Managed Care Round TableManaged Care Round Table

Beth Spoto, Spoto & AssociateMike Scribner, SHP Savannah

shpllc.com& Associates, LLCSpoto

Georgia’s Payer MixGeorgia’s Payer Mix• Medicare 13%• Medicaid 16%• State Health Benefit 7%• Commercial 46%

• (52% 4 years ago)

• Uninsured 18%

Georgia’s Current Population is 9.6 million

shpllc.com& Associates, LLCSpoto

State Retirees Retirees moving to be under either Cigna (2) or UHC

(2) Medicare Advantage PFFS Plans effective 1/1/10

Plans must move from PFFS to MA PPO/HMO for 2011

Active State Employees

All new employees must be enrolled in HRA or HSA

high deductible plan

United PPO no longer offered to state employees

State Health Benefit PlanState Health Benefit Plan

shpllc.com& Associates, LLCSpoto

WellCare◦ Small impact of HB 1234◦ Aggressive stance to avoid cost increases

Peach State◦ Outsourcing therapy network to TRS with caps on

daily rates◦ Requesting take-backs based on adjusted CCR or

pricing increases (assumed or actual). Need to check your letter/computed amounts.

◦ Increasing triage rate

CMO UpdateCMO Update

shpllc.com& Associates, LLCSpoto

• PFFS plans must be contracted by 2011 to continue

• Coventry and Wellcare discontinuing PFFS plans effective 12/31/2009

(they will still have MA PPO/HMO plans

• Clients received solicitations from many plans recently:Humana Aetna United (Secure Horizons)

Cigna Sterling AmerigroupWellcare

• Many solicitations will attempt to add PPO/HMO as well.• SHBP moving retirees to Cigna/UHC MA Plans

• Cigna – No action required, providers will be “deemed” into PFFS• UHC – Opt In for PFFS and Opt Out for PPO/HMO

shpllc.com& Associates, LLCSpoto

Medicare AdvantageMedicare Advantage

Blue Cross Blue Shield of GABlue Cross Blue Shield of GA

Losing market share in rural areas

Overtaken by UHC in several markets

Still retained Board of Regents / University SystemBig push to complete Open Access products

statewide and MA in targeted areas

Moving business to POS product

shpllc.com& Associates, LLCSpoto

% of Patient Liability (Sample Hospital)

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

BCBS UHC Cigna Aetna Other Commercial

2006

2009

• 3 Major Initiatives Ongoing• Move to OOPS

• Moving to Medicare rates/methodology for PPS hospital

• CAH move to Medicare rates/methodology• 12/01/09

• Selected as program administrator • United awarded contract from Humana – effective 4/1/09• Humana appealed award –final decision 12/31/2009• Humana will now administer at least through 9/30/2009

shpllc.com& Associates, LLCSpoto

TRICARETRICARE