Health thicket greets Assembly Managed-care push likely to be at center of many battles

January 12, 1996|By M. William Salganik | M. William Salganik,SUN STAFF

Members of the Maryland General Assembly are about to resume wrestling with changes in the health marketplace.

"Health care was one of the top five issues of the '95 session, and it will be again in '96," predicted Sen. Larry Young, the Baltimore Democrat who chairs the Senate Finance Health subcommittee.

"Health care is a $15 billion-a-year industry in the state of Maryland," said Michael E. Busch, the Anne Arundel County Democrat who chairs the House Economic Matters Committee. "The big players are always going to want to gain an advantage somewhere along the line."

The most contentious issues generally revolve around managed care -- efforts to cut costs through controlling patient access to medical care.

Among the top issues:

* The state's effort to move its Medicaid recipients to managed care.

* A drive by hospitals and other health providers to function like health maintenance organizations.

* Another debate over whether in-surers should be required to pay for two days of hospitalization for a mother giving birth.

* Efforts by Blue Cross and Blue Shield of Maryland to reduce the amount of regulatory control that the state exercises over its only nonprofit health insurer.

The administration's chief health legislation for this year's session involves moving the state's 467,000 Medicaid patients into managed care.

Managed care controls costs by assigning patients to a "gatekeeper," a primary-care physician who determines when the patient needs expensive tests or specialist visits. Also, it is hoped that the primary doctor will provide enough preventive services to avoid expensive treatments later.

"Hopefully, there won't be a lot of opposition, because everybody has had their say," said Sen. Paula C. Hollinger, a Baltimore County Democrat and nurse who takes an active role in health legislation.

Among the efforts to give interested groups a chance to comment on Medicaid plans: More than 1,000 Marylanders jammed 11 public hearings throughout the state last year to discuss the Medicaid managed-care plan. A 125-member steering committee held three-hour weekly meetings. And a group from the University of Maryland Baltimore County prepared a lengthy report.

Despite the effort at building consensus, however, interest groups are anxious to read the fine print in the final legislation.

"There are still concerns," said Jay Wolvovsky, who heads the Baltimore Medical System, a network of six health centers in East and Southeast Baltimore. "Even with the task forces and the hearings and the paper produced by UMBC, there were a lot of details that needed to be filled in."

The industry is watching to see how the Medicaid managed-care plan deals with mental health and nursing home services, said Robin Shaivitz, a lobbyist for several health-provider groups, including the Maryland Association of Nonprofit Homes for the Aging.

Others are waiting to see how specific health problems, such as AIDS, are covered.

And people such as Mr. Wolvovsky want to know how the plan will determine those who qualify as managed-care organizations: Would it be primarily existing HMOs or could networks of community health centers, such as Mr. Wolvovsky's, participate directly?

A similar question is at the center of the argument over how to regulate "community health networks," formed by hospitals, doctors and other providers. Some already have formed and are beginning to seek contracts with large employers -- raising the threat that the new networks could take millions of dollars in business away from insurance companies and HMOs.

The Maryland Hospital Association has made community health network legislation its "biggest priority" for this session, Nancy Fiedler, the association's senior vice president, said. She said hospitals want to see legislation that "makes sure we have flexibility."

On the other hand, the Maryland Association of HMOs says, in effect, if you want to act like an HMO, then become an HMO -- with all the accompanying regulations on medical quality and fiscal solvency.

Marty Roach, executive director of the HMO group, said of the community health network legislation, "We oppose it. We oppose the concept."

The HMOs also plan to oppose new legislative action on maternity hospital stays. Concerned because some insurance companies and HMOs were requiring hospital discharges in 24 hours after routine births, the legislature last year required them to pay for a 48-hour hospital stay or provide a home visit on the second day. When most insurers opted for the home visit rather than another day in the hospital, supporters of the legislation were annoyed.

"Call it getting snookered," Ms. Hollinger said. "We thought it would be up to the mom, but it was, 'Go home.' "

"This is now a consumer issue, and the consumers are demanding a 48-hour stay," said Bobbi Seabolt, lobbyist for the American Academy of Pediatrics.

Blue Cross is seeking permission to change the rates it pays doctors, pharmacists and other providers without having to get approval from the state insurance commissioner. Other insurers are already free to set the rates, and, "I don't know what reason there would be for the legislature not to grant them the same privilege as anybody else," Mr. Busch said.

However, legislators may see this as an opportunity to the Blue Cross' nonprofit status, the delegate said. "Commercial insurers are going to object because they see Blue Cross getting a large tax exemption and competing with them in the marketplace."

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