Healthcare, State Government, West Virginia Legislature

Auditor J.B. McCuskey comes to Mon Health for roundtable on PEIA and health care issues

MORGANTOWN – State Auditor J.B. McCuskey came to Mon Health Medical Center on Wednesday for a roundtable discussion on health care issues with Mon Health System leaders.

The conversation was grounded in what’s ahead for PEIA as legislation works through the Legislature, but ranged out to insurance coverage in general and fundamental problems in health care.

As MetroNews’ Brad McElhinny has reported, SB 268 makes a range of changes to PEIA, out of concern that the agency faces growing financial stress. The bill is expected to result in $76 million in savings to the state in the first year and more than $500 million by 2027. Costs for insured employees will likely go up but accompanying legislation for $2,300 across-the-board pay raises would serve as an offset.

About 600,000 West Virginians are covered by PEIA, it was said at the roundtable.

McCuskey asked, “How is this going to affect regular people? There’s going to be a lot of very, very scared people soon.”

One of the problems they addressed is that no government plan – PEIA, Medicare, Medicaid reimburses providers or hospitals for the cost of care. They rely on private insurers to make the bottom line.

McCuskey observed that Obamacare didn’t solve the cost problem, or the general health problem.

Mon Health President and CEO David Goldberg agreed. “I think it opened up more access, but most still use urgent cares and emergency rooms for their primary care; don’t follow up on what their issue is, and then they come back when they’re having a heart attack, diabetes or whatever, and it’s more expensive. … It fixed access, giving people a funding mechanism for insurance, but it didn’t fix overall health.”

Dr. Bradford Warden, executive director and interventional cardiologist at Mon Health Heart & Vascular Center, added, “The people who are really trapped in the state are the working poor.”

They are among those who use emergency rooms as their primary care. Some make too much for Medicaid but don’t have coverage through work, and don’t go to doctor because they can’t afford it.

They talked about the tug-of-war between insurers and providers, with patients in the middle. Insurers employ an array of delaying tactics – medical reviews, peer-to-peer conversations with company doctors not qualified in the field, and more.

McCuskey said, “It is interesting that the patient’s advocate is the ultimate biller. Meaning that the only person who is advocating for the patient to have coverage is the person who’s trying to get paid by the insurance company. The person who is most at risk is being fought over by two people – neither of them have their best interest financially at heart, they both have their own financial interest.”

Michelle Coon, president of Vandalia Health Network (Mon Health’s parent organization, in partnership with Charleston Area Medical Center), took partial exception to McCuskey’s point.

Each company has its own rules on what’s medically necessary, on filing guidelines, on hoops to jump through, she said. “Our clinicians just want to provide care to their patients. We have all kinds of resources dedicated to protecting that patient’s financial interests in place. It’s part of our mission.” Putting patients in the poor house serves no one.

Goldberg said the old fee-for-service health care model has failed and Vandalia is working with a new model, which includes such things as managing a person’s health in their community, reducing overuse (ERs for primary care, staying in a hospital longer than need to be), directing people to their primary care doctors instead of directly to more expensive specialists that may be doing things not needed.

Goldberg pointed out another PEIA problem. It pays out-of-state providers along the borders three to five times more than it does to in-state providers. That means $40 million goes out in excess fees that could come back to state hospitals.

Dipti Patil, Mon Health System director of Population Health, said Vandalia Health serves 120,000 beneficiaries. “Our main goal is to improve quality of life of the patients and detect a medical condition in its early stage when its treatable.”

They’re battling an insurance system that doesn’t genuinely exist to serve patients, but to make profits, they said.

“Every plan design is different for the patients,” Goldberg said. And McCuskey replied, “There’s a reason why everyone is miserable about this: it’s because they don’t understand it.”

And Dr. Tom McClellan, cofounder of Intermed Labs at Mon Health, summed it up, “It’s designed to work that way, that’s how people make money.”

Coon stressed the need for good data from insurance companies for health systems to be able to see how their patients are using the system, to make sure they’re under care of a PCP, that they have adequate access to care.

“While this sounds like a good idea. PEIA isn’t able to provide good data timely like our other payor partners are able to.”

Goldberg said, “PEIA has a funding problem. If we can get people into a [primary care] home and reduce costs, then your coverage and the cost the state has to pay for PEIA will go down.”

McClellan noted that in his private practice, he’s reduced his insurance partnerships from 15 down to three because of all the game-playing. Medicare underpays, but they at least pay within three weeks, not months or years or never.

McCuskey’s final observation was, “What the government fails to understand is that predictability is worth money. They never understand that. They both shortchange you and make it unpredictable.”

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