Hospitals Keep An Eye On Medicaid Expansion, Other Bills

Jan. 20--Medicaid expansion is on the minds of Billings' two hospitals as the 2019 Montana Legislature continues its work, though that's not the only issue they're focused on.

"The No. 1 priority is Medicaid expansion and removing the sunset in June," said Jesse Laslovich, regional vice president for network development for SCL Montana, which includes St. Vincent Healthcare.

Laslovich acknowledged it will take compromise to get the Medicaid expansion "and we want to be at the table to make sure it doesn't have negative impacts on patients."

The 2015 Legislature first passed, and Gov. Steve Bullock signed into law, a bill that provides health insurance to nearly 100,000 low-income people. The bill is set to expire this summer unless legislators vote to extend it.

Medicaid priorities

Two bills have been mentioned for introduction into the House this session, one by Rep. Mary Caferro (D-Helena) and a second by Rep. Ed Buttrey (R-Great Falls). Though Buttrey's bill hasn't yet been made public he has said it will include some sort of work requirement, which for people who can't work, could include volunteering.

Laslovich pointed that that in Arkansas, a state that imposed stringent work requirements, 18,000 Medicaid recipients are no longer enrolled in the program.

"Our goal, our philosophy as we approach the session is to keep as many people on the program as possible so they have access to health care," he said.

At Billings Clinic, JJ Carmody, director of reimbursement, and Dr. Heidi Duncan, family medicine physician and Billings Clinic's physician director of health policy, have worked together on the hospital's health policies for the past five years.

Like SCL Montana, Billings Clinic is keeping a close eye on the Medicaid issue.

"The No. 1 one issue is how patients would be impacted if the sunset were to be in place," Carmody said. "We're looking at what it's done for access for our patients."

In terms of preventative medicine, Duncan said, people with insurance are more likely to stay on top of their health rather than wait until an emergency forces them to seek care.

"There are people I would see every once in a while for a very specific problem," Duncan said. "I'd say, 'You haven't had a mammogram,' and they'd say 'I can't afford it.'"

Now her patients covered under the Medicaid expansion are able to get mammograms, cancer screenings, check their cholesterol and take other proactive steps to stay healthy.

"That's a huge benefit for everybody," Duncan said.

Just being able to pay for medications is another help to patients, Carmody added.

Both hospitals have said the amount of uncompensated care -- patient care for which they aren't reimbursed -- has decreased over the past two years the Medicaid expansion has been in effect. At St. Vincent Healthcare and its physician clinics, that amount totaled $7.6 million in 2015, then dropped to $4.4 million in 2016 and $3.5 million in 2017.

Higher levels of uncompensated care force hospitals to shift costs to paying patients through their insurance companies, Laslovich said.

"At the end of the day, we're all in this together," he said. "We want to make sure this doesn't cost shift to everybody else."

At the same time, "It has an impact on our ability to provide high quality care and special services," Laslovich said.

Since the introduction of expanded Medicaid, Billings Clinic has seen a similar drop in the cost of uncompensated care, Carmody said.

"We've been able to use the savings to not increase our rates," she said. "Billings Clinic hasn't had a substantial rate increase in the last five years."

When the Affordable Care Act was enacted, which included the option of Medicaid expansion, the hospital industry gave up a lot in reimbursements from Medicare in exchange for less uncompensated care costs, Carmody said. The idea was more people on insurance would cut that cost.

Duncan said they've heard of the ideas being floated around regarding Medicaid bills. They will keep a close eye as bills are introduced.

"I think the devil will be in the details," she said.

Medical costs

Another bill both hospitals are keeping an eye on is HB 152, introduced by Rep. Kathy Kelker (D-Billings), which has to do with price transparency and preventing consumers from getting surprise medical bills. Part of that is informing patients about out-of-network health care costs.

For example, Laslovich said, if a person has surgery at a hospital that's in-network for the patient's insurance company but the anesthesiologist is out of network, the patient might not know that until they get a higher-than-expected bill.

There is less chance of that happening in Billings, he said, because at St. Vincent, some physicians are employed and others are affiliated with the hospital, while physicians at Billing Clinic are employed there.

Carmody said Billings Clinic has been in contact with Kelker, making sure there's no unintended consequences with the bill.

"We definitely support price transparency, and we let people know, to the best of our ability when they're out of network," she said. "We're wanting to make sure the language in the bill makes sense."

Opioid epidemic

With opioid abuse a continuing national concern, both hospitals are focusing on the issue. Carmody said St. Vincent, Billings Clinic and RiverStone Health plan to launch an opioid task force this month.

Rep. Vince Ricci (R-Laurel) is sponsoring a bill, HB 86, that, among other things, will restrict first-time opioid prescriptions to a five-day supply. Laslovich said. Working with physicians across the state and the Montana Medical Association, the hope is to expand the number of days to seven.

People who live in rural Montana may have to travel long distances to pick up prescriptions.

"And if they need it over the weekend and the limit is five days, then they will be without that medication for a day or two before they can get it refilled," Carmody said. "We think seven days will cover the weekend and allow folks who need it to have access to an opioid prescription and give more flexibility to physicians."

Other legislation

Carmody said other items on Billings Clinic's radar includes any legislation that has to do with workforce training, with the graying of the state's workforce and the aging population.

Another concern is potential violence against health care workers. A hope is that legislation would be introduced to make that a felony.

Carmody and Duncan also are interested in anything to do with mental health, including suicide prevention, as well as bills that will boost the ongoing effort to develop a robust health information exchange among hospitals throughout the state.

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