Mississippi Today

A look at what Blue Cross reimburses UMMC, both before and after the contract dispute

Published

11 months ago

June 13, 2023

Blue Cross and Blue Shield of Mississippi and the University of Mississippi Medical Center went head to head for months last year over reimbursement rates.

Turns out, it wasn't for nothing.

An analysis by Mississippi Today and The Hilltop Institute at the University of Maryland, Baltimore County shows that in March 2022, during the throes of the dispute, Blue Cross' negotiated rates were largely lower than other major private insurance companies — Aetna, Cigna, Humana and United — for several common procedures. This was especially true for more expensive procedures and emergency room visits.

A negotiated rate is how much an insurer has agreed to pay an in-network provider through a plan for covered services.

Hospitals perform and are reimbursed for thousands of procedures each year, but what they charge and what insurers pay has largely been kept a secret — that is, until 2021, when the federal government ordered hospitals to start publishing the data.

Mississippi Today worked with The Hilltop Institute to identify 21 common adult and pediatric procedures, then analyzed what Blue Cross reimbursed the hospital for each of those in March 2022, before the entities entered the contract dispute, and in March 2023, after the two entities renegotiated their contract.

Both Blue Cross and UMMC declined to answer any of Mississippi Today's questions for this story.

The data show that for the selected services, Blue Cross almost never paid close to what UMMC charged, unless it was for cheaper procedures. The only exam that Blue Cross paid exactly what UMMC charged in 2022 was for a fetal non-stress test, which costs $231. (In 2023, when the cost was raised to $400, Blue Cross' payment increased to $380.)

Hospital prices as of September 2022 show that in general, commercial negotiated rates are on average around 58% of the hospital charge for a given service, according to Morgan Henderson, principal data scientist at Hilltop.

In 2022, Blue Cross largely paid less than other private insurers for more expensive procedures, though the data shows that these insurance companies generally pay less than what UMMC charges.

According to data over the past three fiscal years from the Center for Healthcare Quality and Payment Reform, UMMC charged four times more for services provided to patients than it cost to deliver those services, which Henderson said was in line with what other hospitals charge.

Hospital charges are arbitrary — they can differ substantially from hospital to hospital. It's rare that any payer gives hospitals the full amount they charge for any service, according to Harold Miller, CEO of the Center for Healthcare Quality and Payment Reform.

Some key findings from 2022 data show:

Other insurers paid UMMC $250 for blood tests called total metabolic panels, $151 for comprehensive metabolic panels and $127 for therapeutic exercises. Blue Cross paid $12, $15 and $35, respectively.
With the exception of X-rays, Blue Cross paid significantly less than other private insurers did for common radiologic procedures.
Preventative care for kids and other services, such as chest radiologic exams and hospital observations, were more equitable compared to what other insurers paid — but they were all services that cost around or less than $150.
Blue Cross paid more for vaginal deliveries, C-sections and fetal tests than other companies.

Henderson pointed specifically to Blue Cross' low reimbursement rates for emergency room visits, one of the more common reasons people visit a hospital.

For the base cost of emergency room visits (not including any other services often charged during ER visits), Blue Cross reimbursed UMMC in March 2022 at far lower rates than other major insurers and what UMMC charges — by thousands.

“In light of this, the fact that BCBS Mississippi pays only $537.38 for a level 5 ED facility fee – for which the charge is almost $4,800 – is especially striking,” Henderson said.

Emergency room visits are categorized, and charged, based on severity. For a mild injury, a patient is charged a base level 1 fee, excluding any tests that might be performed during that visit. The most severe injury constitutes a level 5 emergency room visit.

And as the severity of the emergency room visit goes up, so does the charge. Depending on the level of injury, UMMC can charge anywhere from $468 to $4,796 for an emergency room visit. But for the most severe ER trip, Blue Cross reimbursed UMMC $537, while other insurance companies paid thousands more.

“This is a very good deal for BCBS Mississippi, especially when compared to the negotiated rates that other large commercial insurers pay for this same service,” he said.

As state lawmakers continue not to expand Medicaid, health care administrators across the state report that people who are uninsured and can't afford preventative care are using the ER more often for general health care needs.

A year later, data from March 2023 shows that payments from Blue Cross for common procedures generally remain lower than other private insurance companies. In some cases, Blue Cross still pays thousands less.

The terms of UMMC's agreement with Blue Cross, which was decided when the dispute ended in December, have not been disclosed.

