State funds for HMO withheld Doctor shortage causes problems

November 06, 1993|By Patricia Meisol | Patricia Meisol,Staff Writer

A Rockville company that enrolled thousands of Medicaid patients into its health maintenance organization in recent months hasn't assembled enough doctors to care for them and is unable to deliver all the promised benefits.

State health officials delayed a $1.6 million monthly payment to the HMO, Optimum Choice Inc., a subsidiary of the Rockville-based Mid Atlantic Medical Services Inc., when they discovered the problem. The company says it is taking corrective steps.

Those include a promise to pay doctors and clinics in at least seven counties that cared for the patients after they signed up for the HMO and found out it lacked the physicians to treat them.

The problems were reported in rural areas and largely affected mental health services.

"There was more demand [for this service] than we had with our commercial population," said Richard Slater, executive vice president of marketing for Mid Atlantic Medical. "The reality of the matter is that our provider network was not as strong as we would have liked."

The state Department of Health and Mental Hygiene pays managed care companies 95 percent of the fee it would normally pay for services by a doctor that accepts Medicaid patients. The state began using managed care companies more than two years ago in a bid to reduce costs and improve care for Medicaid recipients.

Some people signed up with Optimum Choice after being offered dental benefits and being assured they could continue to see their regular doctors, according to health officials in several Maryland counties.

However, dozens of people soon found they could not see their own physicians without paying additional fees because those doctors were not part of the HMO program.

The problem came to light two weeks ago, when county health officials discovered that patients who regularly visited its clinics had switched to Optimum Choice but expected to continue to use the clinics.

Judith A. Sensenbrenner, health officer for Wicomico County, said the county continued to provide care to about 20 Medicaid recipients who are longtime patients of county psychiatric services after those patients signed up with Optimum Choice.

Her office is trying to get the company to convert the patients back to Medicaid so county-employed psychiatrists can continue their care. In the meantime, the county is providing service to patients for free.

In Carroll County, a dozen Medicaid patients who signed on with Optimum Choice continue to receive services from county mental health officials. Complaints also cropped up in Allegany, Cecil, Frederick, Kent, and Worcester counties, health officials said.

"They had what I would characterize as start-up difficulties," said Nelson J. Sabatini, secretary of the Department of Health and Mental Hygiene. "Some of the sale techniques they used kind of bothered us. They had a problem, also, getting their network [of doctors] in place."

Confronted by state officials, the company offered in the past week to repay county health officials that had continued to treat patients at the Medicaid rate, which for mental health is $84 per visit.

But Mr. Sabatini said Mid Atlantic is negotiating for a contract that, in essence, would have the HMO pay the government clinics to provide health services to its customers.

Mr. Slater of Mid Atlantic and another company official, Thomas P. Barbara, executive vice president for government relations, said yesterday that Mid Atlantic has recalled its sales force for retraining after complaints that Medicaid recipients were not given full information.

They described such incidents as "isolated," but said the company will issue new literature to employees to ensure they give out clear information.

Mid Atlantic specializes in low-cost medical services and is one of the fastest growing regional companies. It reported revenues of $580 million in 1992 and provided insurance for 940,000 clients in Maryland, Virginia and Washington, D.C., as of Sept. 30.

Its Optimum Choice HMO has enrolled 7,500 Maryland Medicaid recipients since it first began marketing to that segment in August, state officials said.

The HMO, in business since 1988, enrolls 150,000 people overall.

It is one of five companies approved to serve Medicaid patients, and is the first to market statewide and in rural areas.

Most of the others serve urban areas, where mental health providers are not in such short supply.

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