Plan Design committee May update
The Plan Design and Expenditures Committee of the UHPGB met on May 1, 2025. (There was no meeting in early April)
Summary by Sandra Coyner, HCAO/HCAO-Action (SandraCoyner@hcao.org)
Meeting started with procedural updates. The main topics of discussion and work were:
Eligibility: The Committee discussed how to change its straw proposal. Many points were raised about tough cases, including minors, children, incarcerated individuals, out of state workers, travelers, overseas travelers, nonresident students, students going out of state, retirees going out of state, university students’ insurance, seasonal workers who work in more than one state. Result: needs more discussion and work.
Behavioral Health: straw proposal was tweaked to meet GBs comments.
Long-Term Care (LTSS): Helen will recruit for the subcommittee that was approved by the GB.
Provider reimbursement – there was a report from consultants and discussion.
Principles are: reimbursement should be adequate; pay parity; meet differing needs.
How reimbursement happens now:
If medicare rate is assigned a hypothetical value of 100% (Medicare supposedly is based on actual costs), then Medicaid pays only 85% and Commercial pays 170%. If all providers are paid the same for the same work (i.e. from a single payer), practices serving Medicare or Medicaid will see an increase in income (of roughly 25-40%) and those who have created a clientele of mostly commercial-insurance patients will see a decrease (roughly 45-50%).
Medicare pays hospitals and providers according to specific standards related to the specific care provided.
Payment methodologies: Reviewed Task Force recommendations. Reviewed existence and some characteristics of CCOs in Oregon (risk-based, risk-adjusted, use networks)
Discussion by committee included what will happen to various entities, including “critical access hospitals” (must stay open no matter what); FQHCs (Federally-Qualified Health Centers), impacts to small family clinics. Committee sentiment was to protect FQHCs, which promote health equity big time. “Harming FQHCs is not possible.” [sc: in the spirit of Susan B. Anthony, who said “failure is impossible”?]
On CCOs: what to disrupt? What to keep? What will happen when they are not risk-bearing? Currently, CCOs get global budgets and if they “save,” they keep it for providers or for designated local projects. What would be the incentive for a CCO to become a “regional entity” under the UHP?
Compensating providers: Should payments to providers be reduced in view of providers’ lowered administrative costs? Reforming malpractice could help. There is some evidence that using FFS (fee for service) is decreasing spending rise.
A subcommittee was created to address these issues of reimbursement, with at least four immediate volunteers from the committee and more expected to come.
End-of-meeting reflections included some suggestions for adding to the principles; a note from Anya that augmenting Medicare benefits is really expensive (will be a key decision), a suggestion that without a federal waiver, Medicare Part A could stand and Parts B&D could be part of our UHP. In public comment, Lou Sinniger noted among several things that “profit vs. nonprofit” with regard to CCOs is a red herring, a waste of time: behavior of corporate-owned practices is a much bigger issue. “All of us want to move from a profit system to a care system.”