Medicare rates are typically used as a gold standard to judge whether insurer payments are too high or too low. While Blue Cross rates are reasonable compared to Medicare payments, they're still lower than other private insurers.

“I found the (Blue Cross) vs. non-(Blue Cross) price gaps for emergency and some other procedures very large, but in general what you found is expected,” said Ge Bai, a professor of health policy and management at Johns Hopkins Carey Business School, in an email to Mississippi Today.

“Large insurers can flex their muscle on the negotiating table and make threats toward hospitals, such as what (Blue Cross) did last year. Small insurers' threats won't be as concerning to hospitals because their beneficiaries do not account for a large portion of the hospital's patient volume. Therefore, small insurers' negotiated prices can be relatively higher.”

At a market share of 55%, Blue Cross insures the majority of Mississippians with private insurance, and UMMC is the state's largest public hospital.

But according to consumer advocates, insurers with lower negotiated rates are supposed to pass those savings on to consumers in the form of low premiums, and if a for-profit company has a big surplus, larger premiums shouldn't be necessary.

However, that doesn't seem to be the case for Blue Cross — at least for the past three years.

Alleging they had to pay more in claims than expected, Blue Cross raised premiums in January 2020 for small business plans and individual plans. Since then, the insurance company has raised rates for individual plans at an average of 18% and small group plans at an average of 15.6%, according to data from 2023.

After UMMC asked Blue Cross for substantially increased reimbursement rates last year and Blue Cross refused, the hospital system terminated its contract with the insurance company and subsequently went out of network in April. The move forced tens of thousands of Mississippians to pay significantly more or go elsewhere for health care, including for some services that are only available at one place in Mississippi: UMMC.

UMMC houses the state's only Level 1 trauma center, Level IV neonatal intensive care unit and children's hospital. It is also home to the state's only organ transplant center, where transplant candidates with Blue Cross insurance were marked as “inactive” on the wait lists when the hospital was out of network with the insurer.

During the dispute, UMMC maintained that it was asking for below-market rates for academic medical centers, while Blue Cross officials said to increase reimbursement rates, Mississippians' premiums would have to go up.

A Mississippi Today investigation found that Blue Cross was sitting on a huge reserve of money, to the tune of $750 million.

While insurers generally try to hold at least three times as much capital as the minimum requirement — a ratio of 300% — to ensure the company can pay out claims, Blue Cross' ratio has been around 1,600% for years, financial records revealed. It's significantly larger than Blue Cross peers in neighboring states, and perhaps the largest such surplus by percentage in the country.

State Insurance Commissioner Mike Chaney said it was UMMC's goal during the dispute to get closer to a 160 to 170% reimbursement rate from Blue Cross compared to Medicare.

Chaney, who advocated on behalf of consumers during the dispute between Blue Cross and UMMC, has long complained about the difficulties in regulating insurance reimbursement rates. He has previously said that Blue Cross won't make that data available to his office.

New health care price transparency rules, which went into effect in 2021, requires hospitals and insurers to publish their rates, but that doesn't mean those numbers are easy to access. They're published on an individual basis, hospital by hospital, and the files, which don't always look the same, are huge and sometimes hard to decipher.

Gov. Tate Reeves axed a bill earlier this year that would have allowed Chaney's office the authority to study and address inequalities in reimbursement rates among insurance companies. The bill, which Reeves called a “bad idea,” would have allowed the commissioner to fine companies thousands per violation if they can't justify unequal reimbursement rates for different hospitals for the same procedures.

“Transparency should provide policy-makers an understanding of what is contributing to the critical financial issues hospitals, clinics, and health providers are facing,” said Mitchell Adcock, executive director of the Center for Mississippi Health Policy. “If payments are not equitable, there are no other financial sources that provide enough revenue to cover health providers' costs.”

And as state leaders continue to oppose expanding Medicaid to the working poor, providers rely on private insurance company payments to offset uncompensated care for people who are uninsured.

Uncompensated care and higher health care costs have worsened the state's hospital crisis. A third of rural hospitals in Mississippi are at risk of closure.

“The current hospital revenue model, good or bad, is private insurance payments to help cover the limited payments from Medicare and Medicaid and help offset some of the uncompensated care cost,” Adcock said. “Therefore, private insurance payment rates have a significant impact on hospitals' ability to operate.”

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.

