Commonwealth v. Eiseman

85 A.3d 1117
Commonwealth Court of Pennsylvania·Decided February 19, 2014·Published·Cited by 32 cases

Opinions

OPINION BY

Judge SIMPSON.

This fact-intensive Right-to-Know Law (RTKL)1 petition for review from a final determination of the Office of Open Records (OOR) implicates rate-setting in the managed care industry.2 OOR ordered disclosure of rates set by contracts related to the Department of Public Welfare’s (DPW) administration of the Medicaid program. DPW asserted the rates were exempt under the Pennsylvania Uniform Trade Secrets Act, 12 Pa.C.S. §§ 5301-5308, (Trade Secrets Act), agency regulations and exceptions under the RTKL, including Section 708(b)(ll) of the RTKL, 65 P.S. § 67.708(b)(ll), which protects confidential proprietary information and trade secrets. Five Managed Care Organizations (MCOs) submitted evidence as direct interest participants below. After a hearing, OOR reasoned these exemptions did not apply. Upon our independent review of the evidentiary record created below, this Court affirms in part and reverses in part.

I. Background

DPW administers the Medicaid program, which provides medical and dental care to low-income children, certain adults and some disabled persons in Pennsylvania. In part, the Medicaid program is funded through federal funds and adminis[1121] tered in accordance with federal law, 42 U:S.C. §§ 1396-lS96w-5. In Southeast Pennsylvania, DPW operates Medicaid through the HealthChoices Program, contracting with five MCOs to provide services to eligible program recipients. The MCOs provide dental care almost exclusively by subcontracting with dental subcontractors (Subcontractors). Four of the five MCOs use the same Subcontractor, DentaQuest.3

DPW does not negotiate rates for dental services, or set parameters for such rates in its contracts. DPW contracts with the MCOs requiring them to ensure access to dental care to eligible recipients.

Pursuant to the RTKL, James Eiseman, Jr. of The Public Interest Law Center of Philadelphia (Requester) requested the following records from DPW:

Each and every document, including correspondence, and appendices, that sets forth any rate of payment, including but not limited to capitation rates, that DPW pays to any Medicaid HMO[4] to provide Medicaid coverage to recipients in Southeastern Pennsylvania, including but not limited to any document that isolates the amount per member per month DPW calculates it pays to provide dental services to Medicaid recipients under 21 years of age. [OOR referred to as Item 1.]
Each and every document including correspondence and appendices, in DPW’s possessions, [sic] custody, or control that sets forth the amount for any one or more individual dental procedure codes that any Medicaid HMO pays to provide dental services to Medicaid recipients in Southeastern Pennsylvania. [OOR referred to as Item 2.]
or (b) otherwise establishes the rate of payment by which any Medicaid HMO and/or Medicaid Dental Subcontractor compensates or has compensated dentists (and/or other providers of dental services) for the provision of dental services to Medicaid recipients in Southeastern Pennsylvania.

(emphasis added). The request is limited to the period from July 1, 2008, through June 15, 2011, and focuses on the provision of dental services.

Essentially, Item 1 of the request sought rates paid by DPW to the MCOs, per member, per month, based on annually negotiated capitation rates (Capitation Rates).5 Item 2 sought the rates the MCOs pay in turn primarily6 to Subcontractors for dental services (MCO Rates).7

Depicted in simplified diagram form, the relationships are generally as follows:

DPW-» MCOs-» Subcontractors-» Providers.

[1122] DPW denied the request, stating it notified the entities implicated as subjects of the Request, namely: United Healthcare of Pennsylvania, Inc. (United); Aetna Better Health, Inc. (Aetna); Health America of Pennsylvania, Inc. d/b/a CoventryCares (Coventry); Keystone Mercy Health Plan, Inc. (Keystone); and, Health Partners of Philadelphia, Inc. (Health Partners) (collectively, the MCOs). The MCOs advised DPW the records are exempt on the following grounds: the Trade Secrets Act; Section 708(b)(ll) of the RTKL (confidential proprietary information and trade secrets exception); and, other state and/or federal regulations and/or statutes. Requester appealed to OOR.

The MCOs asked to participate in the proceedings. OOR permitted the MCOs to participate and, at the MCOs’ request, authorized a hearing.

OOR designated a hearing officer to hold one of its first hearings under the RTKL.8 During the hearing, the MCOs submitted testimony of one fact witness each: John Sehi, then Vice President of Finance at Health Partners; Deborah Nichols, CEO at Aetna; William Morsell, Senior Vice President at Keystone; Heather Cianfrocco, President at United; and, Nancy Sirolli-Hardy, Vice-President of Operations at Coventry. The MCOs’ fact witnesses emphasized the confidentiality of the MCO Rates, both in their maintenance, and in confidentiality provisions of their upstream agreements with DPW and of their downstream agreements with Subcontractors.

In addition, Henry Miller, Ph.D., an expert in the field of health care consulting, testified. Dr. Miller testified about the formulation of MCO Rates (MCO-* Subcontractors) and the significance of competitors knowing these rates. He opined that in his more than 40 years in the industry, he has not seen instances where rate information was disclosed outside the MCOs. He also provided his expert opinion that rates MCOs pay are trade secrets and confidential proprietary information to the MCOs. He testified that disclosure of MCO Rates would reduce the value of the MCOs’ considerable investment in negotiating favorable rates. Notably, Dr. Miller did not testify about the Capitation Rates (DPW-> MCOs).

Requester did not submit testimonial evidence or affidavits.

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Commonwealth v. Eiseman, 85 A.3d 1117 (Pa. Ct. App. 2014).

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