January 28, 2013

Cook Children's, Aetna take disagreement to mediator

The disagreement between Cook Children's and Aetna affects 42,500 Medicaid members.

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State regulators are scheduled to meet next week with representatives from Cook Children's Health Care System and Aetna insurance to help resolve a contract dispute affecting thousands of Tarrant County Medicaid beneficiaries.

Cook Children's, Tarrant County's specialty pediatric hospital, was dropped from Aetna's network of providers on Nov. 1 because of a disagreement over reimbursements. That means the 42,500 Medicaid members in the Aetna Better Health network who had been seeing doctors in the Cook Children's physician network have had to find another pediatrician or go to another facility for tests or procedures.

Aetna is the smallest of three Medicaid managed care networks in Tarrant County. The others are Amerigroup and Cook Children's Health Plan.

Aetna and Cook Children's have agreed to meet Feb. 7 with an official of the Texas Health and Human Services Commission, which offered to mediate the disagreement, representatives of both parties said.

"We want it to be as easy as possible for children to access care," and the state aims "to discuss and hopefully resolve" the stand-off, said HHSC spokeswoman Linda Edwards Gockel in Austin.

Dr. Sealy Massingill, president of the Tarrant Council Medical Society, urged a settlement.

"We're disappointed these two groups can't reconcile their differences," said Massingill, chairman of obstetrics and gynecology at JPS Health Network. "It puts the pediatric population of Tarrant County at risk."

It's unclear just how disruptive the dispute has been to patient care.

Fort Worth pediatrician John Menchaca, who has been vocal about the issue, said thousands of patients could be left without a "medical home" and a pediatrician to coordinate care. And pediatric specialists are better qualified to review a child's test results or x-rays.

Rami Cavazos, another Fort Worth pediatrician, said that so far, when he has needed to send an Aetna patient to a Cook specialist, "they will see them. But it's certainly a problem" if it continues, he said.

Aetna has contracted with Children's Medical Center of Dallas to provide pediatric services, including at its big Southlake clinic opened in 2011, said Aetna spokeswoman Anjanette Coplin. State rules require that a Medicaid network offer hospitals and specialists within 75 miles of a member's home.

Virtually all other Tarrant-area hospitals are in Aetna's network, which also includes scores of physicians.

Cook Children's is part of Amerigroup's provider network in addition to its own network, which also includes at least 300 affiliated physicians. And spokeswoman Winifred King said that if an Aetna Medicaid member "was already in our system, or if they come through the emergency department, we take care of them."

Edwards Gockel said that since Sept. 1 the state has received four complaints regarding "access to care" by Aetna members in Tarrant County -- two from patients and two from physicians.

"In each case an Aetna case manager reached out and the complaints were resolved within 30 days," she said. "We will continue to monitor the situation."

Aetna Better Health is the smallest of three Medicaid HMOs in Tarrant County, which together serve nearly 280,000 people, according to the Texas Health and Human Services Commission. Amerigroup is the largest with 128,000 members, and Cook Children's Health Plan is second with 108,000 members.

In what could be a sign of the impact of the dispute, Aetna since September has lost about 650 members. In that same period, Amerigroup added 1,400 members and Cook Children's Health Plan added 3,300.

There is no financial difference to patients. The plans are paid a per capita rate by the state and are then responsible for managing total medical expenses for their members.

Neither Aetna nor Cook Children's would specify the cause of their disagreement, although Aetna did say "the main issue we have with Cook Children's is the methodology used for reimbursements."

King said Aetna asked "for some things we hadn't been doing before."

Bryan Sperry, president of the Children's Hospital Association of Texas, said Medicaid managed care "involves lots of contracting, and in every region it's a little different." He said he wasn't aware of another Texas market in which a Medicaid managed care network lacked the local pediatric hospital, if there was one.

But Tarrant County is unusual, he said, in that Dallas' pediatric hospital is an option fairly nearby, whereas other metropolitan areas have only one specialty pediatric hospital in their region.

Sperry said he doesn't know the details of the Aetna-Cook Children's dispute, but said "managed care companies can contract all different ways" for payment of services. For example, he said, one company might seek to pay for members' time in an intensive care unit with a flat rate per day, while a hospital might want to be paid based on a discounted fee schedule.

Tarrant County and three adjacent counties in 1996 became one of the first areas in Texas to move to a managed care program for Medicaid beneficiaries. Jim Fuquay, (817) 390-7552

Twitter: @jimfuquay

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