DC leaders clash over best insurer to care for low-income patients

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correction

A previous version of this article incorrectly described a lawsuit against insurer CareFirst. The lawsuit was about CareFirst’s insurance plan benefits in the district, not its contract with DC Medicaid. The article has been updated.

As DC lawmakers prepare to award some of the city’s most lucrative contracts — paying three insurance companies more than $2 billion to provide health care to about a third of all DC residents — board members are locked in a tug of war over which insurers should win.

The city’s Medicaid program has been embroiled in controversy for years. After a court ruling against old contracts with insurers, a major hospital system’s threat to stop seeing Medicaid patients and legislative battles, Mayor Muriel E. Bowser (D) last year vowed to start over with a new market to re-select the three insurance companies the district would pay to provide care for Medicaid beneficiaries.

DC plans to revive its struggling Medicaid contracts

The city’s Office of Contracts and Procurement accepted the bids, scored the proposals, and awarded the contract to two vendors already in the system – MedStar and AmeriHealth – as well as a third company, Amerigroup, replacing existing provider CareFirst.

Bowser asked the DC Council to approve the contracts at its legislative meeting on Tuesday. But some board members have expressed concerns about whether Amerigroup is fit to insure low-income patients.

The company has a troubled track record, as CareFirst lobbyists, including former DC Council member David Catania, pointed out: More than a decade ago, an audit revealed that Amerigroup had overcharged the district. He has also been criticized for his role in Medicaid programs in other states, including Florida, where he paid a $2 million fine for denying speech therapy to children.

“We are about to bring back a [insurance plan] with a checkered history in the District and a well-known reputation for denying care to vulnerable Medicaid members,” Councilman Vincent C. Gray (D-Ward 7) wrote in a letter to City Administrator Kevin Donahue and board members, saying he was “considering strongly” urging members to vote against all three contracts on the grounds that the process went wrong and resulted in a bad winner. “We can’t stick our low-income residents with underperforming health plans for the next five years and pretend our hands are tied and we’ve done our best for our residents.”

But CareFirst also has a history of legal battles in the district, recently agreeing to pay a $95 million settlement to end a more than 13-year battle over allegedly taking too much of its insurance plan. And Adrian Jordan, president of Amerigroup’s DC plan, said many of the issues Gray raised had nothing to do with his plan. The Amerigroup brand includes insurance plans that act completely separately from state to state, he said, and the company is under a different owner than the plan that malfunctioned in the district in the 2000s.

“The health plans are completely separate and independent,” Jordan said. “Amerigroup DC is an autonomous health plan responsible for me and me alone. I have no visibility on the other plans of the country.

Amerigroup proved unpopular in DC the last time it held a Medicaid contract. Twenty percent of its members chose to switch to another Medicaid provider, more than those who switched from other plans.

Jordan – who is close to some council members himself as a former council staffer – said it won’t happen again. MedStar operates both an insurance program and a major hospital system popular with low-income patients in the district, and in the past the company has not reached agreement on a contract with certain other insurers, including Amerigroup. . This meant a large number of Amerigroup patients who wanted to see a MedStar physician had to change plans.

MedStar’s dual role became far more problematic last year, when the company, faced with the prospect of losing its insurance contract, threatened to stop letting its doctors treat patients on any other Medicaid plan, an ultimatum which threw the Medicaid system into chaos and led to the new procurement process the city is currently conducting.

Since then, the DC Department of Health Care Finance has been working on rules and agreements intended to require all hospitals in the district to accept all Medicaid patients. If these deals work, Amerigroup patients won’t have the same reason to switch insurers.

Yet in its attempt not to lose the high-paying contract, CareFirst hired lobbyists, including Catania, to try to convince board members that transferring tens of thousands of Medicaid patients from its plan to other plans would be detrimental, especially if the change is at Amerigroup.

“If the board approves the contracts, more than 70,000 DC Medicaid enrollees would transition from a proven, high-quality plan to one with a demonstrated history of overcharging and denial of patient care,” said Ieisha Gray, COO. of the CareFirst DC plan. CareFirst argued it lost out to Amerigroup based on small technicalities in how DC scores purchases, not quality or cost. “Minor typos could cost more than 70,000 district residents their health care, and I don’t think that point can be stressed enough.”

In 2017 and 2020, DC Contracts Appeals Board judges ruled that the Office of Contracts and Procurement erred in awarding Medicaid contracts. But this time, the contract appeal board heard CareFirst’s protest and ruled that the procurement process had been conducted properly.

Judge says DC erred in awarding lucrative Medicaid contracts

Council Member Robert C. White Jr. (D-At Large) urged members to vote yes on all three contracts, saying they should follow the procurement process. “The size of these contracts is so large that there has been more scrutiny and more money and lobbying poured into them. Ultimately, this is a public contract that the city has managed, which has been appealed, which has been finalized and which the council should not intervene in,” White said in an interview. “It would be a disaster for the council to send the message that we We are going to get involved in the purchases because every time there is a major market, we are going to be invaded by lobbyists.

White also criticized the focus on Amerigroup’s ability to hold the contract, noting that its competitors have also caused major problems in the district’s Medicaid program.

CareFirst to pay DC $95 million, ending 13-year legal battle over excess funds

“We shouldn’t be looking for the right actor, because we’re going to be looking for a long time. The city just finalized a $95 million lawsuit with CareFirst. MedStar single-handedly broke our Medicaid system,” he said. “Everyone has problems here.”

Michael Brice-Saddler contributed to this report.

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