Uninterrupted coverage for thousands as Graves Gilbert, Humana announce new contract

Graves Gilbert Clinic previously anticipated terminating Medicaid and Medicare Advantage participation with the insurance provider Humana — but Thursday, GGC announced a new contract, meaning coverage will continue uninterrupted for thousands of patients regionwide.

The contract, which starts March 1, preserves in-network access to the clinic's primary and specialty care, prevents disruptions to ongoing treatment and scheduled appointments, and eliminates the need for patients to seek new referrals or change providers, according to GGC.

"We are pleased to continue our relationship with Graves Gilbert Clinic and continue providing the people we serve in Southern Kentucky with uninterrupted access to the integrated care they deserve," Humana Regional President John Litting said.

The new agreement will benefit GGC in ways it had previously sought in a contract that it anticipates will improve patient access, coordinate care, control costs and ensure high clinical quality. Simultaneously, GGC sees the agreement opening up opportunities for new childbirth and pediatric programs, GGC CEO Mike D'Eramo told the Daily News.

"This new agreement reinforces our commitment to patients across the state and secures our relationship with Humana as a real partner," D'Eramo added in a statement.

At stake last year was what coverage would look like for approximately 10,000 patients about evenly split between Medicaid and Medicare Advantage, who would have become out of network without the new GGC-Humana agreement. Without the new contract, they would have needed to find a new health insurance plan or new in-network doctor, or pay out of pocket, D'Eramo previously told the Daily News.

The two-year contract — longer than last year's one — has Humana's agreement to bring an executive presence to Bowling Green three to four times yearly, D'Eramo said.

He previously told the Daily News that this local executive presence would indicate that an organization cares about Bowling Green: Other companies such as Anthem and Wellcare would previously bring CEOs to the table, whereas Humana hadn't brought that executive presence.

"They've agreed to all of that. I trust them," said D'Eramo, adding, "They got some new leadership, we like (…) the new leaders, and we're going to give them the opportunity."

The agreement also entails a commitment from Humana to create reports better enabling doctors to respond to data and improve patient care, D'Eramo said.

Data that health plans give doctors are intended to indicate the doctors' performance at lowering costs and raising quality, D'Eramo said. Health plans impart feedback through report cards with the healthcare providers, who pursue financial incentives for lowering costs and raising quality.

But previously, the reports would often çomprise reams of spreadsheets, dashboards and PowerPoints that were not effective for improving doctors' performance because they weren't interpretable in a way that changes behavior, D'Eramo said. And, GGC had previously found that Humana's reports on GGC's performance didn't line up with other insurance providers' reports that aligned with one another, which GGC previously said had come probably close to $1 million in lost opportunity.

GGC is asking Humana to change their reporting and make the timelines timelier and more consistent so GGC can use the information to improve care — and GGC anticipates that Humana's commitment to improved, more meaningful feedback will make the reports more accurate, also better enabling GGC to more effectively improve quality and reduce costs, according to D'Eramo.

Humana has also committed to telling GGC in real time when the clinic makes errors in claims. GGC previously took issue with Humana issuing money and then taking it back months later.

"If we made a mistake, let me know about that mistake before you pay me," D'Eramo said. "Imagine you get your paycheck, six months go by and HR says, 'We overpaid you in February, and your next check is zero' — it feels like that: where you receive a check, you have to pay people, pay for supplies, pay for insurance, and then a few months come by, Humana, says, '(…) we found a mistake, we're going to take that money back."

An issue between GGC and Humana concerning nearly $800,000 is also being remedied — a situation where Humana recouped the money from previously paid claims without warning, notice or opportunity for due process, D'Eramo said. It's now being rectified, D'Eramo said, where GGC owes Humana some of the dollars, and much of the money Humana owed GGC.

"It's still trickling in, but it's all going forward in good faith," D'Eramo added.

There will be no service cutbacks or cost increases for patients stemming from the new plan, D'Eramo said.

OB Observation

Humana has shown optimism in participating in a new GGC idea to better monitor patients during pregnancy — a project GGC calls OB observation.

Often, D'Eramo said, women unwell during a pregnancy often end up in the emergency room, when they really just need monitoring by a capable nurse to ensure they're okay.

Monitoring pregnant women is also difficult for ERs because the rooms are also not ideal for monitoring pregnant women, as patients with emergencies, such as heart attacks, can take priority. Avoiding the ER also saves patients money, D'Eramo added.

"There's no reason for that mom to go into the emergency room, but right, now that's often their only option — so how does Humana incentivize doctors to monitor) patients? Because right now, they don't … There's no incentive for a physician office to cancel patients and put a mom in a room and monitor them. Now, Humana is saying, "Let's come up with a way to pay for that monitoring — it could take two to four hours of just keeping an eye on mom, maybe giving the mom some IV fluids — very simple things."

GGC is also looking to the creation of a pediatric urgent care, involving health plans such as Humana and Wellcare as well as, potentially, Norton's Children's. As the idea has been newly presented to Norton's, it hasn't yet issued GGC its response, D'Eramo said; Humana has shown a willingness to participate, he said.

Such centers, dedicated to kids, may have a specialist, and it avoids mothers and their children needing to take kids to a big hospital or emergency room in an emergency.