives in support of integrated and coordinated health care delivery, and to encourage the development of appropriate population or community health strategies to better serve Medicaid beneficiaries and the state's health care delivery system as a whole, the Legislature hereby authorizes and encourages the creation of provider-sponsored health plans as defined in Section 2 of this act.

The key words in this section: Medicaid and "provider-sponsored health plans".  That means the MHA and various medical groups want to get in the health insurance bidness.  Section 2 gives the game away.

SECTION 2. As used in this act, "Provider-Sponsored Health Plan" means a Mississippi not-for-profit corporation formed for the purposes of operating a not-for-profit health plan or managed care entity, with its principle place of business within the State of Mississippi, and which is owned and governed exclusively by (a) not-for-profit Mississippi hospital or physician industry or trade association in which the majority of the hospitals or physicians within the state are members, or (b) a combination of (i) not-for-profit Mississippi hospital or physician industry or trade associations that represent a majority of the hospitals or physicians within the state, and (ii) licensed Mississippi hospitals or physicians who participate in the Mississippi Medicaid Program. At least one purpose of the provider-sponsored health plan shall be to contract with the Division of Medicaid to provide managed care services on a capitated basis pursuant to Section 43-13-117(H). To qualify as a provider-sponsored health plan under this section, the entity must further meet the requirements of Section 4 of this act

The devil is always in the details and JJ found a few demons. Beelzebub hangs out in Section 2 (posted above). The bill allows a non-profit located in Mississippi to provide a health insurance plan to Medicaid patients.  Just one problem: the state allows two private insurance companies, United Healthcare and Centene, to provide managed care to Medicaid patients.  Two companies that were selected through the bidding process.

However, the bill will allow valued trade associations such as the Mississippi Hospital Association or the Mississippi State Medical Association to establish their own managed care/health insurance plans and compete for Medicaid patients with private insurance companies. Numerous sources told JJ that these two groups are pushing the bill and are not doing so in a mild and meek manner.  MHA already sells medical malpractice insurance coverage in Mississippi, as the state suffered a crisis in finding coverage for doctors years ago. (The annual report is posted below.)  However, the bill gets better for MHA and MSMA.

Section 3 is just boilerplate language giving the Commissioner of Insurance the authority to certify plans on an annual basis.  However, Section 4 is where Mephistopheles appears.

SECTION 4. Provider-sponsored health plans shall meet the following additional minimum requirements:

(a) Demonstrate ownership or substantial representation in governance and operations by licensed Mississippi hospitals and physicians that participate in the Mississippi Medicaid Program. Notwithstanding any other provision of law to the contrary, for the purpose of meeting this requirement, hospitals owned by the state and hospitals owned by local governmental entities are authorized to provide funds for the establishment and operation of provider-sponsored health plans, provided the hospital governing body first determines that such participation is in the best interest of the hospital and the communities it serves;

(b) Satisfy the minimum financial and reserve requirements to be established by the Department of Insurance; (Forget Mephistopheles, this is Loki and Majin Bu combined.). 

(c) Meet all contractual requirements for contracting with the Division of Medicaid to provide managed care or coordinated care services to Medicaid recipients pursuant to Section 43-13-117(H). Compliance with this requirement shall be determined and supervised by the Division of Medicaid. Nothing in this act shall be construed as giving the Department of Insurance responsibility or authority for the operation of the State Medicaid Program; and

(d) Such other requirements as may be established by valid regulation of the Department of Insurance.
This section is very interesting because there is already a Mississippi Code Section that specifically provides the guidelines on how managed care plans are to operate. Mississippi Code Section 41-83. Section  4 will allow a "friendly" Insurance Commissioner to allow those providing such plans to get around the law.  Section 41-83-7 of the Mississippi Code regulates HMOs.   It defines an HMO as:

