Maryland doctors a step ahead of reform Change afoot as Clinton offers plan

September 20, 1993|By David Conn and Sandy Banisky | David Conn and Sandy Banisky,Staff Writers

For 30 years, Dr. Joshua R. Mitchell III was a sole practitioner, running his own family practice in West Baltimore. This year, rattled by the health care reform tremors building in Maryland and the nation, he gave up his independence and threw himself into the sea of "managed care."

Dr. Mitchell, 63, a past president of the Maryland Academy of Family Physicians, signed up to receive patients from four managed care companies. He did it, he said, "to protect myself."

"The solo practitioner is going to go the way of the country doctor," Dr. Mitchell said, and independent physicians can't hold their own against an increasingly integrated health care industry. "It's like, how could the corner grocery compete with a big chain?"

Dr. Mitchell finally listened to a message that the savviest people in the health care industry have been preaching for years: The business is changing, and Maryland's doctors, along with consumers, hospitals and insurers, will have to adapt.

This week in Washington, President Clinton will present a national health care reform plan that would transform the way health care is delivered. But even before the White House proposed action, Maryland took its first, tentative steps toward reform. Last spring, the General Assembly passed a law that has begun to prepare the state for change.

Maryland's new law requires insurers to prepare to offer a standard package of benefits to small businesses and to guarantee policy renewal on demand. It also sets up a powerful new state commission with broad powers to collect information and, ultimately, control fees of all health care practitioners in the state.

Although the new law doesn't put Maryland in the vanguard in health care reform -- some other states are requiring insurance for all citizens -- it gives the state a framework for implementing the proposed federal program.

Harold A. Cohen, a consultant who helped shape the legislative package last spring, said Annapolis was monitoring Washington's ideas on reform. "We weren't interested in conflicting with it. We wanted Maryland positioned to take advantage of it."

Some legislators believe Maryland, with 600,000 uninsured residents, has to continue its work on reform in case the promised federal changes don't make it through Congress. In the next General Assembly session, Delegate Casper R. Taylor Jr. says, his House Economic Matters committee will consider ways to cover the costs of long-term care. And he'd like to find a way to make insurance more available to people who are self-employed.

Partly because they've anticipated well-telegraphed moves in Annapolis and Washington and partly because of economic pressures, Maryland's health care industries have been reshaping the way they practice and pay for medical care.

For example, physicians such as Dr. Mitchell are reluctantly acknowledging that as managed care becomes the norm, they either must join up or risk being locked out.

"I don't think you're going to find any solo practitioner without an affiliation with some group," said Dr. Mitchell, the family practitioner.

Group physician practices have become more widespread. But just this year, from scattered offices around the Baltimore area, a group of 15 primary care physicians -- internists, pediatricians and family practitioners -- formed an organization called the Baltimore Medical Group, one of the first groups without a common office.

By closely tracking the prices, treatment practices and quality of its members, the group plans to offer itself as a cost-effective network to HMOs, insurers and any other health care decision-maker. It's in discussions with several other physician groups and eventually plans to include hundreds of member physicians, according to its chairman, Roland Park internist Alan Kimmel.

The group was formed for the old reasons, such as economies of scale, expense-sharing and the like. But more important are the new reasons: "to negotiate contracts with HMOs, to create a power base to work with hospitals and other health care providers," Dr. Kimmel explained.

Not only the doctors, but just about every type of player in the industry, has been making new friends in Maryland. Last month, the Prudential Health Care Plan of the Mid-Atlantic, a Baltimore-based HMO, signed an agreement with a Sinai Hospital subsidiary to run a primary care clinic for the HMO's Medicaid patients. Prudential already has an arrangement with Liberty Medical Center, and is negotiating one with the Harbor Medical Center.

In July, the Sheppard Pratt Health System signed a contract to provide mental health services to the 30,000 Baltimore-area members of the Kaiser Permanente HMO. And in February, the University of Maryland Medical System picked a Towson firm to help the hospital re-enter the pharmacy business.

Companies that used to be in one line of business have been expanding their reach.

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