Analyzing and Stirring the Pot: Fight over Managed Care Medicaid Expansion is serious business

Pat McGuigan

OKLAHOMA CITY – Just after deadline for last week’s story (“Starting to get down in the weeds”), much of the medical establishment made official what everyone paying attention already knew – they don’t like the managed care plan for Medicaid expansion announced in January by Gov. Kevin Stitt and the Oklahoma Health Care Authority (OHCA).

It was hardly breaking news, and in fact did not get as much attention as might have been expected in pre-pandemic times. Nonetheless, the big hitters came out swinging, characterizing (in a March 11 press release) Stitt’s plan as “a flawed scheme to privatize the state’s Medicaid system.”

That’s not all. Representatives for the anti-coalition characterized managed care as more than just a bad idea. They deemed it a “Health Care Holdup” – complete with a new website full of familiar arguments. The assertions of a “holdup” are aggressive, indeed, but could be viewed as a classic example of stirring the pot, politically speaking, to smoke out the other side early in an important confrontation.

As for that other side, the four managed care organizations (MCOs) Stitt and his team selected for Medicaid expansion were characterized, in the announcement press release, as “qualified and experienced” entities.

Introducing the Cast of the This Spring’s Clash 

Blue Cross Blue Shield
has been a staple in the Sooner State’s health insurance dynamic for 80 years. Humana Healthy Horizons extends the brand in Oklahoma of a group with 800,000 members nationwide. Oklahoma Complete Health (subsidiary of Centene) is already deeply involved in Sooner Select and its Specialty Children’s Plan. UnitedHealthcare is the ubiquitous behemoth (with long-term ties to the American Association of Retired Persons) involved in the full spectrum of health care systems, working with more than a million physicians and health professions, plus 6,500 hospitals and care facilities.

The high-decibel foes of managed care include these state associations: Medical, Dental, Hospital, Osteopathic Association, Home Care and Hospice, Psychological, Pharmacists, Ambulance, and Medical Equipment Provider. Also among the opponents of managed care: Oklahoma Society of Anesthesiologists, American Academy of Pediatrics – Oklahoma Chapter, Alliance of Mental Health Providers of Oklahoma, Oklahoma Academy of Family Physicians, Leading Age Oklahoma, American College of Obstetricians and Gynecologists – Oklahoma Chapter and The Arc of Oklahoma.

Woody Jenkins
, a Stillwater doctor and co-chair of the Oklahoma State Medical Association Rural Physicians Section, said, “Oklahoma has been down this road once before, and it was a dismal failure. It’s imperative that Oklahomans understand what is about to happen to Oklahoma’s highest-risk populations.”

The reference was to a previous managed care effort that the state health care system abandoned after a short time.

Patti Davis
, on behalf of the Oklahoma Hospital Association, said, “The Legislature allocates taxpayer dollars, and yet our legislators have not had the opportunity to weigh in on this important decision that impacts their communities.”

The most passionate anti-MC speaker at the “holdup” press conference last week was Dr. Twana Duncan, whose Antlers dentistry practice serves several southeast Oklahoma counties. She stated, “Ninety percent of Oklahoma dentists dropped out due to extremely low reimbursement rates imposed by the private insurers. This had a catastrophic effect, particularly on rural Oklahomans and children, as it left less than 100 dentists to treat Medicaid patients. I have no doubt this will happen again unless this effort is stopped.”

An Astute Observer’s Viewpoint 

Kaitlyn Finley
, a policy research Fellow at the Oklahoma Council of Public Affairs, is among the most astute observers of this emerging “Clash of the Titans” (as this reporter characterizes it).

In an interview last week, Finley said: “The push-and-pull fight between medical providers, insurance companies and government is nothing new. By implementing managed care for Oklahoma’s Medicaid program, it will better align incentives to ensure Medicaid members are receiving superior coordination of care, including preventive care services, as well as safeguarding against unnecessary over-servicing of some procedures and tests. Managed care will provide clearer budget projections for the Legislature, as well. Managed care organizations will be incentivized and held accountable to help achieve better health outcomes.”

Although the anti-MC organization asserted in last weeks’ press release that “virtually every aspect of Oklahoma health care” opposes Stitt’s plan, it is clear that the four designated managed care organizations support it – and they have allies.

Supporters explain why they advocate Managed Care

In a letter to the editor posted at, an online news service based in Oklahoma City, Jeff Hughes of Progressive Independence wrote in February: 
“The debate to move Oklahoma to a Medicaid managed care system is complex. It requires all decision makers to focus only on facts in order for the citizens of Oklahoma to be well informed when the Oklahoma Legislature determines where to allocate funds for the approximately 200,000 new Medicaid recipients that will be added to the system this fall because of Medicaid expansion.”

He continued, “As the executive director of an Oklahoma non-profit organization that supports Oklahomans with disabilities, I believe a managed care model is the best choice. It is a system proven in other states to improve health outcomes for Medicaid beneficiaries while saving millions of dollars annually.”

