Medicaid care plans penalized

State finds 4 of 8 groups aiding poor fell shy of standards

$233,000 in payments held

Despite sanctions, officials point to gains made in year

July 26, 2000|By Diana K. Sugg | Diana K. Sugg,SUN STAFF

State health officials are penalizing half of the eight managed care organizations that serve Maryland's poor for failing to provide adequate prenatal care, diabetes screenings and other health services.

The sanctions, announced yesterday, stem from an independent audit of medical records and operations in 1999. More than $233,000 in payments is being withheld from four managed care organizations, HMO-like plans for the poor and disabled.

The results are an improvement over the first audit last year, when about $640,000 was withheld from five managed care organizations.

But state officials - and advocates - said the health plans must continue to do better.

"I was pleased to see improvements from last year, but they still didn't meet the standards," said Debbie I. Chang, the state's deputy secretary of health care financing.

"We want to be sure that quality care is being provided," she said.

The audit is one of a few crucial ways to track what is happening in the program, which started three years ago. More than 363,000 poor and disabled Marylanders on Medicaid were moved into managed care to control costs and better coordinate care.

Every state is trying the same experiment, but Maryland's program, called HealthChoice, is considered one of the most far-reaching and ambitious.

In a survey by the state health department, more than half of patients rated their health plans as excellent; 26 percent rated them as good. But critics have long worried that in the new system, a vulnerable population won't get what it needs.

"This was set up specifically to provide comprehensive quality care to previously underserved populations. The review shows that, at least in some crucial areas, that's not happening," said Dr. Peter L. Beilenson, health commissioner of Baltimore, home to roughly a third of the state's Medicaid recipients.

The audit said two managed care organizations - Priority Partners, which is partially owned by Johns Hopkins HealthCare, and PrimeHealth, which is in state receivership - failed to meet the state standard of 75 percent compliance in all six clinical areas studied.

None of the plans met the standard for diabetes care, in particular making sure patients get eye and foot exams. And only one organization, Jai Medical Plan, met the standard for mental health, which involves coordination between primary care physicians and mental health providers.

The plans posted the worst scores in the area of prenatal care, at an overall rate of 52 percent. Specifically, the rate of retesting for syphilis between 25 and 30 weeks of a pregnancy - which is required by Maryland law and is important because of the syphilis epidemic in Baltimore - was only 27 percent.

Physicians are also failing to fill out a form that links at-risk pregnant women to Healthy Start, a government program that provides nutritional, educational and social services. That is a problem in Maryland, which posts some of the worst rates of infant mortality and low birth-weight babies nationwide.

"The woman may be getting medical, technical aspects of the care, but she may not be getting thorough case management and other services," said William Sciarillo, president of Baltimore HealthCare Access, which serves as the ombudsman for the Medicaid patients.

But the plans' managers defended their progress from last year's audit. This year, several did a better job in diabetes care, mental health and immunizations, according to the audit. Pediatric asthma was a standout, with six of the eight plans reaching the standard.

"Our quality improvement plans are beginning to work. This is a long-term process. It's not instantaneous," said Lorraine Doo, director of Medicaid managed care for FreeState Health Plan. The subsidiary of CareFirst BlueCross BlueShield had $104,316 withheld this year by the state.

"We feel that most of the results came back fairly positively and are moving in the right direction," she said.

Plan officials also pointed out their high scores in the "systems" area, which includes credentialing of doctors, availability and access, and medical records.

And they noted that grading measures being used in the audits are still being refined, and that they're dealing with patients who can be hard to reach.

Cynthia Demarest, chief operating officer for Priority Partners, from which $86,465 was withheld, noted their scores were close to the overall scores.

Brian Fischer, chief executive officer of Maryland Physicians Care, said it will continue to work on the problems.

"We believe that the external quality review process is an important component of the program," said Fischer, whose plan had $36,504 withheld.

The chief executive officer at Jai Medical Plan, from which $5,900 was withheld, declined to comment.

Each managed care organization is required to submit a correction plan. Dollars withheld will be given back next year if performance improves.

Advocates for Children and Youth, a statewide advocacy group, is doing its own study of HealthChoice.

Staffers for the organization are looking into issues like people being wrongly dropped from the program, and problems getting dental care and prescriptions.

"This is a very, very vulnerable population," said Matthew Joseph, the group's director of public policy, adding that more needs to be done. "Maryland has gone full force into managed care, more than any other state, and these were protections that were supposed to prevent problems."

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