Poor's care below par, study says

State to withhold $640,000 from 5 of 8 health service groups

`To get people's attention'

Review targets prenatal efforts, immunizations

August 28, 1999|By Greg Garland | Greg Garland,SUN STAFF

Five of the eight managed care organizations providing health care for Maryland's poor failed to meet required standards, according to a study released yesterday.

As a result, the state will withhold $640,000 in payments to the companies until their performance improves, said Maryland Department of Health and Mental Hygiene Secretary Georges C. Benjamin.

"These fines are in the range to get people's attention," Benjamin said. "I would like to see them improve."

The report was the first independent evaluation of the state's HealthChoice program since it began in 1997. About 340,000 Medicaid recipients -- mostly pregnant women and children -- are enrolled at a cost to the state of $800 million a year.

Across the nation, states have used managed care as a way to control exploding medical costs for the poor. The experience of many states has been rocky, and advocates here worried that health care organizations were more interested in collecting money than in offering adequate care.

The evaluation by the Delmarva Foundation For Medical Care found, among other things, that "outreach efforts are inadequate or poorly documented" and that there was "very little evidence" of screening for substance abuse.

The study involved a review of 5,000 randomly selected medical records and looked at six areas of health care services to determine whether managed care organizations were adequately diagnosing illnesses and treating patients. For the most part, the providers fell short.

State officials focused on three areas -- immunizations, prenatal care and treatment of patients with diabetes -- in deciding on financial penalties.

The focus

Benjamin said they are three critical concerns.

For example, children are supposed to have all their immunizations by age 2, and some regular tests and screenings are needed for pregnant women to ensure that infants are born healthy, Benjamin said.

Diabetics need regular blood tests and eye and foot exams to detect progression of the disease, which could lead to other medical problems such as the loss of a limb or blindness, he said.

Only one company, Helix Family Choice, met state standards for care for all three areas.

Six of the eight care organizations met requirements for immunizing children in 1998, and only three provided proper prenatal care. Helix was the only provider to adequately screen diabetic patients.

Benjamin said he decided to withhold payments only from the five managed care organizations that failed to meet state standards for two years in a row.

Companies that had payments withheld are: FreeState Health Care, $152,230; United Health Care, $82,519; Maryland Physicians Care, $32,898; and Priority Partners, $16,384. Prudential Health Care left the state's HealthChoice program in June but will be billed $356,219 for failing to meet the standards while in it, Benjamin said.

Penalties

The penalties were assessed based on the number of people enrolled in each managed care organization and the degree to which the organization fell short of meeting the state's minimum requirements for providing services.

Two other companies -- JAI Medical System and PrimeHealth Corp. -- also failed to meet state requirements but did not have money withheld. JAI was not sanctioned because it did not enter the HealthChoice program until late 1997, and Prime Health was excluded because it went into state receivership after the sample was drawn.

Health department Deputy Secretary Debbie I. Chang said the companies that had money withheld from them can recoup it if they improve their services.

"Our strategy is to withhold some funding from them, and if they improve in next year's audit, with the standards a little bit higher, they would get that money back," Chang said.

Although most of the managed care companies fell short of meeting state standards for care, Benjamin said he believes the managed care program is working well. Before, Medicaid patients were in a fee-for-service program and often relied on emergency rooms for routine treatment, driving up costs.

"I think it is a better system than the one we had before, " Benjamin said.

Benjamin also said that a survey by his department a year ago indicated that most people enrolled in the state's managed care program were satisfied with the medical services they were receiving.

Program limits

William G. Sciarello, the president of Baltimore HealthCare Access, which serves in an ombudsman role in helping the poor get access to health care services, said Maryland did a better job in setting up its managed care program than many other states did.

Still, Maryland's program has its limits.

"I think the most serious problem with the program is that probably most of these managed care organizations were not experienced in dealing with the Medicaid population," Sciarello said.

The managed care groups found themselves dealing with people with complex problems, including HIV infections and substance abuse, and more effort is required to ensure they get the services they need, he said.

"If there's anything learned from this system, it is that health insurance does not equal access to health care," Sciarello said.

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