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Mississippi Today

Federal panel prescribes new mental health strategy to curb maternal deaths

Published

3 hours ago

May 16, 2024

Staff Editor

For help, call or text the National Maternal Mental Health Hotline at 1-833-TLC-MAMA (1-833-852-6262) or contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.” Spanish-language services are also available.

BRIDGEPORT, Conn. — Milagros Aquino was trying to find a new place to live and had been struggling to get used to new foods after she moved to Bridgeport from Peru with her husband and young son in 2023.

When Aquino, now 31, got pregnant in May 2023, “instantly everything got so much worse than before,” she said. “I was so sad and lying in bed all day. I was really lost and just surviving.”

Aquino has lots of company.

Perinatal depression affects as many as 20% of women in the United States during pregnancy, the postpartum period, or both, according to studies. In some states, anxiety or depression afflicts nearly a quarter of new mothers or pregnant women.

Many women in the U.S. go untreated because there is no widely deployed system to screen for mental illness in mothers, despite widespread recommendations to do so. Experts say the lack of screening has driven higher rates of mental illness, suicide, and drug overdoses that are now the leading causes of death in the first year after a woman gives birth.

“This is a systemic issue, a medical issue, and a human rights issue,” said Lindsay R. Standeven, a perinatal psychiatrist and the clinical and education director of the Johns Hopkins Reproductive Mental Health Center.

Standeven said the root causes of the problem include racial and socioeconomic disparities in maternal care and a lack of support systems for new mothers. She also pointed a finger at a shortage of mental health professionals, insufficient maternal mental health training for providers, and insufficient reimbursement for mental health services. Finally, Standeven said, the problem is exacerbated by the absence of national maternity leave policies, and the access to weapons.

Those factors helped drive a 105% increase in postpartum depression from 2010 to 2021, according to the American Journal of Obstetrics & Gynecology.

For Aquino, it wasn't until the last weeks of her pregnancy, when she signed up for acupuncture to relieve her stress, that a social worker helped her get care through the Emme Coalition, which connects girls and women with financial help, mental health counseling services, and other resources.

Mothers diagnosed with perinatal depression or anxiety during or after pregnancy are at about three times the risk of suicidal behavior and six times the risk of suicide compared with mothers without a mood disorder, according to recent U.S. and international studies in JAMA Network Open and The BMJ.

The toll of the maternal mental health crisis is particularly acute in rural communities that have become maternity care deserts, as small hospitals close their labor and delivery units because of plummeting birth rates, or because of financial or staffing issues.

This week, the Maternal Mental Health Task Force — co-led by the Office on Women's Health and the Substance Abuse and Mental Health Services Administration and formed in September to respond to the problem — recommended creating maternity care centers that could serve as hubs of integrated care and birthing facilities by building upon the services and personnel already in communities.

The task force will soon determine what portions of the plan will require congressional action and funding to implement and what will be “low-hanging fruit,” said Joy Burkhard, a member of the task force and the executive director of the nonprofit Policy Center for Maternal Mental Health.

Burkhard said equitable access to care is essential. The task force recommended that federal officials identify areas where maternity centers should be placed based on data identifying the underserved. “Rural America,” she said, “is first and foremost.”

There are shortages of care in “unlikely areas,” including Los Angeles County, where some maternity wards have recently closed, said Burkhard. Urban areas that are underserved would also be eligible to get the new centers.

“All that mothers are asking for is maternity care that makes sense. Right now, none of that exists,” she said.

Several pilot programs are designed to help struggling mothers by training and equipping midwives and doulas, people who provide guidance and support to the mothers of newborns.

In Montana, rates of maternal depression before, during, and after pregnancy are higher than the national average. From 2017 to 2020, approximately 15% of mothers experienced postpartum depression and 27% experienced perinatal depression, according to the Montana Pregnancy Risk Assessment Monitoring System. The state had the sixth-highest maternal mortality rate in the country in 2019, when it received a federal grant to begin training doulas.

To date, the program has trained 108 doulas, many of whom are Native American. Native Americans make up 6.6% of Montana's population. Indigenous people, particularly those in rural areas, have twice the national rate of severe maternal morbidity and mortality compared with white women, according to a study in Obstetrics and Gynecology.

Stephanie Fitch, grant manager at Montana Obstetrics & Maternal Support at Billings Clinic, said training doulas “has the potential to counter systemic barriers that disproportionately impact our tribal communities and improve overall community health.”