Hughes added to this argument: “Unfortunately, a recent Government Accountability Office report has been used to further a narrative that managed care and managed care organizations lack oversight and will cause considerable financial strain to the state while not improving health outcomes of the hundreds of thousands of Oklahoma Medicaid recipients. Nothing could be further from the truth. The GAO report looked specifically at managed long-term supports and services programs, which contain the most difficult populations: elderly and disabled Medicaid members. The Oklahoma Health Care Authority is not proposing converting these members to managed care under the current system. The OHCA plans to start managed care with relatively healthy adults and children in order to provide time to effectively manage these populations before enrolling more complex populations.”

In his recent comments, Jeff Hughes stressed, “Oklahoma’s success in contract oversight and driving quality improvement will depend on OHCA’s program management. The professionals at OHCA have talked and will continue to talk with other states regarding best and worst practices related to managed care organization contract oversight.”

The Oklahoma Department of Rehabilitation Services describes Progressive Independence as “a community-based, cross-disability, non-residential, non-profit agency designed and operated by individuals with disabilities to provide an array of independent living services.”

In another missive, managed care supporter Karma Robinson of Oklahomans for Better Medicaid wrote, “Oklahoma has some of the worst health outcomes in the country. Now that the citizens of Oklahoma have spoken on the issue of Medicaid expansion, it is the state’s responsibility to cover the approximately 200,000 additional Oklahomans who will become Medicaid beneficiaries.”

Robinson’s group asserts, “Now is the time to take advantage of a tremendous opportunity to improve Oklahoma’s poor national health rankings and outcomes by implementing a new-age managed care model outlined in Sooner Select — a model that will truly provide quality and value to Oklahomans needing them the most.

“This is not the managed care model of the 1990s and early 2000s. It is a modern health care system, managed by health care professionals, that has been implemented and proven in dozens of other states. In fact, Oklahoma is one of only a few states not utilizing Medicaid managed care.”

Oklahomans for Better Medicaid is described at its website as a “multi-stakeholder group committed” to a system “that improves access, quality, outcomes and affordability through managed care in Oklahoma.”

A sketch of the Beginning of the Beginning … 

Patti Davis
, with the anti-MC Hospital Association, complained on March 11 that the Governor left the Legislature out of his deliberations. 
But also on March 11, the state House of Representatives sent House Resolution 1091 to the Senate.

In a March 12 press release, Davis said H.R. 1091 would remove “the ability of OHCA to unilaterally implement managed care.”

A legislative press release sketched the provisions of H.R. 1091, which would require that OHCA require of “any proposed or potential plan participating in capitated managed care” these contract provisions:

    •  90 percent of all claims shall be paid within 14 days of submission to the plan;
    •  Authorizations shall be facilitated within 24 hours for inpatients transferring to post- and long-term acute-care facilities;
    •  All plans shall offer network contracts to all community providers designated as essential by the Centers for Medicare and Medicaid Services;
    •  All plans shall offer payment rates to contracted providers that are no lower than the fee schedule of OHCA in effect on the date of service;
    •  All plans shall formally credential and re-credential physicians or other providers at a frequency that may be less than once in three years;
    •  All funds appropriated to OHCA shall be used in accordance with legislative intent; and
    •  Plan reviews and determinations for prior authorization must be timely and in accordance with established guidelines.

In response to an inquiry from this reporter, Katelynn Burns, senior media relations professional for OHCA, said, “OHCA is monitoring all legislation related to the agency. As always, we will comply with any legislation passed that affects our agency.”

H.R. 1091 cleared the lower chamber with a strong 81-13 vote. It moved to the Senate (where Chris Kidd, R-Waurika, is the sponsor) at the end of deadline week – when the respective chambers must review one another’s proposed new laws. It is what is called, in legislative parlance, “a work in progress.”

The strong “yes” vote is not necessarily a sign of the final result. Although it is arguably the most anti-MC proposal in the current Legislature, which is considering a range of health care proposals beyond managed care, the old sports expression is apt: “It ain’t over ’til it’s over.”

In a brief interview on St. Patrick’s Day (March 17), state Sen. Kim David, R-Porter, said the upper chamber planned “to take a measured to approach to the bill [HR 1091] from the House. We have several people who will work on that – literally a committee – who will go over the bill carefully. In the Senate, we plan to do what is best for the people of Oklahoma.”

Groups opposing any move toward managed care declare it will result in high administrative costs at the four MCOs, but OCPA’s Finley cautions, “Before decrying MCOs’ supposed greater administrative costs as a percentage of total costs compared to the OHCA, one must keep in mind, if total costs go down a larger percentage of a significantly smaller number may still net cost savings. Safeguards are in place in contracts as well as federal law to ensure providers will be held accountable and incentivized to help improve health outcomes for beneficiaries and not skimp on care.”

Additionally, Finley succinctly stated one of the strongest arguments for managed care of Medicaid expansion. “Oklahoma’s Medicaid program is growing unchecked,” she said. “Thanks to the passage of Obamacare Medicaid Expansion, [State Question] 802, hundreds of thousands of able-bodied adults will be added to the program. The Oklahoma Health Care Authority needs a way to manage the rising costs of the program.”

In the foregoing, an attempt to shed some light, some wind to blow away the smoke and mirrors.
And, to be sure, a long-time analyst … stirring the pot.