HMO delays hurt poor

June 20, 1995|By Diana K. Sugg | Diana K. Sugg,Sun Staff Writer

Many Medicaid patients in Baltimore, unable to get routine care through the health maintenance organizations paid to cover them, instead are seeking treatment at city and community clinics for conditions ranging from strep throat to asthma attacks.

Dr. Peter Beilenson, city health commissioner, and several clinic managers said yesterday that poor children in the HMOs are even having difficulty getting immunizations.

"We are having a big problem getting people in for health care in a timely manner, and it's not a bottom-line issue here. It's a health issue," Dr. Beilenson said. "And it's in the best interest of the HMOs to see these kids regularly and prevent conditions from worsening."

Complaints from patients to Dr. Beilenson's office date back three years, but are becoming increasingly significant as state officials move to put all of Maryland's 467,000 Medicaid recipients into HMOs.

Parents have reported that they can't get a physical for a child for three months. Rather than wait, many of these families show up at clinics, where managers struggle to decide what to do. Sometimes, they send the patients away, sometimes they treat the children. Because their efforts to get reimbursed often fail, revenue at school-based clinics has fallen 35 percent.

Of 400 children immunized through the city's mobile van program during the first four months of this year, roughly a quarter are enrolled in either a Medicaid HMO or the other managed care program for Medicaid recipients, known as MAC, said Dr. Penny Borenstein, director of the city's immunization bureau.

Local community clinic directors give similar accounts. At the People's Community Health Center, director Patricia Cassatt said some Medicaid patients enrolled in HMOs pretend they are uninsured so they can get treated. New Song Community Church's free clinic sees many Medicaid patients who are supposed to go to distant HMO locations but don't have transportation.

Officials at four of the five HMOs said yesterday they do not believe there is a significant access problem.

About 25 percent of Maryland's Medicaid recipients are enrolled in one of five HMOs that have contracts with the state to provide the health care. Another 45 percent are in MAC, which loosely directs the patients' care, and the remainder still see physicians without restrictions.

The state has recently renegotiated its Medicaid HMO contracts, adding a financial penalty if HMOs don't meet standards such as treating patients in a timely manner, said Larry Triplett, director of the Medical Care Finance and Compliance Administration at the state Department of Health and Mental Hygiene.

The state is paying $2.2 billion yearly to care for these patients, who include the poor and disabled. In an effort to control costs and give patients better access, state officials have been increasingly emphasizing managed care, and plan to request federal permission to put all Medicaid patients into HMOs.

But around the country, and now in Maryland, experts and advocates for the poor are raising questions about whether commercial health plans are prepared to work with large numbers of Medicaid recipients, who are often poorly educated and lack transportation.

Gerry Waterfield, a nurse practitioner who supervises nine school-based clinics, gave some examples of why parents fail to get their children to their doctors. "When you don't have a phone and you have to go to a phone booth or go to a neighbor . . . it's no surprise that then they say, 'I tried three times and I couldn't do it.'. . . I've had parents who took asthmatic kids [to an HMO] and got tired of waiting and go home without the kids being seen."

Many Medicaid patients don't understand how HMOs work -- that they have to go to certain doctors or pharmacies and get approval to see specialists. More than half of the 4,000 yearly telephone calls to a Medicaid HMO hot line are from patients confused about the system.

HMO officials said they are working to help the patients cope.

Leon Kaplan, CEO of Chesapeake Health Plan, said the plan has hundreds of primary care physicians in offices around Baltimore, and that officials closely track how quickly patients can get in to the doctor.

Michael Savage, spokesman for Optimum Choice, said members can call a 24-hour, seven-day-a-week member services unit for help.

At Prudential Health Care Plan, senior medical director Dr. David Yalowitz said immunization and access rates are carefully monitored. After discovering that the Medicaid children who had been continuously enrolled for two years had an immunization rate in 1992 of just 26 percent -- which officials said was partially due to under-reporting -- they set out to improve.

With a combination of patient and provider education, reminder phone calls and postcards, and even a team of interns who tracked down children, the rate doubled to 52.6 percent in 1993, Dr. Yalowitz said.

At Columbia Medical Plan, which does not serve Baltimore, Medicaid program manager Lorraine Doo said its immunization rate was 95 percent.

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