Medicaid hopes to improve care, cut costs

HELPING THE POOR

October 08, 1990|By Maria Mallory

Many people are suffering the results of inadequate medical care in Maryland because of ignorance, lack of access to care or a combination of both.

The statistics are as tragic as they are costly. The numbers give a glimpse of how bad the situation is. There are roughly 5,000 doctors treating the state's more than 340,000 Medicaid patients.

About 50 percent of Medicaid mothers in the state give birth to children without the benefit of essential prenatal care. Some don't know any better. Others don't know where to go or whom to see, since the doors of private obstetricians are generally closed to poor mothers.

The result is that thousands of sick babies are born each year needing extensive medical treatment to survive the first weeks of their lives.

Multiply an average cost of $20,000 for each stay in neonatal intensive care per sick newborn and the financial burden quickly exacerbates an already dismal situation.

And that's just part of the problem.

Every day, poor, disadvantaged and uninformed members of the community visit hospital emergency rooms for illnesses and injuries that a family doctor could treat.

On the other hand, faced with inadequate reimbursement rates, often the family doctor cannot afford to treat Medicaid patients, said Nelson Sabatini, deputy secretary of the Maryland Department of Health and Mental Hygiene.

Too little reimbursement money, excessive paperwork, and poor verification of eligibility combine to dissuade doctors from treating Medicaid patients, according to Dr. Reynaldo L. Lee-Llacer, president of the Medical and Chirurgical Faculty of Maryland.

Against a backdrop of ever-skyrocketing health care costs, all of these realities -- in addition to the physical penalty paid by the patient -- drain millions of dollars from state medical assistance coffers.

In the struggle to rein in these costs and to provide more complete care for its beneficiaries, the Maryland Department of Health and Mental Hygiene is changing its strategy.

Instead of the current system of piecemeal medical care delivered to Medicaid patients who seek out doctors and clinics willing to see them, the state health department is switching to a "managed care" approach for providing health services to Medicaid recipients.

Following the lead of many private sector employers, the state will begin linking up patients with a personal physician who will orchestrate and oversee their medical needs. The state's program, dubbed Maryland Access to Care, will strive to foster patient-doctor relationships not achieved with the current system.

The goal is to redirect the department's funds into preventive maintenance medical treatment. Without a particular doctor managing their health care needs, Medicaid patients frequently rely on reactionary inpatient and hospital care, which are typically more expensive.

The current system does not effectively encourage preventive care, unless the patient is a member of a health maintenance organization, which usually promotes such care.

On their own or with the help of the health department, Medicaid patients will be required choose a physician who will be their primary "source of care," Mr. Sabatini explains.

That "source" may be a doctor in private practice, at an HMO or a clinic, Mr. Sabatini says. In any case, that provider will monitor Medicaid patients and serve as a "gatekeeper" for patients requiring specialty care.

"If they need specialty care, they can get it, but they have to do it under the care of that provider," Mr. Sabatini says. Any MAC patient who shows up at an emergency room not needing urgent care will be denied treatment and instructed to see her primary physician for the necessary treatment.

Mr. Sabatini and his department hope the MAC program will foster patient-physician relationships and that doctors will encourage Medicaid patients to have routine checkups and come in for preventive care.

Through the MAC program, doctors will register individually with the state as willing medical liaisons for Medicaid patients.

"There are a lot of doctors who feel they have a social obligation to see Medicaid people," Mr. Sabatini says.

Additional savings from MAC will go toward greater reimbursement for participating doctors.

"We are going to be taking some of the savings and putting them back into the reimbursement levels," an added incentive for private doctors who may have had trouble covering the cost for serving Medicaid patients, he says.

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