Twelve states and Washington, D.C., have Medicaid coverage for doula care, according to the National Health Law Program. They are California, Florida, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, Oklahoma, Oregon, Rhode Island, and Virginia. Medicaid pays for about 41% of births in the U.S., according to the Centers for Disease Control and Prevention.

Jacqueline Carrizo, a doula assigned to Aquino through the Emme Coalition, played an important role in Aquino's recovery. Aquino said she couldn't have imagined going through such a “dark time alone.” With Carrizo's support, “I could make it,” she said.

Genetic and environmental factors, or a past mental health disorder, can increase the risk of depression or anxiety during pregnancy. But mood disorders can happen to anyone.

Teresa Martinez, 30, of Price, Utah, had struggled with anxiety and infertility for years before she conceived her first child. The joy and relief of giving birth to her son in 2012 were short-lived.

Without warning, “a dark cloud came over me,” she said.

Martinez was afraid to tell her husband. “As a woman, you feel so much pressure and you don't want that stigma of not being a good mom,” she said.

In recent years, programs around the country have started to help doctors recognize mothers' mood disorders and learn how to help them before any harm is done.

One of the most successful is the Massachusetts Child Psychiatry Access Program for Moms, which began a decade ago and has since spread to 29 states. The program, supported by federal and state funding, provides tools and training for physicians and other providers to screen and identify disorders, triage patients, and offer treatment options.

But the expansion of maternal mental health programs is taking place amid sparse resources in much of rural America. Many programs across the country have run out of money.

The federal task force proposed that Congress fund and create consultation programs similar to the one in Massachusetts, but not to replace the ones already in place, said Burkhard.

In April, Missouri became the latest state to adopt the Massachusetts model. Women on Medicaid in Missouri are 10 times as likely to die within one year of pregnancy as those with private insurance. From 2018 through 2020, an average of 70 Missouri women died each year while pregnant or within one year of giving birth, according to state government statistics.

Wendy Ell, executive director of the Maternal Health Access Project in Missouri, called her service a “lifesaving resource” that is free and easy to access for any health care provider in the state who sees patients in the perinatal period.

About 50 health care providers have signed up for Ell's program since it began. Within 30 minutes of a request, the providers can consult over the phone with one of three perinatal psychiatrists. But while the doctors can get help from the psychiatrists, mental health resources for patients are not as readily available.

The task force called for federal funding to train more mental health providers and place them in high-need areas like Missouri. The task force also recommended training and certifying a more diverse workforce of community mental health workers, patient navigators, doulas, and peer support specialists in areas where they are most needed.

A new voluntary curriculum in reproductive psychiatry is designed to help psychiatry residents, fellows, and mental health practitioners who may have little or no training or education about the management of psychiatric illness in the perinatal period. A small study found that the curriculum significantly improved psychiatrists' ability to treat perinatal women with mental illness, said Standeven, who contributed to the training program and is one of the study's authors.

Nancy Byatt, a perinatal psychiatrist at the University of Massachusetts Chan School of Medicine who led the launch of the Massachusetts Child Psychiatry Access Program for Moms in 2014, said there is still a lot of work to do.

“I think that the most important thing is that we have made a lot of progress and, in that sense, I am kind of hopeful,” Byatt said.

Cheryl Platzman Weinstock's reporting is supported by a grant from the National Institute for Health Care Management Foundation. KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.

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Mississippi Today

New law gives state board power to probe officer misconduct

Published

4 hours ago

May 16, 2024

Staff Editor

mississippitoday.org – Jerry Mitchell – 2024-05-16 10:59:23

The state's officer certification and training board now has the power to investigate law enforcement misconduct.

Gov. Tate Reeves signed the bill making it official.

Public Safety Commissioner Sean Tindell, who pushed for the legislation, said that House Bill 691 authorizes the Board of Law Enforcement Officer Standards and Training “to launch its own investigations into officer misconduct. This change, along with the funding to hire two investigators, will improve the board's ability to ensure officer professionalism and standards.”

The new law comes in the wake of an investigation by the Mississippi Center for Investigative Reporting at Mississippi Today and The New York Times into sheriffs and deputies across the state over allegations of sexual abuse, torture and corruption.

Tindell said the new law will “improve law-enforcement training in Mississippi by requiring all law enforcement officers to receive continuing training throughout an officer's career.”