(n) "Health maintenance organization" means any person that undertakes to provide or arrange for the delivery of basic health care services through an organized system which combines the delivery and financing of health care to enrollees on a prepaid or other financial basis (except for enrolled responsibility for copayment or deductibles) through an organized system which combines the delivery and financing of health care. When an organization accepts and assumes risks and accepts payments, fees, premiums or premium equivalences for that risk it is deemed to be a health maintenance organization.
That little definition sounds very much like Sections 1 and 2 of SB #2441, doesn't it?  However, that is not the most troublesome part of the bill.  That little section (b) that covers net worth requirements is worthy of your attention.  Section 83-41-325 specifically covers net worth requirements: 

(1) Before issuing any certificate of authority, the commissioner shall require that the health maintenance organization have an initial net worth of One Million Five Hundred Thousand Dollars ($ 1,500,000.00) and shall thereafter maintain the minimum net worth required under subsection (2). Section 325.

Let your skulls filled with mush percolate for a minute.  Current law requires these insurance companies to keep at least a net worth of $1.5 million dollars. Think of it as a floor, a safety net.  SB #2441 removes that protection and allows the Commissioner of Insurance to set that floor at whatever level he desires.  If MHA and its allies can somehow elect a Commissioner of Insurance "friendly" to  their interests, they can effectively control the regulations.   A friendly Commissioner could set the net worth requirement at $1 million, $500,000, or whatever his department thinks is necessary. These plans can and do fail. Google "Promina" and "Georgia".   What happens if a plan goes belly-up and there are not enough reserves to cover the plan?  It's a serious question worth asking. It's much easier to herd one cat than several hundred. Legislatures are such pesky things.

The bill passed the Senate unanimously.  Yes, even the Tea Party trio voted for the bill.  However, the bill was amended in the House.  The House changed Section 3 and requires managed care plans to follow the requirements spelled out in the Mississippi Code for HMO's.  In other words, there will be no "friends" in state government who will be able to write "friendly" regulations at will for these "nonprofits" and "trade associations".   Such plans will have to follow the Mississippi Code- as does everyone else.

The bill is currently enjoying the hospitality of the Conference Committee. Numerous sources inform JJ that the MHA is quietly but strongly pushing for the stuffing of tax credit language into the final conference committee bill.  Forget tax cuts for the common folk, its about the tax breaks for the connected cronies.  Stay tuned.

*Capitated: Negotiated price per patient. If the actual cost is below that price, the insurer makes a profit. If it is above the price, the insurer loses money. It's an incentive to control costs.


Anonymous said...

Meet the Mississippi Republicans. SAME as the Mississippi Democrats. Their sole objectives are to screw over the average Mississippian and line the pockets of their chosen cronies.

Anonymous said...

And because your legislature exempts itself from open meetings laws, you will not be allowed to witness the true negotiation process on this and many other pieces of legislature.

Anonymous said...


Anonymous said...

For years the federal government has supplement Mississippi hospitals-- it's about time the state starts supplementing them as well. We need them here and this is a great move by leadership.

Never Trust Nobody said...

We will need all the supplementing we can get when these venues are busting at the seams with illegals and families of thirty in the waiting rooms.

Anonymous said...

1) no accountability laws for most of these hospitals ( breeding room for corruption)

2) check a box, kill someone, and get paid.

3) ughhh. cue Pink Floyd.

4) don't tell me abortion is sooooo horrible when this is going on and they're about to up the anty BIG TIME.

Anonymous said...

This is a good law

Anonymous said...

Changed my mind. This is a bad law.

Anonymous said...

This is MHA's Obamacare Light---

Anonymous said...

This is Governor Bryant's Anser to Ombabama Care.
And I hear he want's to give his new best friend Timmy Moore the money to fund it.

Sorta scary, right??!

Anonymous said...

For years now, Gov. Phil Bryant (R - Mississippi) has refused to adopt the new method of reimbursing hospitals for care provided to those without insurance and unable to pay. This has driven a good number of our Mississippi hospitals to the brink of closure, and some straight into bankruptcy. The reason he always gives is "we can't afford it."

