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 February CERES ends 1998 with excess mental health revenue While a Multnomah County Mental Health Task Force grapples with shrinking revenues and escalating costs as more people seek help from the public sector, Oregon Health Forum has learned that one of the major contractors has surplus revenue in 1998. CERES Behavioral Health, a for-profit entity, set aside 20% if its $10.86 million budget for inpatient costs. However, when the year ended, only 13% of the impatient budget or $1.4 million had been spent on the 396 Oregon Health Plan clients statewide, said Ray Hudson, director of Oregon operations. The remaining money was returned to mental health contractors, as part of their risk withhold. For example, Advanced Behavioral Health, comprised of Unity, Centers for Community Mental Health, the Children's Federation, CODA and Oregon Health Sciences University, split $350,000. But those weren't new dollars, said Kristin Angell, Unity's executive director. CERES withheld part of its capitation payment for the entire year. Tualatin Valley Centers, Mt. Hood Mental Health and Network Behavioral Healthcare - all minority co-owners of CERES - also received money, said Hudson. "Regence (BlueCross BlueShield of Oregon) got some additional money," Hudson admitted. "And CERES kept money that contributes to our bottom line. Everyone shared in that surplus." Overall, CERES keeps 12% of state revenues for administration, giving another 5% to Regence for other services. Hudson said he would provide data showing the exact surplus kept by Regence, his corporation and how much went to the minority shareholders. Will employer-based health insurance come to an end? Fixing the health care system has emerged once again on the national political agenda, and a wide variety of voices are beginning to whisper a radical concept: End employer-based health insurance. Open discussion of the idea has been confined largely to policy papers and conferences sponsored by think tanks and benefits firms. But a recently announced bill in Congress - giving lower-income individuals tax credits for buying their own insurance - could set in place the first stepping stone toward such a system. If the nation begins moving down that path, though, employers might face rebellion among their workers. Take the example of what happened to Xerox Corp. in December. Consumer board favors buying anti-psychotic drugs A plan to inject nearly $2 million into the mental health system to pay for anti-psychotic drugs for the chronically mentally ill overcame another hurdle. The Mental Health Association's board voted unanimously Feb. 7 to support Senate Bill 941 as it heads to the Legislative Emergency Board later this month. Cecelia Vergaretti, the association's executive director, said the board supported the bill as long as people aren't forced to take anti-psychotics. Money for the pilot program, passes as a line item in the 1999 legislative budget, was to have been released Jan. 1. But first the Health Services Policy Committee, with officials from the Mental Health Division, must decide the distribution formula. "The leadership determined that all reserves in the E-Board's control should pass through a substantive committee first," said Barry Kast, Mental Health Division administrator. The delay is unnerving, said Sen. Eileen Qutub (R-Beaverton), who chaired the Human Resources Subcommittee that appropriated the money last session. "It is frustrating in a sense, although if things aren't ready and you let the money go it sometimes goes down a hole," she said. The pilot program is intended to serve mentally ill Oregonians who do not qualify for Medicaid services. "These medications are very expensive, and this program would remove a barrier to state-of-the-art treatments available for people who can't afford them," Kast said. Tensions remain high over Klamath County's mental health system In 1997, when the Oregon Health Plan began covering mental health, Klamath County was unprepared to take on the role. The program director had just retired, and a series of interim directors followed. "There was a lot of concern about how accountable the county would be," said Mike Gregory, who became the county's mental health director in August 1998. These days, the picture is much brighter, Gregory said. With OHP money and a "fairly clear vision" by county commissioners, providers and others, the mental health program has achieved a number of successes since Gregory's arrival, including the hiring of a full-time psychiatrist and a plan to expand services. "We're still a work in progress," Gregory said. "There are still issues that need to be addressed. But by and large, the feedback from the community is that we're moving in the right direction." Not everyone is convinced Klamath County's mental health program is rebounding. Bill Guest, who heads Cascade Comprehensive Care, a consortium of heath care providers in Klamath Falls, said he hasn't seen statistics to show if care actually has improved. "We would like an accounting of how OHP dollars are being spent," he said. "We'd like to see how much money has been going to administration and computer services that could be spent for services for enrollees." Tobacco advocates fight hospital initiative Standing alone, the Oregon Assn. of Hospitals and Health Systems is trying to convince tobacco prevention advocates not to meddle with its ballot initiative, which would lock the federal tobacco settlement money in a trust fund. Ellen Lowe, a long-time tobacco-free advocate challenged the ballot title. Although the attorney general conceded most of Lowe's objections, Lowe could still appeal to the Oregon Supreme Court, tying the hands of the hospital association so it could not gather signatures for 60-90 days. Unless tobacco prevention money is part of the initiative, Lowe's unwilling to back down. But Ken Rutledge, its president, has taken a firm stance. "The measure we filed is the way we're going forward," he said. "If they're successful in stopping this, we'll make certain people in the legislature and those who support the Oregon Health Plan understand how self-serving this effort wasÉ They're basically helping to undermine the Oregon Health Plan and the people who will benefit from it. People trying to throw roadblocks in our way need to take a careful look at what they may be doing to the Oregon Health Plan by doing that. If we don't get the kind of support we need, we're not going to go tilting at windmills and spending a lot of money." The hospital association led the campaign for Ballot Measure 44, he said, which increased tobacco cessation funding from $300,000 to $17 million. Rutledge estimates it will cost $175,000 to gather the 67,000 signatures if the campaign gets under way in February. Further delays will mean another $100,000 in costs. "If we cannot get this on the ballot in a timely fashion, we can't go into bankruptcy," he said. "Anyone concerned about the Oregon Health Plan should be concerned about tactics to stop this." Emergency room docs contend insurers violate the law A 10-month-old infant was brought into the emergency room after choking on a peanut. A woman in her third trimester of pregnancy had been assaulted. These were among the 94 patients who came into Legacy Emanuel or Salem Hospitals' emergency room last November. Most patients had Providence Health Plan or Regence HMO Oregon coverage. The insurers refused to pay for the emergency room visits because of no authorization or they considered the condition "non-emergent," according to Med Data, Inc., which handles billing for over 50% of emergency room departments in Oregon. If these medical bills remain unpaid, the insurers violated the prudent lay-person standard, which requires insurers to pay for screening exams if a person has a condition threatening their health. "This is just the tip of the iceberg," said Dr. David Toovy, practice management chair for the Oregon College of Emergency Physicians, who works at Legacy Meridian Perk Medical Center and helped pass the prudent lay-person standard in Oregon. "If we opened this everywhere, every carrier would be implicated, probably by virtue of their size." Ed Nieubuurt, director of regulatory affairs at Providence Health Plan, reviewed the denials sent by Med Data and found the cases were miscoded as outpatient rather than emergency room visits. A similar problem occurred in Maryland following a year-long investigation by its insurance administration. The investigation exonerated health plans and concluded the main culprit was lack of communication. Regence HMO Oregon "does not make denials based on technicalities such as no authorization," said Ken Strobeck, vice president of corporate communications. Also in this issue...
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