Under that law, deputies, sheriffs and state law enforcement officers will join police officers in the requirement to have up to 24 hours of continuing education training. Those who fail to train could lose their certifications.

Other changes will take place as well. Each year, the licensing board will have to report on its activities to the Legislature and the governor.

Tindell thanked Reeves “for signing this important piece of legislation and the legislative leaders who supported its passage, including the author of HB 691, Representative Fred Shanks.”

Shanks, R-Brandon, praised the “team effort with some very smart people who want a top-notch law enforcement community.”

The new law creates a 13-member board with the governor having six appointments – two police chiefs, two sheriffs, a district attorney and the director of the Mississippi Law Enforcement Officers' Training Academy.

Other members would include the attorney general or a designee, the director of the Mississippi Highway Patrol, the public safety commissioner and the presidents of the Mississippi Association of Chiefs of Police, the Mississippi Constable Association, the Mississippi Campus Law Enforcement Association and the Mississippi Sheriffs' Association (or their designees).

“We obviously need checks and balances on how law enforcement officers conduct themselves,” said state Sen. John Horhn, D-Jackson. “This is a good first step.”

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.

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Mississippi Today

Lawmakers punt to next year efforts to expand college aid for low-income Mississippians

Published

5 hours ago

May 16, 2024

Staff Editor

mississippitoday.org – Molly Minta – 2024-05-16 09:49:59

A bill to open a college financial aid program for the first time ever to Mississippians who are adult, part-time and very low-income students fell to the wayside in a legislative session dominated by fights over Medicaid and K-12 funding.

The effort to expand the Mississippi Resident Tuition Assistance Grant, called MTAG, died in conference after it was removed from House Bill 765, legislation to provide financial assistance to teachers in critical shortage areas. The Senate had attached MTAG's code sections to that bill in an attempt to keep the expansion alive.

This takes Jennifer Rogers, the director of the Mississippi Office of Student Financial Aid, back to the drawing board after years of championing legislation to modernize the way the state helps Mississippians pay for college.

“At the end of the day, there was no appetite to spend any additional money on student financial aid,” Rogers said. “Obviously, I'm disappointed.”

All told, the original proposal would have resulted in the state spending upwards of $30 million extra each year, almost doubling OSFA's roughly $50 million budget.

The increase derived from two aspects of the proposal: An estimated 37,000 Mississippians who have never been eligible for college financial aid would have become eligible to receive it, and the scholarship amounts would have increased.

While college students from millionaire families can get MTAG, the state's poorest students are not eligible, Mississippi Today previously reported.

Rep. Kent McCarty, R-Hattiesburg, said he supports efforts to help low-income Mississippians afford college, but that HB 765 was not an appropriate vehicle to do so because it was not an appropriations bill. Attempting to expand MTAG through that legislation would have put the original subject of HB 765, the Mississippi Critical Teachers Shortage Act, at risk.

“We didn't feel it was appropriate to include an appropriation in a bill that had not been through the appropriations process,” he said.

McCarty, a member of the House Universities and Colleges Committee, added that he is in favor of changing MTAG and doesn't understand the logic behind excluding from state financial aid Mississippi college students who receive a full federal Pell Grant, meaning they come from the state's poorest families.

“What is the purpose of financial aid? To aid those who need financial aid,” he said. “Excluding a group of students because they're eligible for other financial aid doesn't make a lot of sense to me.”

Ultimately, the Mississippi House deemed the proposal too expensive. It never passed out of that chamber's Appropriations Committee.

Rogers said she plans to work with lawmakers to convince them that it is a good use of state dollars to invest in financial aid. She added that the support of the business community helped keep the bill alive as long as it did this session. The Mississippi Economic Council supported the legislation.

“I don't understand why there is such a hesitancy to invest more in the future workforce of the state,” she said. “I don't understand why there isn't a willingness to invest in student financial aid as a way to help more Mississippians complete meaningful certificates or degrees, valuable certificates or degrees and improve the quality of the workforce.”

Senate Education Committee Chairman Dennis DeBar, R-Leakesville, told Mississippi Today that he hopes to take a closer look at MTAG this summer, noting that the Senate's version of the proposal, which also included a last-dollar tuition scholarship, was a priority of the lieutenant governor on last year's campaign trail.

“We had so many issues last session,” DeBar said. “Hopefully there won't be as many next year so we can just focus this year and get it across the finish line.”

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.

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