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There are a few routes by which one might end up in the care of a Providence health system specialist—say, a neurologist. As of this week, a subset of lower-income Portlanders would find that an important path has been closed.
In the latest sign of a health system struggling with rising costs, Providence Medical Group as of Feb. 15 halted new referrals to most of its specialty clinic services for members of the CareOregon/Health Share version of the Oregon Health Plan, the state’s Medicaid system.
With more members than any other within Health Share of Oregon—which has more than 400,000 Medicaid enrollees in total—the CareOregon plan is easily the largest in the Portland metro area
With the new restriction in place, those on the affected CareOregon plan will now generally need to look beyond Providence to receive adult specialty services in neurology, cardiology, behavioral health, oncology, pulmonology and orthopedics, among others.
To be sure, most plan members won’t actually need to see a specialist any time soon. Certain old referral paths that remain open (to Providence OB-GYNs, for example), and CareOregon Medicaid patients who are already seeing a Providence specialist can keep doing so.
Meanwhile, for anyone else on the plan, CareOregon notes, there are other options in town.
“We are confident,” says a spokesperson for the insurer, “that our statewide network of providers can absorb this shift without significant impact to new members.”
Others are not so confident.
“It’s a bad sign,” says John McConnell, director of the Center for Health Systems Effectiveness at Oregon Health & Science University.
The issue is that Providence is far from the only Portland health care institution under strain. All health systems try to optimize their patient mix to make the finances work, and just because the other big dogs—Legacy Health and OHSU—could theoretically provide specialty care to more Medicaid patients doesn’t mean they’d have the bandwidth to do so in a timely fashion. Or be keen to, for that matter: Medicaid plans tend to pay less than commercial ones.
As the fragmented U.S. system for financing health care frays, observers worry not only about mounting wait times to see specialists, but a broader dynamic of a system incentivized to limit care to the most vulnerable.
McConnell says other health care players may see Providence’s move as a signal that they too can restrict Medicaid patients from receiving the full continuum of care.
“It may,” he says, “create a permission structure for other places to close their networks as well.”
Providence emphasizes its ongoing commitment to Oregon’s Medicaid population, of which 1 in 3 Oregonians is a member.
The health giant says it saw 170,000 unique Oregon Medicaid patients in the last fiscal year, with the care often funded through Providence’s own Medicaid product, which—though far smaller than CareOregon’s Portland-area plan—continues to allow access to Providence specialists. (Last year, Providence says it provided specialty health services to about 7,000 members of the affected CareOregon plan.)
A Providence spokesperson says it made the change with CareOregon as part of an effort to “adapt to an evolving and underfunded health care landscape.”
The spokesperson adds: “As we are faced with difficult choices to preserve stability, we deeply value our long-standing relationship with CareOregon. Working together, we are making sure no one is left without necessary care during this transition.”
CareOregon, for its part, lists mounting costs, reduced subsidies, and a shrinking provider workforce among the problems at hand. “Like many others in these challenging times, we are making adjustments to our provider network that will best protect care for our current members while developing long‑term strategies to sustainably deliver high‑quality care," a spokesperson says.
As network adjustments often do, the latest shift with Providence has many exceptions and quirks.
Even as most of its specialists are now harder for CareOregon’s Portland-area Medicaid patients to access, some paths remain open. Maternity, pediatric and immediate care services remain available to the affected CareOregon cohort.
And hospitals can’t just turn someone facing a health emergency away. Say a CareOregon Medicaid member in Portland walks into a Providence emergency room and urgently needs to see a neurologist: “The patient would continue to receive ongoing care through Providence specialty care until they could reestablish seamlessly with a new CareOregon provider,” says a Providence spokesperson, asked about this hypothetical instance.
But health system observers worry more trouble could lie ahead.
“The overall concern for Medicaid is always about access to care,” McConnell says.
That a health insurance plan covers a service in theory is not much use if there are few doctors willing or available to provide that service at the price the plan is offering. And it can be difficult to assess the actual adequacy of an insurance network to provide health care to a particular population. McConnell noted research from his team documenting numerous cases in which Medicaid insurance plans in Oregon and beyond list doctors in their networks who don’t go on to actually provide care to Medicaid patients at all.
Some feel wait times are a good proxy for network adequacy. CareOregon did not answer WW questions about how long it currently takes a CareOregon Medicaid member to see a neurologist or a cardiologist.
The Oregon Health Authority contracts with coordinated care organizations that deliver Medicaid services. Asked if the agency believes that CareOregon’s network capacity for specialty medical services was sufficient, a spokesperson said it “continues to track potential changes” for Oregon Health Plan members, including in the Portland metro area.
“CCOs are wholly responsible for their network,” the OHA said in the statement, which noted that hospitals have discretion as to how they want to participate in the network.
“We understand that news of possible provider changes may cause concern for OHP members,” the agency spokesperson said. ”OHA’s highest priority is maintaining access to health care services for OHP members, including monitoring network adequacy through regular CCO reporting, training, and auditing.”
