Md. panel proposes Medicaid changes Plan would include HMOs for elderly, new care package

November 04, 1996|By Diana K. Sugg | Diana K. Sugg,SUN STAFF

More than 100,000 Marylanders who are elderly, disabled, or chronically ill will face sweeping changes in the health care and other services they receive.

Prompted by soaring costs and anticipating the demands of aging baby boomers, state officials are attempting what few other states have tried: overhauling the costliest and most complicated part of Medicaid.

An advisory committee was scheduled to present a report today to the state health secretary, Dr. Martin P. Wasserman, who is charged with submitting a proposal to the legislature in January. Hearings will be held starting this week to solicit public reaction to the provisions. Some of the boldest ones would:

Shift the elderly poor from traditional medical coverage to health maintenance organizations.

Create a new type of managed care plan, in which long-term care services like nursing homes and assisted living would be integrated in a package that includes standard medical treatment. The state would experiment with several pilot projects.

Continue to move the mentally ill and developmentally disabled from institutions into the community, with the goal of eventually closing state facilities such as mental hospitals.

All this means tampering with systems that care for the frail, the sick and the impaired: people in nursing homes, the mentally retarded, people with cerebral palsy or AIDS. They are frightened. Their relatives fear their care will be turned over to profit-seeking companies.

"We have worked. We have paid taxes," said Gwendolyn Johnson, 72, of Cherry Hill. "We don't want to worry that we won't get what we need in our golden years."

But the changes also bring a chance for improvement.

"We want to see what money can be saved and where the quality is," said state Sen. Paula C. Hollinger, a committee member and the Baltimore County Democrat who sponsored legislation calling for Medicaid reform. "We certainly can't go any longer turning our back on this population and the care they need, and we certainly can't go any longer turning our back on what it is costing the state."

In one year alone, Medicaid spends more than a billion dollars in Maryland on long-term care, roughly half in state money, the remainder federal. The biggest chunk -- $450 million in 1995 -- went to nursing homes. Many of these patients are middle class people who exhausted their savings and wound up on Medicaid. The remainder goes to services like private nursing, rehabilitation, and live-in facilities for the mentally retarded.

Everyone agrees the state can't afford to sustain the rate of increase. Long-term care costs in Maryland have risen 64 percent from 1990 and 1995.

"There is no one right answer to this. There is no magic solution," said Dr. Richard G. Bennett, the committee chairman who also holds positions at the Johns Hopkins School of Medicine and Bayview Medical Center. His group found an ad-hoc system of nursing homes, group homes and other long-term care services that has grown up over the past few decades with little coordination. The result: services are duplicated and fragmented, and some needed ones don't exist.

Disabled people in Maryland, for example, can get personal care services, like grooming and meals, through three separate public agencies, each with its own eligibility requirements and payment plans. Yet many frail elderly people on the Eastern Shore who need meals delivered are landing in nursing homes because Medicaid and Medicare coverage of in-home meals is limited.

Perverse incentives, although unintentional, have also developed.

If a nursing home patient has a medical problem, for instance, it behooves the facility to ship the person to a hospital, even though the condition could be treated easily with intravenous antibiotics. That's because patients who are on Medicare because they are elderly or Medicaid because they are poor must go to the institution eligible to receive payment.

"The hospital bill is very expensive for often a simple illness that could have been managed easier in the nursing home, for only a little more money," Bennett said.

The way benefits are structured seems to force some people into nursing homes, said Stan Alliker, president of Levindale Geriatric Center and a committee member.

To qualify for services in his or her own home that might allow an elderly person to stay there longer, Alliker said, the person can have a maximum monthly income of $350. But once someone enters a nursing home, the cutoff allows much higher income -- about $1,200.

But if eligibility levels are changed, committee members fear too many Marylanders would request home services and the state couldn't afford to pay for them.

Trying to better coordinate the system, and get more value for the billions spent, means tangling with the complicated Medicare and Medicaid bureaucracy. Depending on how far the plan goes, the federal government would have to approve it.

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