Imposing further limits on a pilot program to offer more services at home and in the community to frail elderly and people with disabilities could sink the program, the state's health secretary told a state Senate panel yesterday.
But advocates for the elderly and disabled called for testing the program on 10,000 people to work out any kinks, rather than the 50,000 planned now by the health department.
"It's better to fly an experimental plane before you load it with people," Lori Doyle, representing the Community Behavioral Health Association of Maryland, told the Senate Finance Committee.
Yesterday's hearing continues a long-running debate. The state has been looking to control how much it spends on nursing home care, currently more than $800 million a year. It doesn't generally pay for services that help keep people out of nursing homes, such as home care aides and adult day care, but proposes to begin doing so under the pilot program.
Advocates, too, have been pressing the state to pay for help at home, giving patients alternatives to nursing homes. Where the disagreement occurs is over who gets the help and how the program is managed.
S. Anthony McCann, the health secretary, wants care to be managed by HMO-like private organizations called Community Care Organizations, or CCOs, to help control costs. However, he told the Finance Committee yesterday, limiting the pilot program to 10,000 might mean CCOs wouldn't want to participate. "That's a very, very difficult circumstance in which to have a provider come in and establish a network," McCann said.
His plan calls for the pilot program to enroll all the low-income frail elderly and disabled in Baltimore City, and Baltimore, Montgomery and Prince George's counties. That would cover about two-thirds of the estimated 72,000 people in the state who would be covered if the program became statewide.
McCann agreed with the advocates that community care can save money for the state. It costs about $80,000 a year to pay for a nursing home for one person, he said, while community care can often be delivered for about half as much.
While there is professed agreement on the concept, however, there has been plenty of back-and-forth over how such a program should be run.
The state initially suggested a statewide program.
The legislature enacted a law - over the veto of Gov. Robert L. Ehrlich Jr. - limiting the program to part of the state, and building in what it described as additional protections for patients.
Now, the sponsor of that bill, Sen. Paula C. Hollinger, a Baltimore County Democrat, is back with a bill tightening enrollment restrictions even further. Hollinger told the Finance Committee yesterday that she thought the health department had interpreted the previous bill too broadly.
As for McCann's comments that additional restrictions could kill the program, she said, "To be honest with you, it wouldn't bother me if that whole program were scrapped." She said she favored expansion of a different program, now limited to about 3,000 seniors, that pays for home and community services but doesn't have CCOs managing care.
Advocacy groups for the elderly and disabled, and two trade associations representing nursing homes, supported the Hollinger bill. Some went further, calling for enrollment in CCOs, even in the pilot area, to be voluntary.
Joining McCann in opposition were representatives of CCOs. "Shrinking this program dooms it to failure, which may be what some people want to accomplish," said Steven B. Larsen, senior vice president of Amerigroup and a former Maryland insurance commissioner.
Timing of the pilot is uncertain, since it depends on federal approval.
The state applied for that approval in October.
A second bill heard yesterday, also with Hollinger as prime sponsor, would loosen the state's medical standard for qualifying for Medicaid support for nursing home or community care. Currently, the state only pays if the patient needs medical attention. Legislative analysts said the change in standards could result in services for 2,500 more people, at a first-year cost of $20 million.
The issue of the medical standard is also the subject of a legal challenge, filed in January by Maryland Legal Aid Bureau and AARP.
In the complaint filed in Baltimore Circuit Court, they charged that Maryland's standard is stricter than is allowed under federal rules. If Hollinger's bill passed, the court case would become moot.
McCann said he wanted to help more people, but noted that legislators were already complaining that the Ehrlich administration's budget is too large.
Hollinger said the cost projections were flawed. She said the state needed to help those, particularly elderly people with dementia, who needed assistance with normal activities such as dressing and preparing meals, but didn't require medical attention.
Michele Douglas, representing the Alzheimer's Association, said she was aware of a case of "a woman who wanders on Route 70 at 2 a.m., but she has been turned down for Medicaid because she's still mobile."