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ACCESS GRANTED

Teachers in the Oregon Trail School District and beyond receive limited access to Adventist health services

Positive news came Tuesday afternoon for residents in East Multnomah and Clackamas counties who have wanted more access to Adventist Medical Center services under their ODS insurance plans.

ODS has officially announced it will reinstate 28 Adventist physicians between Welches and 1-205 whose patient coverage would have been uncovered Nov. 1 because they were incorrectly listed in the ODS system as preferred providers.

Adventist and ODS also spoke Monday about a possible future contract that would provide complete access to Adventist Medical Center services -- not just physicians.

'It is our hope that in renewed discussions, we can develop a larger contract,' said Tom Russell, CEO of Adventist Medical Center.

BACKGROUND

Three weeks ago, Russell had received calls from ODS-insured families in the area, saying they no longer had access to their longtime Adventist physicians.

As negotiations have been made for reinstatement of these Adventist physicians under ODS coverage, the events of the past couple weeks revealed a broader issue: educators and ODS-insured families are saying their medical options are limited in an area where Adventist services are prominent.

While ODS hadn't seen access in East Multnomah and Clackamas counties as an issue, Adventist did.

Julie Frederick, a Cedar Ridge Middle School teacher, was one of the concerned teachers who called Adventist three weeks ago when she learned access to her longtime physician was in jeopardy.

'It shouldn't even be a question,' Frederick said of access to Adventist physicians and medical services. 'When you're in survival mode, the last thing you want to do is deal with insurance.'

Frederick's son battled brain tumors and continues to fight post-traumatic stress disorder as a result.

Frederick's family has seen Dr. Grise of Hoodland, an Adventist physician, through the whole process and built a patient-physician relationship. She said they couldn't imagine switching doctors several weeks ago.

Adventist believes thousands of lives like Frederick's in the East Portland area have been impacted by its exclusion from ODS and their restriction from a medical provider.

Jonathan Nicholas, vice president of marketing at ODS, said contracting with Adventist was certainly a possibility, and now it's a possibility being looked at more seriously.

CONTRACTING IN THE PAST

Russell and David Russell, the medical center's vice president, said Adventist has tried for years to contract with ODS, and ODS said the two parties have had discussions in the past.

In 2008, Adventist sought to contract with ODS, and was under the assumption contract negotiations would go through that year.

At that time also, the Oregon Educators Benefit Board (OEBB) was created and began administering benefits for school districts in Oregon.

Adventist wrote a letter of agreement that ODS patients, including school staff members insured through OEBB, could come to Adventist hospitals for 12 months under the assumption ODS would eventually include Adventist in its panel, but it never did.

Robin Richardson, senior vice president of ODS, said contracts are made based on the combinations of access and competitive rates. Historically, because ODS hasn't heard complaints of access issues from East Multnomah and Clackamas counties, they haven't seen the need to add a contract with Adventist.

THE TEACHERS AND ODS-INSURED PARTIES

For teachers who are insured through ODS by Oregon Education Board of Benefits, ODS has offered to reinstate with independent contracts the Adventist physicians whose patient coverage would have been uncovered Nov. 1.

And yet, even with the reinstatement of the physicians, these teachers and others insured through ODS are unable to access Adventist medical centers and services beyond their primary care providers, making their access to care inconsistent.

In communities such as Sandy, where there is one urgent care location operated by Adventist, this creates safety and proximity issues.

According to Nicholas, ODS looks into altering its contracts when its members identify access issues.

'We always like to hear from members,' Nicholas said. 'We're in the business of getting members what they want.'

OEBB AND TEACHERS UNIONS

Teachers, including Julie Frederick, raised concerns about OEBB and its role in administering benefits. Since OEBB, a public board of appointees, began in 2008, the Oregon Trail School District has seen its insurance premiums go up 56 percent.

Frederick thinks the board is a good idea, but said she and other teachers were under the impression the board had a responsibility to shop for the best insurance option this year that would reduce costs, not drive them up.

According to Joan Kapowich, administrator for the Oregon Educators Benefit Board, the board believes it is getting a good rate and service and will evaluate again in 2014.

Kapowich said one of OEBB's biggest goals is to minimize any disruption to members' access to care. She said a number of factors could drive up the rate, including high utilization of services by members.

OEBB is responsible for insuring 235 groups statewide and beyond. With this large group comes a disruption rate in existing care of 3-5 percent for particular areas, but Kapowich said OEBB is responsive to its members' concerns. And until the past three weeks, they just haven't heard complaints about access in East Multnomah and Clackamas counties.

'Fixing the problems in healthcare are very difficult,' said Alan Moore, a consultant for Oregon Education Association's Mount Hood UniServ. 'The rising costs are not because of OEBB, but because of a broken healthcare system. OEBB doesn't have a magic wand.'

Moore said that in the long run, it's more affordable for OEBB to stick with one provider rather than several insurance companies.

'No one knowingly created the problem,' Moore said of the access issue to Adventist physicians. 'I have faith that ODS is going to come through with their commitments. It's in everybody's best interest that they do.

'There's really no villain in this story. The folks at ODS identified the errors. They have been responsive to what we wanted to have happen. To think large institutions will be flawless is Pollyanna-ish.'

A SOLUTION

Adventist is hopeful a broader contract between Adventist and ODS is on the horizon.

'We have teachers on the Eastside who are told they can't go to the accredited chest pain center (one of two in Oregon),' said Tom Russell, Adventist CEO. 'Those are the kind of real issues that come to bear.'

With the issue of access, Nicholas and Richardson said they were open to a possible contract in the future.

'We're not taking this lightly,' Richardson said. 'From my perspective, we're moving forward with Adventist and having conversations. We'll evaluate the network and see where we go. A lot has changed in the last three years.'