Well, here's a comparison of the cost of the tax cut plan before the House today and the costs associated with the new method of hospital reimbursement:

Tax Cut: $12.3M
Hospital Reimbursement: $29M

Tax Cut: $56.2M
Hospital Reimbursement: $94M

Tax Cut: $108.6M
Hospital Reimbursement: $108M

Tax Cut: $166.8
Hospital Reimbursement: $124M

Tax Cut: $233.7M
Hospital Reimbursement: $167M

Total cost from 2016-2020:
Tax Cut: $577.6M
Hospital Reimbursement: $522M

(Source: Lt. Governor’s office tax cut data and “An Economic Analysis of the State and Local Impact
of Medicaid Expansion in Mississippi” David Becker and Michael Morrisey, November 2013)

Now, I may be a graduate of our chronically underfunded Mississippi public schools, but even I can understand when I'm being sold a bill of goods.

Anonymous said...

The Republicans expect y'all to fall right in line no different than the Democrats expect the blacks to do the same. No dissension in the ranks will be tolerated.

Anonymous said...

But at least we are transparent!! NOT.

Anonymous said...

Isn't the Medicaid budget at 1 billion dollars? And MHA wants to add 30 million more to sunsidize their plan???

Anonymous said...

Physicians do not support this plan

Anonymous said...

Moore said yesterday on Gallo they would have investors in their plan -- who are their investors? Who invest in a plan that is destined to fail?

Anonymous said...

God help us!

Anonymous said...

Stark law oversees and prohibits physician referral to a entity that they have a financial interest in. It is impossible to reconcile this with the fact that the hospitals will be in charge of and profit from their governing of their own insurance policy. Where are the cries for rationing care? How can Medicaid, who reimburse at the lowest levels, find the money to add a whole new level of bureaucracy? Maybe they could pay the physicians a touch more.

Kingfish said...

There are other Medicaid bills still moving forward. SB 2588 fixes the UPL model and deficit so there is some relief.

Anonymous said...

UPL has to be fixed. My rural hospital will be in trouble if the flawed model isn't fixed--- it's a shame power : money hungry MHA is pursuing 2441 and not the UPL fix. Four hospitals lead the conversation,the big hospitals.

Anonymous said...

Great point @8:41

Anonymous said...

8:41 - Stark only applies to Medicare. There is a bill now in committee to create a Medicaid version of of the physician self-referral law similar to Pete Stark's version, but it hasn't passed.

Anonymous said...

But forming a trade association does not shield joint activities from antitrust scrutiny: Dealings among competitors that violate the law would still violate the law even if they were done through a trade association. For instance, it is illegal to use a trade association to control or suggest prices of members. It is illegal to use information-sharing programs, or standardized contracts, operating hours, accounting, safety codes, or transportation methods, as a disguised means of fixing prices.

Anonymous said...

These grand plans are ways to grab "Obamacare" dollars without having to call them that. It is that simple. So the Governor's support of this legislation is simply to avoid the term "Obamacare."

What is worse it that the plan is a dangerous and unproven experiment that will to work in our state. HMOs all fail in rural areas. There is no way to avoid it. There are no large or small physician groups who will "sign up" to be the capitated providers for Medicaid patients in Mississippi.

Without a large physician network, there is no network. Without a network there is no HMO.

So this is spinning of wheels and distraction whether it passes, fails, or flies to the moon.

We either accept the $1 billion due Mississippi (from "Obamacare") or we let our rural hospitals die with out a massive state supplement, which will cost Mississippians even more.

The MHA and the governor are idiots.

Anonymous said...

Correct. We will have to accept the money and expand Medicaid. I'm sure the hospitals saw this coming and this is why they have such a push to nestle up to the government tit. Also eventually Obamacare and Medicare/Medicaid will be one large entity. There will be plenty of doctors who accept Medicaid. Already plenty who take Magnolia/United and that is a capitated system. Obviously medicaid is going to get a big boost in revenue. Increased budget or federal dollars. Either way none of it will make its way down to the doctors.

Anonymous said...

Doctors always get their share. They avoid the Medicare cuts hospitals get most every year. Expansion of Medicaid would push more dollars to them. However, expansion isn't happening while Phil is in office, and by the time he's out of office, the federal dollars that pay for the expansion will be gone and the states will be left to pay for the expansion themselves.

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